The Journal of Pediatrics September 1978

Editorial correspondence

sclerosing panencephalitis (SSPE) at JO months of age. There was some question as to the diagnosis. We would like to add a few remarks. The onset of SSPE has been observed in children undergoing an immunodeprcssive treatment. To which extent can they be considered typical SSPE? Perhaps the patient referred to by Bhettay, Kipps , and McDonald belonged to the same group. . Having studied more than 250 SSPE cerebrospinal fluids, OUT results indicate that in all cases, without exception, the IgG are increased and a marked fractionation is observed after agar .gel electrophoresis. In our experience the diagnosis of SSPE was established clinically and confirmed by measuring the measles antibody titer in the serum and the CSF, and sometimes after biopsy or autopsy or electroencephalographic examination. Therefore we think that in order to accept the case of Bhettay, Kipps, and McDonald or similar ones as SSPE, serum and CSF protein agar gel electrophoresis should be carried out in order to confirm the diagnosis . The oligoclonal pattern observed after agar gel electrophoresis was described by us as early as 1959. In 80% of all sera (about 250 samples) we found an oligoclonal reaction or antibody restricted heterogeneity. The CSF and serum oligo clonal reaction is often observed before the electroencephalographic anomalies set in, or in patients in whom no electroencephalographic anomalies ever appeared during the course of the disease and the diagnosis later is confirmed by the neuropathologic examination. Our conclusion is that before accep tin g Bhettay, Kipps, and McDonald 's cases or analogous cases as SSPE, serum and CSF should be examined by agar gel electrophoresis. Prof. Dr. A . Lowenthal Dr. D. Karcher Born-Bunge Stichting Untversitaire Instelltng Antwerpen

Geneeskunde II Universiteitsplein, 1 B'-2610 Wilrijk Belgium

REFERENCES 1. Modlin JF, Halsey NA , and Herrmann KL: Infantile onset of SSPE , J PEDIATR 92: 168, 1977; Bhettay E, Kipps A, and McDonald R: Reply, J PEDlATR 92:168, 1977. 2. Bhettay E, Kipps A, and M cDonald R: Early onset of subacute sclerosing panencephalitis, J PEDIATR 89:271, 1976.

Reply To the Editor: The case report to which Professor A. Lowenthal's letter refers gave the information on which we based our considered diagnosis. The child was not on immunosuppressive therapy. We agree that the demonstration of oligoclonal measles antibody in the cerebrospinal fluid would have provided helpful supportive information, but these techniques were not available to us then,

and unfortunately confirmatory biopsy and autopsy studies were not possible for religious reasons. E. Bhettay R. McDonald Department of Paediatrics & Child Health A. Kipps MRC/UCT Virus Research Unit University of Cape Town South Africa

Kidney transplantation in infants To the Editor: The article by Kwun et al' concerning the successful transplantation of a kidney into a 3-month-old infant represents a significant accomplishment in medical and surgical management. The substantial technical ad vances in the hemodialysis of small infants' in recent years have accelerated renal transplantation to the place of an alternative therapy regardless of age or size. At least over the short run , Kwun and her colleagues have now demonstrated that renal transplantation can be accomplished in this very young age group. However, I am concerned about their conclusion. They bel ieve that a kidney transplant is worth trying in this youn g age group because "chronic dialysis rarely results in adequate gro wth and development." I do not believe any pediatric nephrologist involved in maintenance hemod ialys is of children will dispute that adequate growth is not achieved in these youngsters. Yet does this justify subjecting the infant and family to a form of therapy that in truth may result in a normal life, but the odds against which are overwhelming? And indeed what about the quality of life of this infant who required hospitalization on five occasions during the first posttransplant year? At age 20 months he is severely retarded in growth and in development. Is this transplant therapy "successful"? The au tho rs experience with three other very young transpl ant recip ients fail to convince me that this therapeutic mod alit y is "worth attempting." Other clinicians have voiced similar concerns ab out transplantation in children under age one.' There is a third alternative to what the authors have offered us-death . It is clearly not an attractive one. But one of the very important roles of a physician who cares for children with fatal diseases is to separate the ordinary and useful therapeutic measures from the extraordinary and questionable ones . Not every patient and family need be subjected to the latest medical "fad" on the assumption "i t might work ." We must consider the patient and family first. Therapy which for one patient and circumstance would be considered ordinary may very well be deemed extraordinary and no t ind icated in another situ ation.' The results of renal transplantation in patients less than one year are extremely poor. Although it technically is possible to perform hemodialysis and tr ansplantation in these children, the myriad of well-known problems (rejection, infection, growth

