L E T T E R S TO T H E E D I T O R Clinical notes
"Clinical notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 Or 4 references, and, if contributoryl one illustration or short table. "Clinical notes" are subject to the same critical peer review and editing as papers published in other sections of THE JOURNAL.
The significance of thche cbrbbrale in neonatal meningitis To the Editor: ;Fhe diagnosis of meningitis during the neonatal period can be difficult when the symptoms and physical findings Of irritability, vomiting, fever, and a tense fontanel are minimal. The following patient presented with vague symptoms and manifested the physical sign of t~che c4rtbrale. CASE REPORT Patient B. L., a 4-week-old male infant, was brought to the emergency room "because of fever." There was no history of itritability, vomiting, or seizures. Gestation and delivery had been uneventful and birth weight was 4 kg. Examination revealed an infant with a temperature of 100.4 ~ in no apparent distress. He was alert; with a good sucking response and Moro reflex. The remainder of the examin~,tion was normal except for the presence of tgtche ctr6brale, After the infant was placed in a secure position, a tongue blade was used to stroke the skin in a tic-tactoe design. Exactly 20 seconds after stroking the skin, a light linear'pattern resulted; 50 seconds later the marks were bright red (Fig 1). The pattern seemed most intense, at 60 seconds and completely disappeared at 2 minutes. Laboratory data. The hematocrit was 34%, the white blood count (WBC), 23,00 (55 lJ01ymorphpnuclear cells [PMN], 1 band, 44 lymphocytes). Cerebrospinal fltiid was grossly purulent with 6,000 WBC/mm 3 (100% PMNs), concenmitions of protein, 240 mg/dl, glucose, 12 mg/dl, with a corresponding serum glucose "concentration of 82 mg/dl. Gram-negative diplococci were seen on smeai- and culture was positive for Neisseria meningitidis group D.. Blood cultures were negative, The patient was treated with intravenous ampieillin (400 mg/kg/day) and 24 hours later a repeat examination of cerebrospinal fluid revealed 1,700 WBC/ mm ~(60% PMNs): no organisms were seen: there was no growth in culture. The patient did well and was discharged two weeks later. The skin stroking test was performed several times and remained present until the eleventh hospital day. The linear erythema Was most evident on the initial evaluation and faded during the first Pew days after initiation of therapy. DISCUSSION T~tche ctrtbrale, first coined by the French physician Armand Trousseau in 1861, is a "sign elicited by stroking the skin with the
Fig. 1. Fifty seconds after stroking the skin in a tic-tac-toe design. The marks are bright red. fingernail and characterized by a red streak or spot flanked by thin, pal e areas. ''1 The finding has been noted in scarlet fever, ~ hydrocephalus, 1 febrile illnesses, 3 and meningitis. 4'5 The sign develops withifi 30 seconds after the skin is stroked and may be evident for several minutes. The finding differs from urticaria or dermatographia "in that, in the latter the central part of the local vasomotor reaction is white, and the margins are red as in a wheal. ''4 In tache ctrhbrale, the entire reaction is red. To determine the incidence of this reaction in normal infants,
TheJournalofPEDIATRICS Vol. 87, No. 2, pp. 321-334
321
322
Letters to the Editor
The Journal of Pediatrics August 1975
40 neonates betweeh 3 and 4 weeks o f age were examined as part of routine well-baby foilow-up. All patients were healthy and exhibited no signs of infection or hypersensitivity. The skin was stroked utilizing the same technique as was done with the patient presented. Seven of the infants developed a linear reaction but only the margins were red. The inner portion o f the streak was pale as compared to the margins. In tache crrrbrale, the entire streak remains red. The presence of tgtche c6rrbrale prompted the examination o f cerebrospinal fluid in this infant. Perhaps an early finding in neonatal meningitis includes a disturbance in vasomotor stability and hence, tgtche crrrbrale. It is a simple procedure to perform and can provide additional information leading to the early diagnosis of meningitis in the neonatal period.
