Richard H. Michaels

The Sequelae of Haemophilus influenzae Meningitis in School-Age Children

BACKGROUND Previous data on the consequences of Haemophilus influenzae type b meningitis for school-age children have been inconsistent, and much of the information on risk factors has been inconclusive. The present study was designed to evaluate the sequelae of this disease with a protocol for the comprehensive assessment of neuropsychological function. METHODS Ninety-seven school-age children (mean age, 9.6 years), each of whom had a school-age sibling, were recruited from a survey of the medical records of 519 children treated for H. influenzae type b meningitis between 1972 and 1984 (at a mean age of 17 months) at the childrens hospitals of Toronto, Ottawa, and Montreal. Of the 97 children, 41 had had an acute neurologic complication. Sequelae were assessed by comparing the index children with their nearest siblings on the basis of standardized measures of cognitive, academic, and behavioral status. RESULTS Only 14 children (14 percent) had persisting neurologic sequelae: sensorineural hearing loss in 11 (unilateral in 6 and bilateral in 5), seizure disorder in 2, and hemiplegia and mental retardation in 1. Although the total sample of index children scored slightly below the siblings in reading ability, the 56 children without acute-phase neurologic complications (58 percent) were indistinguishable from their siblings on all measures. The differences between the groups were small even for the 41 pairs in which the index child had had an acute neurologic complication (mean full-scale IQ, 102 for the index children vs. 109 for the siblings). Sequelae were also associated with lower socioeconomic status and a lower ratio of glucose in cerebrospinal fluid to that in blood at the time of the meningitis. Behavioral problems were more prominent in index boys than index girls and in those who were older at the time of testing, but sex and age were not related to cognitive or academic sequelae. CONCLUSIONS We find a favorable prognosis for the majority of children who are treated for meningitis caused by H. influenzae type b.

Efficacy of topical antibiotic therapy in acute conjunctivitis in children

We studied 102 children aged 1 month to 18 years in a randomized, double-blind trial designed to determine both the natural history of bacterial conjunctivitis and whether topical antibiotic therapy is beneficial. Affected eyes were treated four times a day for 7 days with drug (polymyxin-bacitracin ophthalmic ointment) or placebo. Eighty-four patients had proved bacterial conjunctivitis (Haemophilus influenzae 61, Streptococcus pneumoniae 22, both one); 66 of these received only topical therapy. By 3 to 5 days, 21 of 34 (62%) patients receiving topical antibiotic were clinically cured, whereas only nine of 32 (28%) patients given placebo were cured (P less than 0.02). By 8 to 10 days, 31 (91%) of the patients given antibiotic and 23 (72%) of the placebo group were cured (P = NS). The bacterial pathogen was eradicated by day 3 to 5 in 71% and by day 8 to 10 in 79% of patients given antibiotic, compared to 19% and 31% of the placebo group (P less than 0.001). Acute bacterial conjunctivitis is a self-limited disease, but topical antibiotic therapy with polymyxin-bacitracin shortens the duration of clinical disease and enhances eradication of the causative organism from the conjunctiva.

ACUTE-PHASE NEUROLOGIC COMPLICATIONS OF HAEMOPHILUS INFLUENZAE TYPE B MENINGITIS : ASSOCIATION WITH DEVELOPMENTAL PROBLEMS AT SCHOOL AGE

The purposes of this study were to describe the incidence of acute-phase neurologic complications in a sample of 126 children with Haemophilus influenzae type b meningitis, and to determine if these complications were associated with higher rates of learning and behavior problems at school age. Risks were assessed by comparing rates of adverse psychoeducational outcomes in the 53 children in the sample with complications to corresponding outcome rates in the 67 children who were free of neurologic complications and who did not have abnormal electroencephalograms (EEGs) or computed tomographic (CT) scans. Comparisons were made by means of logistic regression analysis. Twenty-nine children (23% of the sample) had seizures, 16 (13%) were comatose or obtunded, 15 (12%) had sensorineural hearing loss, 8 (6%) had hemiparesis, and 7 (6%) had cranial nerve deficits other than hearing loss. Relative to children without complications, those with complications had higher rates of grade repetition and substandard performance on neuropsychological and achievement testing. Adverse outcomes, however, consisted primarily of more subtle cognitive and learning problems; only two of the children in the sample obtained prorated IQ scores below 70. Sequelae were associated with persistent neurologic deficits and bilateral hearing loss, as well as with transient symptoms including seizures, coma, and hemiparesis. While study findings argue against adverse consequences for the vast majority of children treated for this disease, the results clarify learning and behavior outcomes and indicate which children are at greatest risk. (J Child Neurol 1997;13:113-119).

Viral Enhancement of Nasal Colonization with Haemophilus influenzae Type b in the Infant Rat

Summary: Infant rats infected with influenza A virus, Sendai (parainfluenza 1) virus or rat coronavirus were used to determine whether viral infection increases the intensity of nasal colonization with Haemophilus influenzae type b (HIB). Intranasal inoculation of HIB in rats previously infected with each of these viruses resulted in nasal HIB titers at least 100-fold higher than those for controls during the first 2 wk after HIB inoculation, and as much as 10,000-fold higher during the first week. Children with cough, sneezing, or rhinorrhea could be effective disseminators of HIB if they were as heavily and persistently colonized as these virus-infected animals.

