Volume 86 Number 5
Letters to the Editor
This has not been reported with lead poisoning, but the possibility that it may be secondary to the increased cerebrospinal fluid protein and pressure cannot be completely ruled out, particularly in such a young infant. Anneliese L. Sitarz, M.D. Department o f Pediatrics Babies Hospital, The Children's Medical and Surgical Center 3975 Broadway New York, N. Y. 10032
REFERENCES 1. Browder AA: Lead poisoning from glazes, Ann Intern Med 76:665, 1972. 2. Klein M, Namer R, Harpur E, and Corbin R: Earthenware containers as a source of fatal lead poisoning (case study and public health considerations), N Engl J Med 283:669, 1970. 3. Clarke KGA: Lead-glazed earthenware, Lancet 2:662, 1972. 4. Block JL: The accident that saved five lives, Good Housekeeping 169:60, 1969.
Hydrocele following placement of a ventriculoperitoneal shunt To the Editor: The ventriculoperitoneal shunt is now widely used in the treatment of hydrocephalus. Since the introduction of the Raimondi peritoneal catheter, there has been considerable reduction in the incidence of distal obstruction. Serious systemic complications of infection and cardiac damage are avoided when this shunt is employed in preference to the ventriculoatrial procedure. ~ Although a variety of complications have been well documented, 2,3 there has been little attention given in the literatureto the association with hydrocele illustrated in the following two cases.
routine pediatric evaluation swelling of the right scrotum was noted without evidence of inguinal bulge. Abdominal films confirmed the shunt tip in the right scrotum and uncompli~;ated surgical repair and shunt repositioning followed. At 8 months of age the child continues to do well. DISCUSSION Hydrocele as a complication of peritoneal shunts has been cited as an infrequent finding in one rePorted earlier series. 4 Since many of these previous shunts were soon obstructed and were generally quickly replaced by other types of procedures, it is not surprising that this complication was met infrequently in the past. Recently a 16% incidence of clinical inguinal hernia has been noted to occur on the average within seven months after the initial ventriculoperitoneal shunt procedure. 5 Thus, itcan be expected that the presence of hydrocele will now be commonly found. This should not be a basis for special concern by the pediatrician nor a contraindication of this type of shunt procedure. Rather, this finding suggests that particular attention should be given to subtle signs of hernia or increasing hydrocele formation both before and especially after peritoneal shunting. In particular, the inguinal and scrotal areas should be regularly observed by all those responsible for evaluating peritoneal shunt functioning. Alfred L. Scherzer, Ed.D., M.D. Associate Professor o f Pediatrics Department o f Pediatrics Cornell University Medical Center 525 E. 68th St. New York, N. Y. 10021
REFERENCES 1.
2. 3.
4. 5.
CASE R E P O R T S Patient C. H., a 3-month-old male, had a low lumbosacral meningomyelocele sac repaired shortly after birth. A ventriculoperitoneal shunt was placed at 13 days using a Raimondi lowpressure peritoneal catheter. The course was uneventful until large bilateral hydroceles were noted during an orthopedic evaluation when a roentgenogram revealed the catheter tip in the left scrotum. On surgical exploration there were bilateral communicating hydroceles with the shunt tubing in the left scrotum and bilateral inguinal hernias. The peritoneal catheter was repositioned in the abdomen and the hernias repaired. The subsequent course to the age of 2 years has been benign. Patient W. M., a 2-month-old male, had a similar history with closure of the meningomyelocele sac at seven hours and placement of a ventriculoperit0neal shunt at the age of 35 days. On
811
Little J, Rhoton A, and Mellinger J: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin Proc 47:396, 1972. Ames R: Ventriculoperitoneal shunts in the management of hydrocephalus, J Neurosurg 27:525, 1967. Weiss S, and Raskind R: Twenty-two cases of hydrocephalus treated with a silastic ventriculoperitoneal shunt, Int Surg 51:13, 1969. Murtagh F, and Lehman R: Peritoneal shunts in the management of hydrocephalus, JAMA 202:1010, 1967. Grosfeld J, et ah Intra-abdominal complications following ventriculoperitoneal shunt procedures, Pediatrics 54:791, 1974.
