532
Clinical notes
This patient was initially in danger of cervical cord and vertebral artery compression. A cervical collar was supplied, but with progression of the spondylitis the cervical spine has now fused and he is thus no longer considered to be at risk of developing these complications. The authors thank Dr. B. Ansell who took care of this patient while he was in England and provided information with respect to his course during that interval. Graham D. Reid. M.B., Ch.B. Resident in Rheumatology Department of Medicine University of British Columbia Canadian Arthritis & Rheumatism Society 895 w: 10th Ave. Vancouver. BC V5Z 1L7 Robert H. Hill, M.A., B.M., B.Ch., F.R.C.P.(C) Associate Professor Department of Pediatrics University of British Columbia
REFERENCES I.
SchaUer 10: Ankylosing spondylitis of childhood onset, Arthritis Rheum 20:398, 1977. 2. Ladd JR, Cassidy JT, and Martel W; Juvenile ankylosing spondylitis, Arthritis Rheum 14:579, 1971. 3. Sharp J, and Purser DW: Spontaneous atlantoaxial dislocation in ankylosing spondylitis and rheumatoid arthritis, Ann Rheum Dis 20:47. 1961. 4. Werne S: Spontaneous dislocation of the atlas, Acta Rheum Scand 3: ioi, 1957.
Acute glossitis due to Hemophilus influenzae type b The abrupt onset of symptoms in acute bacterial glossitis, characterized by rapid enlargement of the tongue occurring within 24 hours,' demands prompt recognition of this entity. Recently, we have observed a child with bacteremia due to Hemophilus infiuenzae type b in whom swelling of the tongue was the distinctive presenting manifestation.
CASE REPORT Patient J. K.. n 20-month-old white boy, awoke on the morning of admission, with a temperature of39.8°C and a tender, swollen tongue. He was unable to swallow clear fluids or oral secretions. Physical examination six hours after onset of illness revealed mild respiratory distress and an enlarged, beefy-red tongue protruding from the oral cavity. A 0.5 ern excoriation was present on the inferior surface of the tongue. The posterior pharynx appeared normal. Dr. Edwards is the recipient of the Eleanor Clay Ford Fellowship in Sexually Transmissible Diseases from the Venereal Disease Research Fund of the Amer/call Social Health Association.
0022·3476178/0393·0532$00.20/0 It'! 1978 The C. V. Mosby Co.
The Journal of Pediatrics September 1978
Laboratory data included hemoglobin 11 gm/dl and WBC count 24.000/mm:l with 50% segmented neutrophils, 20% bands, 21% lymphocytes, and 9% monocytes. A radiograph of the lateral neck revealed massive swelling of the tongue and soft tissues of the lIoor of the mouth; the epiglottis and supraglottic soft tissues appeared normal. Lumbar puncture yielded clear cerebrospinal fluid containing no WBC, protein 12 mg/ dl, and glucose 17 mg/dl. The serum glucose concentration was 108 mg/dl. Intravenous therapy with ampicillin 275 rug/kg/day, chloramphenicol 100 rug/kg/day, and dexamethasone 4 mg initially followed by I mg/kg/day was instituted. The child was transferred to Texas Children's Hospital because tracheostomy was anticipated. However, several hours after therapy was initiated, dramatic clinical improvement ensued. Twenty-four hours after the onset of illness, the patient's tongue could be contained within the oral cavity, and within three days the tongue appeared normal. Counterimmunoelectrophoresis (eIE) of a urine specimen obtained on the day of admission was positive for H. influenzae type b using antisera from Hyland Laboratories. elE of serum and cerebrospinal fluid specimens was negative. H. tnfluenzae type b, sensitive to ampicillin by disc susceptibility testing, was isolated subsequently from the admission blood culture. Throat culture also yielded H. tnfiuenzae. The patient received therapy for ten days with ampicillin intravenously. Serum immunoglobulin levels and thyroid function studies (T. and Til performed during the hospital admission were normal.