Editorial correspondence

Volume 93 Number 3

failure) and the unknown factors (psychologic impact on child and family, enormous family investment in one child, impact on medical staff) should contraindicate such therapy except under the most unusual circumstances. The decision not to offer such therapy may well require as much or more physician time and support as doing the transplant. However, I suspect the impact of that humane effort may have longer and more favorable effect on such families than we can imagine. John K. Hurley, M.D. Assistant Professor of Pediatrics Attending Nephrologist Children's Memorial Hospital 2300 Children's Plaza Chicago, lL 60614





Kwum VA, Butt KMH, Kim KH, Kountz SL, and Moe! 01: Successful renal transplantation in a 3-month-old infant, J PEDIATR 92:426, 1978. Mauer SM, Shideman JR, Buselmeier TJ, et al: Long-term hemodialysis in the neonatal period, Am J Dis Child 125:269, 1973. Hodson EM, Najarian JS, Kjellstrand CM, et al: Renal transplanta tion in children ages 1 to 5 years, Pediatrics 61:458, 1978. Curran WJ: The Saikewicz decision, N Engl J Med 298:499, 1978.

Reply To the Editor: We appreciate the interest and criticism raised by Dr. Hurley regarding our infant transplant paper. It is a fact that infants with chronic renal failure approaching end-stage are delayed both in growth and psychomotor development. However, it is surprising how relatively healthy these infants may appear both to the parents and medical staff. Infant-maternal bonding begins very early in life, perhaps even before the child is born. Under these circumstances the physician cannot unilaterally decide the fate of the infant. The family must be informed as to the various options and strong consideration given to their wishes. The decision to attempt a transplant in the 3-month-old infant was strongly influenced by the child's mother. The mother intellectually understood that the child's kidneys would never function, that he would never grow and that he would probably die in the near future. However, emotionally she could not give up hope. With all the current publicity regarding kidney transplantation, it was not surprising that the child's mother asked about transplantation as a possibility. No matter how hard we tried to convince her that past efforts to transplant infants had been dismal failures, she hoped we would try to give her child a chance to live. We certainly could not have told her that such an effort would unequivocably fail, since we really did .not know. We attempted the transplant both to honor the parents' wishes


and to study an interesting clinical problem that had not previously been closely examined. Donald I. Moel, M.D. Physician-in-Charge Pediatric Nephrology Y. Anne Kwun, M.D. Pediatric Nephrology Fellow Downstate Medical Center State University of New York 450 Clarkson Ave. Brooklyn, NY 11203

Methods for the thoracostomy neonates To the Editor; Moessinger, Driscoll, and Wigger' have established the danger of the Trocar method of tube thoracostomy in neonates. An alternative method employed in our unit for the past four years has allowed us to avoid this complication. A small interspace incision is made with a No. 11 scalpel blade and carried into the intercostal muscle. The chest is then entered by "popping" a small mosquito hemostat through the pleura. The tract is then enlarged with the hemostat (this immediately relieves the tension pneumothorax), and a Mallecott or other thoracostomy tube is then inserted with the hemostat. Pediatric house officers have mastered this techniqlie, which appears to be safe and does not require the time investment in utilizing a teaching model. Martin J. Bell, M.D. Associate Professor of Surgery (Pediatric) Washington University School of Medicine St. Louis Children's Hospital St. Louis, MO 63110

REFERENCE 1. Moessinger AC, Driscoll JM, and Wigger HJ: High incidence of lung perforation by chest tube in neonatal pneumothorax, J PEDlATR 92:635, 1978.

Reply To the Editor: Any procedure or therapy is associated with the risk of complication(s). The nature of neonatology or intensive care medicine does not always allow one to evaluate this risk fully until after the procedure has been used. Unfortunately, even then, a complication is recognized only when an obvious sign or symptom develops immediately thereafter. We feel that a procedure should not be considered safe until a systematic, prospective search for early as well as late complications has been conducted and the results have been critically analyzed.

Kidney transplantation in infants.

538 The Journal of Pediatrics September 1978 Editorial correspondence sclerosing panencephalitis (SSPE) at JO months of age. There was some questio...
177KB Sizes 0 Downloads 0 Views