Supraventricular tachycardia in an infant associated with a rhinoviral infection To the Editor." We have recently seen a 4-week-old boy who developed supraventricular tachycardia in association with virologic and
812
Letters to the Editor
serologic evidence of a rhinoviral infection. Follow-up electrocardiogram demonstrated a Type A Wolff-Parkinson-White pattern. Although acute acquired cardiac diseases are frequently attributed to viral infections, the documentation of viral infection in arrhythrnias is rare. 1 In some instances, arrhythmia is just one manifestation of extensive viral myocarditis, but in other situations it appears that the arrhythmia is the sole clinical manifestation of a viral infection. 2 Sevy and associates 3 reported a child with fatal uncontrolled paroxysmal atrial tachycardia. At autopsy, a striking focal infiltration of the Purkinje system was noted. Although viral studies were not done, the lesions suggested focal viral involvement. It seems probable that selective viral involvement in regions of cardiac conduction networks is a more frequent cause of arrhythmias, but this has not generally been appreciated. The finding of a Type A Wolff-Parkinson-White pattern in the follow-up electrocardiogram of our patient raises three interesting possibilities. The conventional opinion would be that the child was congenitally afflicted with the Wolff-Pa~'kinsonWhite anomaly and that the viral infection was incidenta!. A second possibility would be that the defect was present prior to the viral infection, but it took a combination of the tWo for supraventricular tachycardia to occur. The occurrence, however, of a normal electrocardiogram on the second day of hospitalization suggests the possibility that the Wolff-Parkinson-White anomaly may not be primary at all but secondary to the viral infection. Rhinoviruses are the most important etiologic agents of upper respiratory illnesses in adults. 4 In children, rhinoviruses are also a frequent cause of bronchiolitis and pneumonia. In addition to respiratory illness, rhinoviruses have been associated with meningoencephalitis, exanthem, parotitis, and sudden infant death syndrome. In two children with sudden infant death, rhinoviral strains were isolated from the b!oodS; this demonstration of viremia adds some support for an etiologic association between the rhinoviral infection and the cardiac arrhythmia in the presently reported case. Despite the prevalence of rhinoviral infections in children, their association with acute acquired cardiac disease has not been reported before. Possibly, cardiac involvement during rhinoviral infections may be more common than generally realized; viral studies are indicated in children with acute acquired cardiac arrhythmias. Mary J. Spencer, M.D. James" D. Cherry, M.D. Forrest H. Adams, M.D. Pamela 11. Byatt, Ph.D. Department of Pediatrics Divisions of lnfectious Diseases and Cardiology Center for the Health Sciences Microbiology Section Clinical Laboratories, Hospital and Clinics University of CaliJornia Los Angeles, Calif. 90024
The Journal of Pediatrics May 1975
REFERENCES
1. Cherry JD, Jahn CL, and Meyer TC: Paroxysmal atria! tachycardia associated with ECHO 9 virus infection, Am Heart J 73:681, 1967. 2. Bairan AC, Cherry JD, Fagan LF, and Codd JE: Complete heart block and respiratory syncytial virus infectio n, Am J Dis Child 127:264, 1974. 3. Sevy S, Kelly J, and Ernst H: Fatal paroxysmal tachycardia associated with focal myocarditis of the purkinje system in a 14-month-old girl, J PEDIATR72:796, 1968. 4. Cherry JD: Newer respiratory viruses: Their role in respiratory illnesses of children, Adv Pediatr 20:225, 1973. 5. Urquhart GED, and Stott EJ: Rhinoviraemia, Br Med J 4:28, 1970.
Cervical lymphadenitis due to Candida albicans infection To the Editor: A case of cervical lymphadenitis due to Candida albicans has been observed in an infant with chronic granulornatous disease. CASE REPORT
An 8-week-old black male infant was seen because of a cervical mass. He was born at term and had an uneventful prenatal and perinatal history. At 6 weeks of age he developed oral moniliasis. One week later the mother noted a lump at the right side of the infant's neck which became progressively enlarged. The infant was afebrile but he seemed irritable. There was an enlarged, warm, and fluctuant cervical lymph node which measured 3 x 4 cm located just below the right mandible. A needle aspiration of the fluctuant lymph node yielded whitish yellow pus. He was treated with dicloxacillin. Cultures of ~the aspirates were negative for bacteria and mycobacteria, and only a few colonies of Candida albicans were isolated. Initially this organism was believed to be a contaminant. However, during the following eight weeks, C. albicans was isolatedfrom subsequent needle aspirations on four different occasions. Subsequently the abscess and swollen nodes were excised surgically. Because of the unusual nature of the Candida infection, he was evaluated at 3 months of age for a possible defect in hostdefense mechanism. The periphe.ral white blood cell count was 14,000/ram 3 with 41% neutrophils. Nitroblue tetrazolium dye test of the neutrophils was less than t% (controls more than 10%) on four different occasions. Endotoxin stimulation of the neutrophils 1did not increase the n u m b e r of NBT positive cells (controls more than 40%). The histopathologic changes of the cervical lymph node were compatible with chronic granulomatous disease (Fig. li. A yeast phase fungal Organism was identified within a giant cell. An extensive evaluation of this patient failed to demonstrate other underlying diseases which may have altered host resistance.