A decline in Haemophilus influenzae type b meningitis.

During the past 50 years, there has been an unexplained fourfold increase in admissions for Haemophilus influenzae type b meningitis to the Childrens Hospital of Pittsburgh, and an equally striking decline that cannot be attributed entirely to immunization.

753 MICROBIOLOGY OF RECURRENT AND CHRONIC OTITIS MEDIA WITH EFFUSION

A study was conducted of 274 children who had recurrent acute or chronic otitis media with effusion or both. Forty-five percent of the ears with effusion were found to contain bacteria and 11 percent contained bacteria that were “probable pathogens” (S. pneumoniae, H. influenzae, and S. pyogenes). Bacteria were also found in 40 percent of the ears without effusions. The type of organism found did not vary with the age of the patient studied or the season of the year. The significance of these bacteria in the etiology of chronic otitis media with effusion remains to be demonstrated.

192 PURULENT PERICARDITIS (PP)–CHANGING ETIOLOGY AND TREATMENT

All cases of bacterial pericarditis admitted to Childrens Hospital from 1961-1980 were reviewed. To exclude patients with sympathetic pericardial effusion, only cases with pericardial fluid that was culture or CIE positive were analyzed. The organisms that caused PP with median age for each were:The most common bacterial cause of PP may be shifting from SA to HIB. All children presented with fever and ST-T wave EKG abnormalities. Associated findings for children with SA and HIB were:All children received antimicrobials. Four children recovered without surgical drainage and 2 recovered after pericardiectomy. Eight children were treated with pericardiotomy with tube drainage. Two of these 8, both of whom had thick pericardial pus, developed constrictive pericarditis requiring total pericardiectomy. One of the two died. The other children have not had evidence of cardiac abnormalities on follow-up evaluations. Patients with thick pericardial pus should undergo pericardiectomy not pericardiotomy.

MULTIPLEX POLYMERASE CHAIN REACTION-BASED ASSAY FOR THE DETECTION OF BORDETELLA PERTUSSIS IN NASOPHARYNGEAL SWAB SPECIMENS. † 1108

MULTIPLEX POLYMERASE CHAIN REACTION-BASED ASSAY FOR THE DETECTION OF BORDETELLA PERTUSSIS IN NASOPHARYNGEAL SWAB SPECIMENS. † 1108

688 PERIORBITAL AND ORBITAL CELLULITIS-A REAPPRAISAL

Important differences between periorbital cellulitis (PC),orbital cellulitis or abscess (OC), and periorbital swelling (PS) associated with sinusitis have been obscured because these terms are often used interchangeably. All cases of PC and OC with a positive blood,tissue aspirate,or abscess culture seen at Childrens or Eye and Ear Hospital in the past 10 years were analyzed. Results (including median age):PC caused by HIB and SP, characterized by bacteremia, fever and periorbital swelling, discoloration, induration and pain, is a distinct clinical entity occurring in young children;sinus radiographs frequently demonstrated “cloudy” sinuses,but interpretation of the radiographs was complicated by the small size and indistinct bony margins of the sinuses of infants, and by concurrent upper respiratory infection and overlying soft tissue swelling. Ophthalmoplegia and proptosis, never present in cases of PC, always accompanied OC as did radiographic evidence of sinusitis. OC due to HIB has not been documented in this study or in the literature. PS secondary to sinusitis is characterized by non-tender, non-indurated edema due to venous congestion, not bacterial cellulitis. Careful differentiation of PC,OC and PS secondary to sinusitis is necessary for the selection of appropriate therapy.

101 BIOFEEDBACK THERAPY FOR FECAL INCONTINENCE IN CHILDREN WITH MENINGOMYELOCELE

Fourteen children with meningomyelocele and significant fecal soiling underwent anorectal manometry using a 3-balloon system connected to a physiograph. The ages of the children ranged from 5 to 17 years. On the basis of manometric criteria demonstrating some rectal sensation, 8 patients were treated with biofeedback conditioning. Children were taught to contract the external sphincter or nearby gluteal muscles in response to various volumes of rectal distention. Four of the 8 patients who received biofeedback had a good clinical response with either disappearance of soiling or a greater than 75% improvement in the frequency of soiling. Followup periods ranged from 3-12 months. The minimal criteria for successful treatment appeared to be: 1) Normal threshold of rectal sensation and 2) Ability to contract gluteal or related muscles. Responses to biofeedback could not be predicted by age, sex, surgery for spinal cord tethering, CSF shunts or bracing, but was best predicted by the anorectal manometric findings. On the basis of this experience, the following conclusions can be drawn: (1) Anorectal manometry is a rapid and inexpensive test to identify children with fecal soiling associated with meningomyelocele who may benefit from biofeedback conditioning. (2) Biofeedback is an effective therapeutic technique for fecal incontinence and should become an important part of bowel management programs for children with primary neurogenic sphincter dysfunction.