William J. Rodriguez

Clinical features of acute gastroenteritis associated with human reovirus-like agent in infants and young children

Between January, 1974, and June, 1975, infection with a human reovirus-like agent was detected in 47% of 152 infants and children hospitalized with acute gastroenteritis. Certain epidemiologic, clinical, and laboratory findings appear to be helpful in distinguishing gastroenteritis due to HRVLA from other causes in those children sick enough to require hospitalization. Age: 76% of infants and children seven through 12 months of age and 76% of those 13 through 24 months of age had infection with the HRVLA, whereas such infection was found in only 21% of infants under six months of age and 23% of children 25 through 60 months of age. Time of Year: 61% of patients studied during the cooler months had HRVLA infection and such infection was not found from June to October. Frequency of vomiting and dehydration: Twice as many patients infected with HRVLA as those who were not had vomiting (92%) and significant dehydration (83%).

Cerebrospinal fluid lactic acid levels in meningitis

Measurement of cerebrospinal fluid lactic acid by gas liquid chromatography and by an enzymatic Monotest lactate test was evaluated for the early detection of bacterial meningitis in 396 patients. Spinal fluid specimens from 62/62 patients with a bacterial or mycoplasma etiology yielded lactate levels greater than the upper limits of normal, whereas specimens from 334 patients with no bacterial involvement gave values within the normal range. The duration of elevated CSF lactate values coincided with the clinical response to therapy. When considered along with the history and physical examination of the patient, determination of lactic acid proved to be a rapid and reliable diagnostic test for the early detection of untreated as well as partially treated pyogenic meningitis.

Fecal adenoviruses from a longitudinal study of families in metropolitan Washington, D.C.: Laboratory, clinical, and epidemiologic observations

During a 29-month period, we studied enteric infection in 70 families from a pediatric practice in suburban Washington, D.C. Fecal adenoviruses were detected in stools of 18 patients by tissue culture and electron microscopic procedures. From 6 through 11 months of age, the incidence of fecal adenoviruses associated with enteritis was seven per 100, and of confirmed enteric adenoviruses (EAds), three per 100 individuals per year. All EAds belonged to subgenus G (type 41). All three patients with EAds had diarrhea; two had vomiting and one had fever, but none required hospitalization. Ten of the 15 patients with non-EAds were younger than 2 years, and 60% had diarrhea, 40% had vomiting, and 20% had fever. Combined gastrointestinal and respiratory symptoms occurred more often in those who shed non-EAds (three of 11) than in matched controls (two of 48, P = 0.04). An adenovirus was detected in approximately 6% of gastroenteritis episodes, and confirmed EAds were present in approximately 2% of episodes of gastroenteritis in children younger than 2 years of age. None of the contacts of patients with non-EAds shed such virus in their stools. None of nine family contacts of those with EAd appeared to shed adenovirus in stool. In contrast, rotavirus spread readily to exposed adults (25% of 65) and children (56% of 62) when a child in similar families had rotavirus infection.

Respiratory syncytial virus infections in infants

Respiratory syncytial virus (RSV) is an important pathogen that causes bronchiolitls and pneumonia in infants, young children, and elderly adults throughout the world. This virus causes approximately 90,000 hospitalizations and 4,500 deaths in the United States each year from lower respiratory tract disease primarily among children with underlying cardiac, pulmonary, or immunologic disorders. In the temperate zones, the virus circulates from late October until late April or May, with a peak usually in mid-January to mid-February. Diagnosis usually is by latex agglutination, enzyme-linked immunosorbent assay (ELISA), fluorescent antibody, or tissue culture of nasal secretions. The nosocomial infection rate may be as high as 22 to 50 percent. Various treatment modalities have been used along with supportive care. The first medication to be approved for treatment of RSV infection was the antiviral ribavirin. Ribavirins use has been accompanied by controversy concerning its efficacy versus cost. Intravenous human IgG with high titer against RSV (RSVIG) has been used to treat patients, including those considered at high risk; it was found to be safe but not efficacious. However, RSVIG has been successful in preventing RSV disease and is now available for immunoprophylaxis in high-risk children, primarily premature infants or those with bronchopulmonary dysplasia (BPD). MEDI-493 or palivizumab (Synagis; Med-Immune, Inc, Gaithersburg, MD), a new humanized monoclonal antibody, also has been studied in a prophylactic trial with 1,500 premature infants and young children with BPD. A 55 percent reduction in hospital admissions resulted when compared with placebo. This prophylactic modality has been approved recently by the Food and Drug Administration (FDA). The use of vaccines for prevention of RSV disease has been fraught with obstacles. Various studies using RSV subunit F and G vaccines are in progress. Live, attenuated vaccines also are under investigation.