Letters to the Editor
This has not been reported with lead poisoning, but the possibility that it may be secondary to the increased cerebrospinal fluid protein and pressure cannot be completely ruled out, particularly in such a young infant. Anneliese L. Sitarz, M.D. Department o f Pediatrics Babies Hospital, The Children's Medical and Surgical Center 3975 Broadway New York, N. Y. 10032
REFERENCES 1. Browder AA: Lead poisoning from glazes, Ann Intern Med 76:665, 1972. 2. Klein M, Namer R, Harpur E, and Corbin R: Earthenware containers as a source of fatal lead poisoning (case study and public health considerations), N Engl J Med 283:669, 1970. 3. Clarke KGA: Lead-glazed earthenware, Lancet 2:662, 1972. 4. Block JL: The accident that saved five lives, Good Housekeeping 169:60, 1969.
Hydrocele following placement of a ventriculoperitoneal shunt To the Editor: The ventriculoperitoneal shunt is now widely used in the treatment of hydrocephalus. Since the introduction of the Raimondi peritoneal catheter, there has been considerable reduction in the incidence of distal obstruction. Serious systemic complications of infection and cardiac damage are avoided when this shunt is employed in preference to the ventriculoatrial procedure. ~ Although a variety of complications have been well documented, 2,3 there has been little attention given in the literatureto the association with hydrocele illustrated in the following two cases.
routine pediatric evaluation swelling of the right scrotum was noted without evidence of inguinal bulge. Abdominal films confirmed the shunt tip in the right scrotum and uncompli~;ated surgical repair and shunt repositioning followed. At 8 months of age the child continues to do well. DISCUSSION Hydrocele as a complication of peritoneal shunts has been cited as an infrequent finding in one rePorted earlier series. 4 Since many of these previous shunts were soon obstructed and were generally quickly replaced by other types of procedures, it is not surprising that this complication was met infrequently in the past. Recently a 16% incidence of clinical inguinal hernia has been noted to occur on the average within seven months after the initial ventriculoperitoneal shunt procedure. 5 Thus, itcan be expected that the presence of hydrocele will now be commonly found. This should not be a basis for special concern by the pediatrician nor a contraindication of this type of shunt procedure. Rather, this finding suggests that particular attention should be given to subtle signs of hernia or increasing hydrocele formation both before and especially after peritoneal shunting. In particular, the inguinal and scrotal areas should be regularly observed by all those responsible for evaluating peritoneal shunt functioning. Alfred L. Scherzer, Ed.D., M.D. Associate Professor o f Pediatrics Department o f Pediatrics Cornell University Medical Center 525 E. 68th St. New York, N. Y. 10021
REFERENCES 1.
2. 3.
4. 5.
CASE R E P O R T S Patient C. H., a 3-month-old male, had a low lumbosacral meningomyelocele sac repaired shortly after birth. A ventriculoperitoneal shunt was placed at 13 days using a Raimondi lowpressure peritoneal catheter. The course was uneventful until large bilateral hydroceles were noted during an orthopedic evaluation when a roentgenogram revealed the catheter tip in the left scrotum. On surgical exploration there were bilateral communicating hydroceles with the shunt tubing in the left scrotum and bilateral inguinal hernias. The peritoneal catheter was repositioned in the abdomen and the hernias repaired. The subsequent course to the age of 2 years has been benign. Patient W. M., a 2-month-old male, had a similar history with closure of the meningomyelocele sac at seven hours and placement of a ventriculoperit0neal shunt at the age of 35 days. On
811
Little J, Rhoton A, and Mellinger J: Comparison of ventriculoperitoneal and ventriculoatrial shunts for hydrocephalus in children, Mayo Clin Proc 47:396, 1972. Ames R: Ventriculoperitoneal shunts in the management of hydrocephalus, J Neurosurg 27:525, 1967. Weiss S, and Raskind R: Twenty-two cases of hydrocephalus treated with a silastic ventriculoperitoneal shunt, Int Surg 51:13, 1969. Murtagh F, and Lehman R: Peritoneal shunts in the management of hydrocephalus, JAMA 202:1010, 1967. Grosfeld J, et ah Intra-abdominal complications following ventriculoperitoneal shunt procedures, Pediatrics 54:791, 1974.