DISCUSSION The spectrum of unusual foci associated with infection due to this organism is broad and includes such diverse entities as appendicitis, urinary tract infection. soft tissue abscess, acute epididymoorchitis, and infected thyroglossal duct cyst.'·' Due to the association of thyroglossal duct cyst infection with H. infiuenzae," careful examination of the base of the tongue and thyroid function studies were performed and were normal. Both Pseudomonas sp. and Streptococcus hemolyticus have been implicated as causes of acute suppurative glossitis in children.' To our knowledge, glossitis due to lI. influenzae is previously unreported. It is unclear whether the small excoriation on the undersurface of the tongue was a factor predisposing to infection in our patient or was due to trauma resulting from massive swelling. Since respiratory impairment requiring operative intervention may occur within hours after thc onset of symptoms, prompt recognition and vigorous management of this entity are imperative for a favorable outcome. Morven S. Edwards, M.D. George E. S. Reynolds III, M.D. Department of Pediatrics Baylor College of Medicine 1200 Moursund Ave. Houston, TX 77030
REFERENCES I.
Chandra T. and Prakash A: Suppurative parenchymatous glossitis, Br J Surg 52:234, 1965. 2. Todd JK, and Bruhn FW; Severe Haemophilus influenzae infections, Am J Dis Child 129:607. 1975. 3. Rogers KB, Zinnemann K, and Foster WP: The isolation
Volume 93 Number 3
Clinical notes
and identification of Haemophilus spp. from unusual lesions in children, J C1in Pathol 13:519, 1960. 4. Feigin RD, Shackelford PG, and Keeney R: Hemophilus infiuenzae abscess associated with septicemia, Am J Dis Child 121:534, 1971. 5. Waldman LS, Kosloske AM, and Parsons DW: Acute epididymo-orchitis as the presenting manifestation of Hemophilus influenzae septicemia, J PEDlATR 90:87, 1977.
533
Health laboratory. A survey of household members revealed that her father was excreting S. typht in his stools. On the third day of treatment, the fever subsided. Simultaneously, her behavior returned to normal. An audiogram on the fifth day of treatment showed a moderate (40 to 50 dB) low-frequency sensorineural hearing loss. Follow-up audiogram 6 weeks later was normal. DISCUSSION
Typhoid fever: Unusual presentation The reported incidence of typhoid fever in the United States has fallen steadily over the past 30 years from 3 to 0.2 cases/ 100,000.' The disease now occurs in scattered outbreaks, usually traceable to a single carrier. Sporadic cases occur mainly in travelers to parts of the world where typhoid is endemic. Because of its rarity, the diagnosis is usually made by chance. Of the nine cases seen in children at University Hospital of Jacksonville in the past ten years, typhoid was included in the initial differential diagnosis in only one. The patient reported here presented with psychosis and hearing loss. CASE REPORT
A 14-year-old girl was admitted to the hospital for changes in behavior. Two weeks before admission, she became withdrawn and uncommunicative, refusing to eat, drink, or walk. She was generally unresponsive to her environment, particularly to sound. She began to sleep more, and had vomiting and pain in the legs and abdomen. There were no previous episodes of unusual behavior and no known exposure to toxins or drugs. All members of her household were well. On examination, she was withdrawn and passive. Vital signs were normal. At times she did not seem to hear. Her speech was slurred and slow, and her responses to simple questions incoherent. Her face was expressionless. The pharynx was injected. Initial impression was of (I) behavior disorder, cause unknown, (2) pharyngitis, and (3) possible hearing loss. The hemoglobin concentration was 8.5 gm/dl, and peripheral blood smear revealed slight anisocytosis, poikilocytosis, and few microcytes, Results of urinary screening for toxic substances, serum electrolytes, lumbar CSF, and chest radiograph were normal. Initial cultures of throat, urine, and blood were negative. Findings of radionuclide brain scan and computerized axial tomograms of the brain were normal. Stool examination for occult blood was positive. A bone marrow cytologic examination was unremarkable. Serum creatinine phosphokinase was 2,850 Ilf /I, with electrophoretic fractionation showing all of the enzyme to be of skeletal muscle origin. Lactic acid dehydrogenase was greater than 600 (shown by electrophoresis to be of hepatic origin), and glutarnic-oxaloacetic transaminase was 279 lUll. On the second day her temperature rose to 104.3°F, and she remained febrile. Her affect remained blunted, and on one occasion she was found wandering aimlessly. On the seventh day, Salmonella typhi was isolated from the bone marrow (four blood cultures having been negative). Salmonella H antibodies were present in a dilution of 1:200. She was treated intravenously with ampicillin (200 rag/kg/day). The identity of the organism was confirmed in the State Board of
0022-3476178/0393-0533$00.1010 © 1978 The C. V. Mosby Co.