Cerebrospinal Fluid Lactate Determination: A New Parameter for the Diagnosis of Acute and Partially Treated Meningitis

The lactic acid level in the cerebrospinal fluid of 250 patients with or without bacterial involvement was determined using Gas Liquid Chromatography (GLC). This recently rediscovered technique proved effective and reliable in distinguishing between bacterial (21 cases) and non bacterial (179 cases) meningitis. There were no false positives nor false negatives in either category. Partially treated meningitis had elevated CSF lactate on admission. The duration of elevated CSF lactate correlated with the clinical response to therapy. This simple and rapid technique warrants further evaluation as a parameter to detect bacterial central nervous system invasion.

Labeling of Pediatric Pain Medications

FDA-approved labeling contains a summary of the available and essential scientifi c information needed for the safe use of a drug for a specifi c use. With few exceptions, only a limited number of medications frequently used to treat pediatric pain or facilitate analgesia are adequately labeled for pediatric patients. Consequently, most drugs are used off-label in children. Pediatric initiatives have generated more than 300 pediatric studies resulting in new product labeling for over 120 drugs. This chapter reviews several important lessons gleaned from these studies, regulatory highlights of the drug approval process, revisions to product labeling due to the Physician Labeling Rule, and controlled substance regulations as they apply to opioids. Pediatric labeling for drugs commonly used to treat acute and chronic pain, headaches, and muscle spasm is also reviewed, highlighting the signifi cant gaps in labeling which remain, particularly for neonates and young children.

Immunologic Findings in a Case of Congenital CMV Compared to Infants with Aids

Infections with viruses of the herpes group, particularly cytomegalovirus (CMV), have been associated with a transient reversal of T-helper/T-suppressor (TH/TS) ratio. This reversal has been reported with CMV mononucleosis, immunosuppressed patients with CMV infection, and a few cases of congenital CMV. In none of these reports has the reversed TH/TS ratio been causally associated with other immune abnormalities. The reversed ratio is also a frequent finding in acquired immune deficiency syndrome (AIDS), and it is unclear as to what causal relationships may exist among the CMV infection of AIDS patients, the AIDS agent, the reversed TH/TS ratio, the other immune defects of AIDS, and the susceptibility to opportunistic infections experienced by AIDS patients. We have studied a child with congenital CMV throughout the first year of life who exhibited a persistently reversed TH/TS ratio, a lack of antibody to CMV in the IgM class, a delay in CMV-IgG antibody formation, and an unusually prolonged high titer of CMV excretion in his urine. In spite of these immunologic changes, he has not experienced opportunistic infections. This case study helps to clarify some of the above relationships.

Evaluation of Cefaclor in Acute Otitis Media Caused by Ampicillin-resistant H. influenzae

Cefaclor was used to treat 13 children with acute otitis media caused by ampicillin-resistant strains of Hemophilus influenzae. The children were re-examined on days 4, 10, and 28. Phar macologic compliance was assessed by means of a bioinhibition assay on a urine specimen obtained on days 4, 7, and 100 Nine of the 13 children had evidence by tympanogram of residual otitis media with effusion (secretory otitis media). Of these, three were noted to have a bulging, yellow or grey eardrum, which suggested an ongoing acute process. A second middle ear culture was obtained from two of the 3 children, but no pathogens were recovered. Two others had recurrence of otitis shortly after cessation of therapy. Cefaclor is an acceptable antibiotic for the treatment of ampicillin-resistant acute otitis media; but, after cefaclor therapy, some children continued to have a bulging eardrum and sterile pus in the middle ear or had recurrences of otitis soon after cessation of therapy.