Supraventricular tachycardia in an infant associated with a rhinoviral infection To the Editor." We have recently seen a 4-week-old boy who developed supraventricular tachycardia in association with virologic and
812
Letters to the Editor
serologic evidence of a rhinoviral infection. Follow-up electrocardiogram demonstrated a Type A Wolff-Parkinson-White pattern. Although acute acquired cardiac diseases are frequently attributed to viral infections, the documentation of viral infection in arrhythrnias is rare. 1 In some instances, arrhythmia is just one manifestation of extensive viral myocarditis, but in other situations it appears that the arrhythmia is the sole clinical manifestation of a viral infection. 2 Sevy and associates 3 reported a child with fatal uncontrolled paroxysmal atrial tachycardia. At autopsy, a striking focal infiltration of the Purkinje system was noted. Although viral studies were not done, the lesions suggested focal viral involvement. It seems probable that selective viral involvement in regions of cardiac conduction networks is a more frequent cause of arrhythmias, but this has not generally been appreciated. The finding of a Type A Wolff-Parkinson-White pattern in the follow-up electrocardiogram of our patient raises three interesting possibilities. The conventional opinion would be that the child was congenitally afflicted with the Wolff-Pa~'kinsonWhite anomaly and that the viral infection was incidenta!. A second possibility would be that the defect was present prior to the viral infection, but it took a combination of the tWo for supraventricular tachycardia to occur. The occurrence, however, of a normal electrocardiogram on the second day of hospitalization suggests the possibility that the Wolff-Parkinson-White anomaly may not be primary at all but secondary to the viral infection. Rhinoviruses are the most important etiologic agents of upper respiratory illnesses in adults. 4 In children, rhinoviruses are also a frequent cause of bronchiolitis and pneumonia. In addition to respiratory illness, rhinoviruses have been associated with meningoencephalitis, exanthem, parotitis, and sudden infant death syndrome. In two children with sudden infant death, rhinoviral strains were isolated from the b!oodS; this demonstration of viremia adds some support for an etiologic association between the rhinoviral infection and the cardiac arrhythmia in the presently reported case. Despite the prevalence of rhinoviral infections in children, their association with acute acquired cardiac disease has not been reported before. Possibly, cardiac involvement during rhinoviral infections may be more common than generally realized; viral studies are indicated in children with acute acquired cardiac arrhythmias. Mary J. Spencer, M.D. James" D. Cherry, M.D. Forrest H. Adams, M.D. Pamela 11. Byatt, Ph.D. Department of Pediatrics Divisions of lnfectious Diseases and Cardiology Center for the Health Sciences Microbiology Section Clinical Laboratories, Hospital and Clinics University of CaliJornia Los Angeles, Calif. 90024
The Journal of Pediatrics May 1975
REFERENCES
1. Cherry JD, Jahn CL, and Meyer TC: Paroxysmal atria! tachycardia associated with ECHO 9 virus infection, Am Heart J 73:681, 1967. 2. Bairan AC, Cherry JD, Fagan LF, and Codd JE: Complete heart block and respiratory syncytial virus infectio n, Am J Dis Child 127:264, 1974. 3. Sevy S, Kelly J, and Ernst H: Fatal paroxysmal tachycardia associated with focal myocarditis of the purkinje system in a 14-month-old girl, J PEDIATR72:796, 1968. 4. Cherry JD: Newer respiratory viruses: Their role in respiratory illnesses of children, Adv Pediatr 20:225, 1973. 5. Urquhart GED, and Stott EJ: Rhinoviraemia, Br Med J 4:28, 1970.
Cervical lymphadenitis due to Candida albicans infection To the Editor: A case of cervical lymphadenitis due to Candida albicans has been observed in an infant with chronic granulornatous disease. CASE REPORT
An 8-week-old black male infant was seen because of a cervical mass. He was born at term and had an uneventful prenatal and perinatal history. At 6 weeks of age he developed oral moniliasis. One week later the mother noted a lump at the right side of the infant's neck which became progressively enlarged. The infant was afebrile but he seemed irritable. There was an enlarged, warm, and fluctuant cervical lymph node which measured 3 x 4 cm located just below the right mandible. A needle aspiration of the fluctuant lymph node yielded whitish yellow pus. He was treated with dicloxacillin. Cultures of ~the aspirates were negative for bacteria and mycobacteria, and only a few colonies of Candida albicans were isolated. Initially this organism was believed to be a contaminant. However, during the following eight weeks, C. albicans was isolatedfrom subsequent needle aspirations on four different occasions. Subsequently the abscess and swollen nodes were excised surgically. Because of the unusual nature of the Candida infection, he was evaluated at 3 months of age for a possible defect in hostdefense mechanism. The periphe.ral white blood cell count was 14,000/ram 3 with 41% neutrophils. Nitroblue tetrazolium dye test of the neutrophils was less than t% (controls more than 10%) on four different occasions. Endotoxin stimulation of the neutrophils 1did not increase the n u m b e r of NBT positive cells (controls more than 40%). The histopathologic changes of the cervical lymph node were compatible with chronic granulomatous disease (Fig. li. A yeast phase fungal Organism was identified within a giant cell. An extensive evaluation of this patient failed to demonstrate other underlying diseases which may have altered host resistance.