Alterations of central nervous system function are not uncommon in typhoid fever. Osuntokin et aI' found confusion or delirium in 57% and schizophreniform psychosis in 0.7% of a large series of patients in Nigeria. Workers in the field have long recognized transient deafness as a manifestation of typhoid fever." • Thiamine deficiency has been invoked as a possible mechanism,' but our patient's normal nutritional state and her recovery without vitamin supplementation argue against this explanation. The purpose of this note is to rem ind the clinician that typhoid fever continues to occur in this country and that its variability of presentation and rarity tend to delay diagnosis. Blood cultures may fail to yield the organism, especially if the patient has received antibiotics:' Clifford B. David, M.D. Chief Resident Asad Tolaymat, M.D. Assistant Professor Department of Pediatrics University Hospital of Jacksonville 655 W. Eighth St. Jacksonville, FL 32209 REFERENCES 1. Morbid Mortal Wk Rep, Annual Suppl. 24:59, 1975. 2. Osuntokun BO, Bademosi 0, Ogunrerni K, and Wright SC: Neuro-psychiatric manifestations of typhoid fever in 959 cases, Arch Neural 27:7, 1972. 3. Huckstep RL: Typhoid fever and other Salmonella infections, Edinburgh, 1962, E. & S. Livingstone, Ltd., pp 57-59. 4. Osler W: Modern medicine, its theory and practice, Vol. 2, Infectious diseases, Philadelphia and New York, 1907, pp 105, 152-154. 5. Gilman RH, Terminel M, Levine MM, Hernandez-Mendoza P, and Hornick, RB: Relative efficacy of blood, urine, rectal, swab, bone marrow and rose-spot cultures for recovery of Salmonella typhi in typhoid fever, Lancet 1:1211, 1975.
Balance studies in newborn infants Nutritional studies often require balance techniques in which intake is controlled and output is monitored through careful collection of urine and feces over a designated period of time. This necessitates adequate separation of urine and feces, a
0022·3476178/0393-0533$00.2010
e
1978 The C. V. Mosby Co.
Clinical notes
This patient was initially in danger of cervical cord and vertebral artery compression. A cervical collar was supplied, but with progression of the spondylitis the cervical spine has now fused and he is thus no longer considered to be at risk of developing these complications. The authors thank Dr. B. Ansell who took care of this patient while he was in England and provided information with respect to his course during that interval. Graham D. Reid. M.B., Ch.B. Resident in Rheumatology Department of Medicine University of British Columbia Canadian Arthritis & Rheumatism Society 895 w: 10th Ave. Vancouver. BC V5Z 1L7 Robert H. Hill, M.A., B.M., B.Ch., F.R.C.P.(C) Associate Professor Department of Pediatrics University of British Columbia
REFERENCES I.
SchaUer 10: Ankylosing spondylitis of childhood onset, Arthritis Rheum 20:398, 1977. 2. Ladd JR, Cassidy JT, and Martel W; Juvenile ankylosing spondylitis, Arthritis Rheum 14:579, 1971. 3. Sharp J, and Purser DW: Spontaneous atlantoaxial dislocation in ankylosing spondylitis and rheumatoid arthritis, Ann Rheum Dis 20:47. 1961. 4. Werne S: Spontaneous dislocation of the atlas, Acta Rheum Scand 3: ioi, 1957.
Acute glossitis due to Hemophilus influenzae type b The abrupt onset of symptoms in acute bacterial glossitis, characterized by rapid enlargement of the tongue occurring within 24 hours,' demands prompt recognition of this entity. Recently, we have observed a child with bacteremia due to Hemophilus infiuenzae type b in whom swelling of the tongue was the distinctive presenting manifestation.
CASE REPORT Patient J. K.. n 20-month-old white boy, awoke on the morning of admission, with a temperature of39.8°C and a tender, swollen tongue. He was unable to swallow clear fluids or oral secretions. Physical examination six hours after onset of illness revealed mild respiratory distress and an enlarged, beefy-red tongue protruding from the oral cavity. A 0.5 ern excoriation was present on the inferior surface of the tongue. The posterior pharynx appeared normal. Dr. Edwards is the recipient of the Eleanor Clay Ford Fellowship in Sexually Transmissible Diseases from the Venereal Disease Research Fund of the Amer/call Social Health Association.
