W. Wong

Use of convalescent plasma therapy in SARS patients in Hong Kong.

In order to evaluate the efficacy of convalescent plasma therapy in the treatment of patients with severe acute respiratory syndrome (SARS), 80 SARS patients were given convalescent plasma at Prince of Wales Hospital, Hong Kong, between 20 March and 26 May 2003. Good outcome was defined as discharge by day 22 following the onset of SARS symptoms. Poor outcome was defined as death or hospitalization beyond 22 days. A higher day-22 discharge rate was observed among patients who were given convalescent plasma before day 14 of illness (58.3% vs 15.6%; P<0.001) and among those who were PCR positive and seronegative for coronavirus at the time of plasma infusion (66.7% vs 20%; P=0.001).

Delivery of salbutamol to nonventilated preterm infants by metered-dose inhaler, jet nebulizer, and ultrasonic nebulizer

To identify the most efficient device for the delivery of bronchodilator aerosol to nonventilated preterm infants with chronic lung disease, we compared the metered dose inhaler (MDI) used in conjunction with a non-valved spacer, an ultrasonic nebulizer with a small medication cup, and two jet nebulizers. The subjects were enrolled in two double-blind randomized crossover studies. In study A (n=10), each infant was given a nominal dose of 200 microg of salbutamol by a MDI (Ventolin) at 4 h intervals, and in random sequence via an Aerochamber (Neonatal Aerochamber) with its one-way valve removed, an ultrasonic nebulizer with a small cone-shaped medication cup (Siemens Electronics), and a jet nebulizer (Side-stream). Their functional residual capacity (FRC) and static respiratory system mechanics were measured before, and at 15, 30, 60, and 120 min after aerosol delivery. Study B (n=10) was carried out in an identical manner, but with a different jet nebulizer (Hudson). In both studies, administration of salbutamol aerosol via the MDI Aerochamber or ultrasonic nebulizer resulted in a significantly greater reduction in respiratory system resistance than via jet nebulizers. Furthermore, the use of MDI Aerochamber or ultrasonic nebulizer was associated with a greater degree of post-treatment tachycardia and improvement in FRC. The bronchodilating effect of salbutamol delivered via the ultrasonic nebulizer appeared to be slightly greater than that via the MDI-Aerochamber, receiving significance only in Study B. We conclude that both the metered-dose inhaler used with a nonvalved Aerochamber and the ultrasonic nebulizer with a small medication cup are both more efficient than the jet nebulizers in preterm infants.

Early onset of hypernatraemic dehydration and fever in exclusively breast-fed infants.

Abstract: Five cases of moderately severe hypernatraemic dehydration were identified within a 5‐month period between two regional hospitals in Hong Kong. Unlike previous reported cases, these exclusively breast‐fed infants presented with the unusual triad of fever, absence of overt signs of dehydration and within the first week of life. Three of the cases also had high serum bilirubin concentrations at presentation. The fever subsided quickly and the serum bilirubin concentration fell rapidly within a few hours of rehydration. All infants made an uneventful recovery without permanent neurological sequelae. Fever, presumably secondary to dehydration, is an useful early warning sign. These cases emphasize the importance of early and regular measurement of bodyweight in exclusively breast‐fed infants so that prompt identification of affected cases may prevent potentially detrimental complications.

Erythromycin treatment for gastrointestinal dysmotility in preterm infants

To report our clinical experience on the use of oral erythromycin for the treatment of severe gastrointestinal dysmotility in preterm infants.

Randomised crossover trial of salbutamol aerosol delivered by metered dose inhaler, jet nebuliser, and ultrasonic nebuliser in chronic lung disease

AIMS To compare the efficacy of salbutamol delivered by metered dose inhaler (MDI), jet nebuliser, and ultrasonic nebuliser in ventilated infants with chronic lung disease. METHODS Twenty preterm ventilated infants with chronic lung disease were enrolled in two studies. In study 1 (n=10), each infant was given 200 μg of salbutamol at 4 hour intervals and in random sequence from a metered dose inhaler–spacer device, a jet nebuliser, and an ultrasonic nebuliser with a small medication cup. The infants were monitored for heart rate, transcutaneous pO2, pCO2, and oxygen saturation, respiratory system resistance and compliance before and after each treatment. Infants in study 2 (n=10) were similarly studied except for the use of a different jet nebuliser. RESULTS The mean (SEM) maximum percentage decreases in respiratory system resistance, observed at 30 minutes after aerosol delivery were study 1: MDI: 44.3 (4.3)% ; jet: 32.3 (3.4)% ; ultrasonic: 56.1 (3.2)% ; study 2: MDI: 28.6 (1.0)% ; jet: 16.9 (1.4)% ; ultrasonic: 42.1 (1.6)%. During the first hour after treatment, a significantly faster heart rate and higher transcutaneous pO2 were associated with the use of the ultrasonic nebuliser or MDI than with the jet nebulisers in both studies. The use of the ultrasonic nebuliser but not the other devices also resulted in a lower transcutaneous pCO2 and improved respiratory system compliance in study 2. CONCLUSIONS These findings suggest that among the devices tested, the delivery of salbutamol aerosol to the lower respiratory tract was greatest using the ultrasonic nebuliser, and least with the jet nebulisers.

