Robert Adler

Rhabdomyolysis with severe hypernatremia

Three children with severe hypernatremia presented with profound generalized weakness and biochemical evidence of rhabdomyolysis and myoglobinuria. These findings in combination have not been previously reported, to our knowledge, in children with severe hypernatremia. Unusual complications included respiratory failure in one child and cardiac arrhythmias in two children. All three children had acute renal insufficiency; one required peritoneal dialysis.

Necrotizing enterocolitis in older infants, children, and adolescents

bocytopenia highlighted the otherwise benign hospital courses. An exanthem has been reported in older children with RSV infection and croup, 4 but not in neonatal RSV infection. Thrombocytopenia has also not been reported to be associated with RSV infection in any age group, though it frequently has been observed in many other generalized neonatal viral infections? Disseminated intravascular coagulation, another common cause of thrombocytopenia in the septic neonate, 6 seems unlikely in our patients in light of their mild symptoms and the normal coagulation factor studies in Patient 2. Both patients had exanthems, but neither developed purpuric lesions. Respiratory syncytial virus is one of the commonest viral respiratory pathogens of children; however, neither of these RSV-infected infants had clinical symptoms of significant respiratory tract infection. By contrast, both initially had a sepsislike syndrome similar to that described for neonatal enterovirus infection. 7 The authors thank Drs. V. A. Fulginiti, J. J. Hutter, and J. J. Corrigan for their review and advice, Drs. C. DeBenedetti and G. Samoy for referral of these patients, and Ms. Nanci Buckley for invaluable assistance in preparation of the manuscript.

Varicella Complicated by Group A Streptococcal Sepsis and Osteonecrosis

A 5-year-old boy presented with primary varicella zoster virus infection, group A streptococcal sepsis, toxic shock, and multisite osteonecrosis. An association between osteonecrosis and group A streptococcal sepsis has not been previously reported. Clinical recognition with supportive radiologic and pathologic findings are presented. Therapeutic guidelines are suggested.

Pupil dilation at the first well baby examination for documenting choroidal light reflex

were negative. The patient was referred by her pediatrician for possible endocarditis. Ten days before the onset of fever, her orthodontist had adjusted her braces. Physical examination revealed her to be thin, pale, well-developed, and in no distress. Heart rate was 128 beats/min; respiratory rate, 12 breaths/min; blood pressure, 82/60 mm Hg; and temperature 38.4 ~ C. The patient had halitosis. Funduscopic examination showed no hemorrhages. There were no carotid bruits, and the lungs were clear. The precordium was quiet; there were no lifts or thrills. The heart sounds were normal; there were no gallops, rubs, or clicks. A grade II1/VI pansystolic murmur was heard maximally at the mid-left sternal border, with some radiation along the sternal border. Peripheral pulses were normal and equal in all extremities. No hepatosplenomegaly was present. The skin had no rashes or petechiae. Significant admission laboratory data included a hemoglobin level of 11.3 gm/dl and a leukocyte count of 9200 mm 3, with 67% segmented cells, 17% band cells, 12% lymphocytes, 3% monocytes, and 1 atypical cell. The platelet count was normal, sedimentation rate was 85 mm/hr, and antistreptolysin O titers were normal. A chest roentgenogram and an electrocardiogram were normal. An echocardiogram showed a small vegetation on the septal leaflet of the tricuspid valve. Three blood cultures were positive for Streptococcus viridans. The patient was treated intravenously for 5 weeks with penicillin (3 weeks in the hospital and 2 weeks at home) and for 17 days with gentamicin. The vegetation disappeared, and she remains well 7 months after the onset of fever.