0022·3476178/0393·0532$00.20/0 It'! 1978 The C. V. Mosby Co.
The Journal of Pediatrics September 1978
Laboratory data included hemoglobin 11 gm/dl and WBC count 24.000/mm:l with 50% segmented neutrophils, 20% bands, 21% lymphocytes, and 9% monocytes. A radiograph of the lateral neck revealed massive swelling of the tongue and soft tissues of the lIoor of the mouth; the epiglottis and supraglottic soft tissues appeared normal. Lumbar puncture yielded clear cerebrospinal fluid containing no WBC, protein 12 mg/ dl, and glucose 17 mg/dl. The serum glucose concentration was 108 mg/dl. Intravenous therapy with ampicillin 275 rug/kg/day, chloramphenicol 100 rug/kg/day, and dexamethasone 4 mg initially followed by I mg/kg/day was instituted. The child was transferred to Texas Children's Hospital because tracheostomy was anticipated. However, several hours after therapy was initiated, dramatic clinical improvement ensued. Twenty-four hours after the onset of illness, the patient's tongue could be contained within the oral cavity, and within three days the tongue appeared normal. Counterimmunoelectrophoresis (eIE) of a urine specimen obtained on the day of admission was positive for H. influenzae type b using antisera from Hyland Laboratories. elE of serum and cerebrospinal fluid specimens was negative. H. tnfluenzae type b, sensitive to ampicillin by disc susceptibility testing, was isolated subsequently from the admission blood culture. Throat culture also yielded H. tnfiuenzae. The patient received therapy for ten days with ampicillin intravenously. Serum immunoglobulin levels and thyroid function studies (T. and Til performed during the hospital admission were normal.
DISCUSSION The spectrum of unusual foci associated with infection due to this organism is broad and includes such diverse entities as appendicitis, urinary tract infection. soft tissue abscess, acute epididymoorchitis, and infected thyroglossal duct cyst.'·' Due to the association of thyroglossal duct cyst infection with H. infiuenzae," careful examination of the base of the tongue and thyroid function studies were performed and were normal. Both Pseudomonas sp. and Streptococcus hemolyticus have been implicated as causes of acute suppurative glossitis in children.' To our knowledge, glossitis due to lI. influenzae is previously unreported. It is unclear whether the small excoriation on the undersurface of the tongue was a factor predisposing to infection in our patient or was due to trauma resulting from massive swelling. Since respiratory impairment requiring operative intervention may occur within hours after thc onset of symptoms, prompt recognition and vigorous management of this entity are imperative for a favorable outcome. Morven S. Edwards, M.D. George E. S. Reynolds III, M.D. Department of Pediatrics Baylor College of Medicine 1200 Moursund Ave. Houston, TX 77030
REFERENCES I.
Chandra T. and Prakash A: Suppurative parenchymatous glossitis, Br J Surg 52:234, 1965. 2. Todd JK, and Bruhn FW; Severe Haemophilus influenzae infections, Am J Dis Child 129:607. 1975. 3. Rogers KB, Zinnemann K, and Foster WP: The isolation
Volume 93 Number 3
Clinical notes
and identification of Haemophilus spp. from unusual lesions in children, J C1in Pathol 13:519, 1960. 4. Feigin RD, Shackelford PG, and Keeney R: Hemophilus infiuenzae abscess associated with septicemia, Am J Dis Child 121:534, 1971. 5. Waldman LS, Kosloske AM, and Parsons DW: Acute epididymo-orchitis as the presenting manifestation of Hemophilus influenzae septicemia, J PEDlATR 90:87, 1977.