Gilbert L Martin M.D. Department of Neonatology Magan Medical Clinic Covina, Calif. 91723 REFERENCES
1. Wain H: The story behind the word, Springfield, Ill., 1958, Charles C Thomas, Publisher, p 305. 2. Adams F: Physical diagnosis, ed 14, Baltimore, 1958, The Williams & Wilkins Company, p .45. 3. Douthwaite AH: French's index of differential diagnosis, ed 8, Baltimore, 1960, The Williams & Wilkins Company, p 954. 4. Ford FR: Diseases of the nervous system. Springfield, II1., 1952, Charles C Thomas, Publisher, pp 561-619. 5. Martin G, and DeGrinneY J: Intrafamilial infection with Neiserria meningitidis, group C, Clin Pediatr 11:538, 1972.
Hemophilus influenzae type b: The etiologic agent in epiglottitis To the Editor: Sinclair 1 was the first to demonstrate that epiglottitis is caused by Hemophilus influenzae type b. Since then others have suggested that epigiottitis may be caused by other infectious agents?, a The present study was undertaken to test previous reports 4 and our own clinical impression that H. influenzae type b is the cause o f childhood epiglottitis. METHODS From June, 1970, to December, 1974, cultures of the blood and/or epiglottis were obtained from all children admitted to the Yale-New Haven Hospital with epiglottitis. Epiglottitis was diagnosed if the epiglottis appeared bright red and edematous on direct laryngoscopy. Cultures of the epiglottis were obtained under direct vision after intubation in the operating room. Blood cultures were incubated in thioglycollate and trypticase soy broth; positive cultures and all swabs were incubated both aerobically and anaerobically. From June, 1970, to June, 1971, acute and convalescent sera were collected from all children with
Table I.
Cultures o f all p a t i e n t s w i t h e p i g l o t t i t i s - J u n e ,
1970, t h r o u g h D e c e m b e r , 1974
l only. ] ~
I and blood land blood I
postttve
postttve
posltwe
negatlve
Total
1
3
26
2*
32
No. of patients
*No organisms were grown from either the blood or epiglottis of Patient 9, while Klebsiella was grown only from the epiglottis of Patient 24.
epiglottitis for measurement of antibody titers against H. influenzae type b. Titers were measured either by dilution or in micrograms per milliliter. ~ Routine tracheotornies 6 were performed on all but the last three patients, who were given a nasotracheal airway until the inflammation subsided. RESULTS Epiglottitis was diagnosed in 32 patients, 18 male and 14 female. The mean age was 3 9/12 (range 1 to 8 11/12 years). Results of bacterial cultures are presented in Table I. Except for Patients 9 and 24, all had a positive blood or epiglottis culture for H. influenzae type b. In addition, except for Patient 9, all 12 patients in whom acute and convalescent antibody titers were measured had at least a four-fold increase between acute and convalescent titers. DISCUSSION In 1941, Sinclair I reported that antemortem or postmortem blood cultures were positive for H. influenzae type b in all of ten children with epiglottitis. However, Streptococcus, Staphlococcus, and Pneumococcus were grown in subsequent series from the cultures of children With epiglottitis, 7 and in adults with epiglottitis, H. influenzae type b has rarely been isolated. Careful review, however, of all studies we could find o f patients with epiglottitis since 1950 shows that in none of these were blood or other cultures routinely obtained, despite the fact that in children with epiglottitis a positive blood culture may be the only evidence of H. influenzae type b infection.' In the present study, H. influenzae type b was cultured from the epiglottis or the blood in 30 of 32 patients with epiglottitis, whereas either the diagnosis or the cultures were in doubt in the other two cases. Our results are consistent with Sinclair's initial observation that 11. influenzae type b is the cause of epiglottitis. Our data also demonstrate that patients with epiglottitis have not been exposed previously to 1t, influenzae, type b. Tile relationship between an etiologic agent and its site o f infection may be viewed as falling on a spectrum. At one end o f the spectrum are agents, such as rabies virus, that strongly prefer specific sites, or sites, such as the dorsal root ganglion, that are invaded by a specific agent. At the other end of the spectrum are agents, such as Streptococcus, that invade many sites, or sites, such as the gut, that are invaded by many agents. Since the epiglottis is invaded by a specific organism, it is at one extreme of this spectrum. One might, therefore, hypothesize that either the epiglottis or its
"Clinical notes" represent clinical and/or laboratory experiences which can be presented in 200 to 400 words, 3 Or 4 references, and, if contributoryl one illustration or short table. "Clinical notes" are subject to the same critical peer review and editing as papers published in other sections of THE JOURNAL.