Classical galactosaemia in Chinese: A case report and review of disease incidence

Abstract: We report a case of galactose‐1‐phosphate uridyl transferase (GALT) deficiency in a full‐term Chinese neonate, who presented with atypical biochemical features of hyperammonaemia in addition to the classical presenting features of jaundice and lethargy after feeding. Red cell GALT activity was virtually absent in the patient while 50% of normal activity was found in parents and a sibling. Mutation screening excluded both Q188R and N314D as the causative mutation in GALT gene, which suggested a possible genetic segregation among ethnic groups. Data from a Taiwan screening program suggested that the incidence of the disease was approximately 1 in 400 000 in the Chinese population which was a sixth of that in Caucasian populations.

Is homozygous α-thalassaemia a lethal condition in the 1990s?

Two cases of homozygous α‐thalassaemia who received active treatment in accordance with parental wishes are reported. One infant survived and the other, although successfully weaned off mechanical respiratory support, unexpectedly developed portal vein thrombosis and died. Homozygous a‐thalassaemia, a condition previously considered to be universally fatal, and an indication for therapeutic abortion, is now potentially curable with advances in diagnostic technology and treatment. However, active management of these cases raises serious ethical questions and has major financial implications on the health‐care system. Invasive prenatal and intensive postnatal interventions should remain experimental and cannot be recommended as routine clinical practice until the questions of long‐term neurodevelopmental outcome, and the morbidity and mortality associated with bone‐marrow transplantation have been fully addressed. As a result of advances in information technology, more and more parents of affected foetuses are likely to request active treatment.

Cavernous Sinus Syndrome Secondary to Tuberculous Meningitis

Case Report A 48-year-old policeman presented with double vision and mild frontal headache which gradually worsened over the next 2 weeks. He did not complain of any visual or sensory symptoms, nausea or vomiting. He had no history of diabetes mellitus. Physical examination showed limitation of right eye abduction and absent right corneal reflex; there was no meningeal irriation or fever. He was admitted for investigation where brain and orbital computed tomography scans were normal, as were complete blood picture, renal and liver function tests. During admission he developed complete right eye ptosis. Examination showed complete right oculomotor, trochlear and abducens nerve palsies with impaired sensation over the territory of the ophthalmic branch of the right trigeminal nerve. A cerebral angiogram was performed to exclude vascular pathology, but this revealed an incidental small arteriovenous fistula in the right frontal lobe only. Cerebrospinal fluid (CSF) total protein was 0.39 g/l and white cell count was 10 ! 106/l with 100% lymphocytes. Gram stain, India ink and acid-fast stains were negative; culture for Mycobacteria was also eventually negative. A brain magnetic resonance image (MRI) scan showed a heterogeneously enhancing soft tissue mass in the right cavernous sinus extending inferiorly to the right temporal lobe (fig. 1). At this point the patient declined further investigation and was lost to follow-up. Two months later, he was readmitted through the casualty department because of generalized headache, repeated vomiting and ataxia. An urgent CT scan of the brain showed multiple cystic lesions in the right cerebellum with mass effect. Posterior fossa decompression was performed. The excised material showed necrotizing noncaseating epithelioid cell granuloma and he was given a 12-month course of drug therapy for tuberculous meningitis (TBM). Postoperative recovery was uneventful. Three years after the operation, the patient remains well but is left with a mild residual right abducens nerve palsy.

Central nervous system candidiasis in preterm infants: Limited value of biochemical markers for diagnosis

Abstract: Two rare cases of isolated central nervous system (CNS) candidiasis in preterm infants have been diagnosed in a tertiary neonatal centre over the past 6 years. Despite the life‐threatening nature of the disease, biochemical infection markers were not useful for the early identification of localized fungal infection. Because the infection was likely to have been blood borne, we postulated that the initial fungal load was probably low and that the organisms were rapidly eliminated from the circulation after a few had been deposited in the CNS. Hence, the absence of fungaemia or systemic involvement precluded the activation of cytokines and cellular markers. Clinicians should be aware of the limitation of biochemical infection markers so that diagnosis and treatment of fungal infection will not be delayed.

Pneumocystis carinii Pneumonia in an Immunocompetent Infant with Congenital Cytomegalovirus Infection

SummaryThe case of a term infant with congenital cytomegalovirus (CMV) infection who developed Pneumocystis carinii pneumonia (PCP) at 4 months of age is reported. Our patient suffered from severe malnutrition and zinc deficiency secondary to necrotizing enterocolitis since the age of 2 months. There was no evidence of human immunodeficiency virus infection. Qualitative and quantitative in vitro leukocyte functions were also normal. This case highlights the fact that PCP can occur in apparently immunocompetent term infants. Malnourished infants with zinc deficiency or congenital CMV infection are at increased risk of developing PCP.