533
Health laboratory. A survey of household members revealed that her father was excreting S. typht in his stools. On the third day of treatment, the fever subsided. Simultaneously, her behavior returned to normal. An audiogram on the fifth day of treatment showed a moderate (40 to 50 dB) low-frequency sensorineural hearing loss. Follow-up audiogram 6 weeks later was normal. DISCUSSION
Typhoid fever: Unusual presentation The reported incidence of typhoid fever in the United States has fallen steadily over the past 30 years from 3 to 0.2 cases/ 100,000.' The disease now occurs in scattered outbreaks, usually traceable to a single carrier. Sporadic cases occur mainly in travelers to parts of the world where typhoid is endemic. Because of its rarity, the diagnosis is usually made by chance. Of the nine cases seen in children at University Hospital of Jacksonville in the past ten years, typhoid was included in the initial differential diagnosis in only one. The patient reported here presented with psychosis and hearing loss. CASE REPORT
A 14-year-old girl was admitted to the hospital for changes in behavior. Two weeks before admission, she became withdrawn and uncommunicative, refusing to eat, drink, or walk. She was generally unresponsive to her environment, particularly to sound. She began to sleep more, and had vomiting and pain in the legs and abdomen. There were no previous episodes of unusual behavior and no known exposure to toxins or drugs. All members of her household were well. On examination, she was withdrawn and passive. Vital signs were normal. At times she did not seem to hear. Her speech was slurred and slow, and her responses to simple questions incoherent. Her face was expressionless. The pharynx was injected. Initial impression was of (I) behavior disorder, cause unknown, (2) pharyngitis, and (3) possible hearing loss. The hemoglobin concentration was 8.5 gm/dl, and peripheral blood smear revealed slight anisocytosis, poikilocytosis, and few microcytes, Results of urinary screening for toxic substances, serum electrolytes, lumbar CSF, and chest radiograph were normal. Initial cultures of throat, urine, and blood were negative. Findings of radionuclide brain scan and computerized axial tomograms of the brain were normal. Stool examination for occult blood was positive. A bone marrow cytologic examination was unremarkable. Serum creatinine phosphokinase was 2,850 Ilf /I, with electrophoretic fractionation showing all of the enzyme to be of skeletal muscle origin. Lactic acid dehydrogenase was greater than 600 (shown by electrophoresis to be of hepatic origin), and glutarnic-oxaloacetic transaminase was 279 lUll. On the second day her temperature rose to 104.3°F, and she remained febrile. Her affect remained blunted, and on one occasion she was found wandering aimlessly. On the seventh day, Salmonella typhi was isolated from the bone marrow (four blood cultures having been negative). Salmonella H antibodies were present in a dilution of 1:200. She was treated intravenously with ampicillin (200 rag/kg/day). The identity of the organism was confirmed in the State Board of
0022-3476178/0393-0533$00.1010 © 1978 The C. V. Mosby Co.
Alterations of central nervous system function are not uncommon in typhoid fever. Osuntokin et aI' found confusion or delirium in 57% and schizophreniform psychosis in 0.7% of a large series of patients in Nigeria. Workers in the field have long recognized transient deafness as a manifestation of typhoid fever." • Thiamine deficiency has been invoked as a possible mechanism,' but our patient's normal nutritional state and her recovery without vitamin supplementation argue against this explanation. The purpose of this note is to rem ind the clinician that typhoid fever continues to occur in this country and that its variability of presentation and rarity tend to delay diagnosis. Blood cultures may fail to yield the organism, especially if the patient has received antibiotics:' Clifford B. David, M.D. Chief Resident Asad Tolaymat, M.D. Assistant Professor Department of Pediatrics University Hospital of Jacksonville 655 W. Eighth St. Jacksonville, FL 32209 REFERENCES 1. Morbid Mortal Wk Rep, Annual Suppl. 24:59, 1975. 2. Osuntokun BO, Bademosi 0, Ogunrerni K, and Wright SC: Neuro-psychiatric manifestations of typhoid fever in 959 cases, Arch Neural 27:7, 1972. 3. Huckstep RL: Typhoid fever and other Salmonella infections, Edinburgh, 1962, E. & S. Livingstone, Ltd., pp 57-59. 4. Osler W: Modern medicine, its theory and practice, Vol. 2, Infectious diseases, Philadelphia and New York, 1907, pp 105, 152-154. 5. Gilman RH, Terminel M, Levine MM, Hernandez-Mendoza P, and Hornick, RB: Relative efficacy of blood, urine, rectal, swab, bone marrow and rose-spot cultures for recovery of Salmonella typhi in typhoid fever, Lancet 1:1211, 1975.
Balance studies in newborn infants Nutritional studies often require balance techniques in which intake is controlled and output is monitored through careful collection of urine and feces over a designated period of time. This necessitates adequate separation of urine and feces, a
0022·3476178/0393-0533$00.2010
e
1978 The C. V. Mosby Co.