The significance of thche cbrbbrale in neonatal meningitis To the Editor: ;Fhe diagnosis of meningitis during the neonatal period can be difficult when the symptoms and physical findings Of irritability, vomiting, fever, and a tense fontanel are minimal. The following patient presented with vague symptoms and manifested the physical sign of t~che c4rtbrale. CASE REPORT Patient B. L., a 4-week-old male infant, was brought to the emergency room "because of fever." There was no history of itritability, vomiting, or seizures. Gestation and delivery had been uneventful and birth weight was 4 kg. Examination revealed an infant with a temperature of 100.4 ~ in no apparent distress. He was alert; with a good sucking response and Moro reflex. The remainder of the examin~,tion was normal except for the presence of tgtche ctr6brale, After the infant was placed in a secure position, a tongue blade was used to stroke the skin in a tic-tactoe design. Exactly 20 seconds after stroking the skin, a light linear'pattern resulted; 50 seconds later the marks were bright red (Fig 1). The pattern seemed most intense, at 60 seconds and completely disappeared at 2 minutes. Laboratory data. The hematocrit was 34%, the white blood count (WBC), 23,00 (55 lJ01ymorphpnuclear cells [PMN], 1 band, 44 lymphocytes). Cerebrospinal fltiid was grossly purulent with 6,000 WBC/mm 3 (100% PMNs), concenmitions of protein, 240 mg/dl, glucose, 12 mg/dl, with a corresponding serum glucose "concentration of 82 mg/dl. Gram-negative diplococci were seen on smeai- and culture was positive for Neisseria meningitidis group D.. Blood cultures were negative, The patient was treated with intravenous ampieillin (400 mg/kg/day) and 24 hours later a repeat examination of cerebrospinal fluid revealed 1,700 WBC/ mm ~(60% PMNs): no organisms were seen: there was no growth in culture. The patient did well and was discharged two weeks later. The skin stroking test was performed several times and remained present until the eleventh hospital day. The linear erythema Was most evident on the initial evaluation and faded during the first Pew days after initiation of therapy. DISCUSSION T~tche ctrtbrale, first coined by the French physician Armand Trousseau in 1861, is a "sign elicited by stroking the skin with the
Fig. 1. Fifty seconds after stroking the skin in a tic-tac-toe design. The marks are bright red. fingernail and characterized by a red streak or spot flanked by thin, pal e areas. ''1 The finding has been noted in scarlet fever, ~ hydrocephalus, 1 febrile illnesses, 3 and meningitis. 4'5 The sign develops withifi 30 seconds after the skin is stroked and may be evident for several minutes. The finding differs from urticaria or dermatographia "in that, in the latter the central part of the local vasomotor reaction is white, and the margins are red as in a wheal. ''4 In tache ctrhbrale, the entire reaction is red. To determine the incidence of this reaction in normal infants,
TheJournalofPEDIATRICS Vol. 87, No. 2, pp. 321-334
321
322
Letters to the Editor
The Journal of Pediatrics August 1975
40 neonates betweeh 3 and 4 weeks o f age were examined as part of routine well-baby foilow-up. All patients were healthy and exhibited no signs of infection or hypersensitivity. The skin was stroked utilizing the same technique as was done with the patient presented. Seven of the infants developed a linear reaction but only the margins were red. The inner portion o f the streak was pale as compared to the margins. In tache crrrbrale, the entire streak remains red. The presence of tgtche c6rrbrale prompted the examination o f cerebrospinal fluid in this infant. Perhaps an early finding in neonatal meningitis includes a disturbance in vasomotor stability and hence, tgtche crrrbrale. It is a simple procedure to perform and can provide additional information leading to the early diagnosis of meningitis in the neonatal period.
Gilbert L Martin M.D. Department of Neonatology Magan Medical Clinic Covina, Calif. 91723 REFERENCES
1. Wain H: The story behind the word, Springfield, Ill., 1958, Charles C Thomas, Publisher, p 305. 2. Adams F: Physical diagnosis, ed 14, Baltimore, 1958, The Williams & Wilkins Company, p .45. 3. Douthwaite AH: French's index of differential diagnosis, ed 8, Baltimore, 1960, The Williams & Wilkins Company, p 954. 4. Ford FR: Diseases of the nervous system. Springfield, II1., 1952, Charles C Thomas, Publisher, pp 561-619. 5. Martin G, and DeGrinneY J: Intrafamilial infection with Neiserria meningitidis, group C, Clin Pediatr 11:538, 1972.
Hemophilus influenzae type b: The etiologic agent in epiglottitis To the Editor: Sinclair 1 was the first to demonstrate that epiglottitis is caused by Hemophilus influenzae type b. Since then others have suggested that epigiottitis may be caused by other infectious agents?, a The present study was undertaken to test previous reports 4 and our own clinical impression that H. influenzae type b is the cause o f childhood epiglottitis. METHODS From June, 1970, to December, 1974, cultures of the blood and/or epiglottis were obtained from all children admitted to the Yale-New Haven Hospital with epiglottitis. Epiglottitis was diagnosed if the epiglottis appeared bright red and edematous on direct laryngoscopy. Cultures of the epiglottis were obtained under direct vision after intubation in the operating room. Blood cultures were incubated in thioglycollate and trypticase soy broth; positive cultures and all swabs were incubated both aerobically and anaerobically. From June, 1970, to June, 1971, acute and convalescent sera were collected from all children with
Table I.
Cultures o f all p a t i e n t s w i t h e p i g l o t t i t i s - J u n e ,
1970, t h r o u g h D e c e m b e r , 1974
l only. ] ~
I and blood land blood I
postttve
postttve
posltwe
negatlve
Total
1
3
26
2*
32
No. of patients
*No organisms were grown from either the blood or epiglottis of Patient 9, while Klebsiella was grown only from the epiglottis of Patient 24.
epiglottitis for measurement of antibody titers against H. influenzae type b. Titers were measured either by dilution or in micrograms per milliliter. ~ Routine tracheotornies 6 were performed on all but the last three patients, who were given a nasotracheal airway until the inflammation subsided. RESULTS Epiglottitis was diagnosed in 32 patients, 18 male and 14 female. The mean age was 3 9/12 (range 1 to 8 11/12 years). Results of bacterial cultures are presented in Table I. Except for Patients 9 and 24, all had a positive blood or epiglottis culture for H. influenzae type b. In addition, except for Patient 9, all 12 patients in whom acute and convalescent antibody titers were measured had at least a four-fold increase between acute and convalescent titers. DISCUSSION In 1941, Sinclair I reported that antemortem or postmortem blood cultures were positive for H. influenzae type b in all of ten children with epiglottitis. However, Streptococcus, Staphlococcus, and Pneumococcus were grown in subsequent series from the cultures of children With epiglottitis, 7 and in adults with epiglottitis, H. influenzae type b has rarely been isolated. Careful review, however, of all studies we could find o f patients with epiglottitis since 1950 shows that in none of these were blood or other cultures routinely obtained, despite the fact that in children with epiglottitis a positive blood culture may be the only evidence of H. influenzae type b infection.' In the present study, H. influenzae type b was cultured from the epiglottis or the blood in 30 of 32 patients with epiglottitis, whereas either the diagnosis or the cultures were in doubt in the other two cases. Our results are consistent with Sinclair's initial observation that 11. influenzae type b is the cause of epiglottitis. Our data also demonstrate that patients with epiglottitis have not been exposed previously to 1t, influenzae, type b. Tile relationship between an etiologic agent and its site o f infection may be viewed as falling on a spectrum. At one end o f the spectrum are agents, such as rabies virus, that strongly prefer specific sites, or sites, such as the dorsal root ganglion, that are invaded by a specific agent. At the other end of the spectrum are agents, such as Streptococcus, that invade many sites, or sites, such as the gut, that are invaded by many agents. Since the epiglottis is invaded by a specific organism, it is at one extreme of this spectrum. One might, therefore, hypothesize that either the epiglottis or its
