Letters to the Editor
strafed that among children of diverse ethnic and socioeconomic groups in New York City there is a rather high prevalence of these markers. The three factors which influenced the prevalence of anti-HBs-age, ethnic group and locale-are those previously demonstrated to be important in the two prior population studies in this area. t, ~ The latter factors, ethnic group and locale, are probably equatable with socioeconomic status or living conditions. CONCLUSION The prevalence of HBsAg and anti-HBs in children below 10 years of age from two different hospital centers was 5.2% for whites, 16.4% for Hispanics, and 21.7% for blacks. Three factors had an independent influence on the prevalence rate of serologic markers of HBV infection: age, ethnic group, and locale. We conclude that hepatitis B virus infections does occur frequently in children in New York City. We wish to thank Drs. Biongasso, Forte, Regala, and Magazine for their assistance with this study~ Tests for HBsAg and anti-HBs were done by the Virus Laboratory of the Lindsley F. Kimball Research Institute; we thank Alfred M. Prince, M.D., for his assistance. Charles' E. Cherubin, M.D. Microbiology Laboratory The Jewish Hosp#al & Medical Center of Brooklyn 555 Prospect Place Brooklyn, N.Y. 11238 Wolf Szmuness, M.D. Edward J. Harley hi. Isaac Much Emelda Roldman, M.D.
1. Cherubin CE, Purcell RH, Lander JJ et al: Acquisition of antibody to the hepatitis B antigen in three socio-economically different medical populations, Lancet 2:149, 1972. 2. Szmuness W, Prince AM, Brotman B, et al: Hepatitis B antigen and antibody in blood donors: An epidemiological study, J Infect Dis 127:17, 1973. 3. Szmuness W, Hirsch RL, Prince AM, et al: Familial clustering of Hepatitis B infection, N Engl J Med 289:1162, 1973. 4. Szmuness W, Prince AM, Efling GF, et al: Development and distribution of hemogglutinating antibody against Hepatitis B antigen in institutionalized populations, J Infect Dis 126:498, 1972.
Pleural effusion in histoplasmosis To the Editor: Histoplasmosis is the most common systemic fungus infection in the United States. Acute pulmonary histoplasmosis is usually
The Journal of Pediatrics May 1976
manifested by symptoms of chest pains, cough, fever, weight loss, and malaise. Pulmonary infiltrates and noncalcified pulmonary masses are usual radiographic findings?, The following is a report of pleural effusion associated with histoplasmosis. CASE REPORT A 9-year-old male was admitted to the Louise Burg Hospital on 2/8/75 because of left flank pain, sore throat, fever, and cough of a few days duration. A few months earlier he had traveled to Alabama where he had played with chickens and turkeys. On admission, the pulse rate was 130; respiratory rate, 20; temperature, 100~ The physical examination was unremarkable. A pleural effusion was noted roentgenographically in the !eft base of the chest. On 2/10/75 the patient complained of left pleuritic chest pain, and two days later there were diminished breath sounds in the left base associated with temperature elevation to 104~ Antipyretics were the only medications given, and the patient gradually defervesced over the next few days. He remained afebrile for the remainder of his hospitalization. Throughout his hospitalization he was ambulatory and in no respiratory distress. Results from throat cultures for viruses and bacteria were negative; urine, stool, and blood cultures were negative for bacteria. An intermediate strength PPD was negative. His gamma G immunoglobulin was 2,300 mg/dl; his gamma M immunoglobulin, 240 mg/dl. The pleural effusion persisted and the patient developed right hilar adenopathy; a tlioracentesis was performed on 2/18/75. About 40 ml of clear straw-colored fluid was obtained. Results of smears and cultures were negative for mycobacteria, bacteria, and fungi. On 2/13/75 the State of Illinois Public Health Laboratory reported a histoplasmosis yeast-phase, complement fixation titer of 1:256. This was the highest dilution evaluated by that laboratory; the elevated titer persisted for the next three months. Upon discharge on 2/24/75 he was asymptomatic, and remained so during the next three months without medication. He regained the three pounds lost during his hospitalization. The pleural effusion and hilar adenopathy persisted. On 5/17/75 the Center for Disease Control in Atlanta reported an Histoplasma capsulation complement fixation titer of 1:1024. DISCUSSION Although histoplasmosis has been well documented in southern Illinois,3 the only endemic area which the patient visited was Alabama where he played with chickens. In a recent review of histoplasmosis in symptomatic children, none of the t~atients had pleural effusion. ~ In another study of asymptomatic histoplasmin-positive schoolchildrenr 186 abnormal chest films were reyiewed out of an original Sample of 9,073 children. No pleural effusion was observed in this study. In a review of hospitalized children who had pleural effusion, none of the children had liistoplasmosis. 5 Marc Weissbluth, M.D. Department of Pediatrics Louise Burg Hospital 255 West Cermak Rd. Chicago, Ill. 60616
Volume 88 Number 5
L e t t e r s to the E d i t o r
1. Riley DH: Systemic mycoses in children, Curr Probl Pediatr 12:7, 1972. 2. Kakos GS, and Kilman JW: Symptomatic histoplasmosis in children, Ann Thorac Surg 15:622, 1973. 3. Buell WF, Tosh FE, Russell JM, et al: Studies of histoplasmosis in two Illinois communities, Ill Med J 144:30, 1973. 4. Whitehouse WM, Davey WN, Engelke OK, et al: Roentgen findings in histoplasmin-positive school children, Mich Med 58:1266, 1959. 5. Wolfe WG, Spock A, and Bradford WD: Pleural fluid in infants and children, Am Rev Respir Dis 98:1027, 1968.
Septic thrombosis following subclavian vein catheterization To the Editor:
In pediatric therapy, subclavian vein catheterization has been used principally for parenteral alimentation. Although there have been numerous reports of complications secondary to subclavian vein catheterization, few of them concern children. Reported complications include hemorrhage, pneumo- and hydro-thorax, brachial plexus injury, air embolism, thrombosis, and infection) We report here a septic thrombus following subclavian vein catheterization in a child. CASE REPORT
Patient C. S., a 14-month-old female, was admitted to the University of Utah Medical Center on August 20, 1975, with Staphylococcus aureus bacteremia and exfoliative dermatitis.
Three weeks prior to admission, prophylactic trisulfapyrimidine therapy had been started for recurrent otitis media. Five days before admission she developed a generalized erythematous eruption with bullae on the soles of both feet, conjunctivitis, stomatitis, and fever to 103.7~ She was admitted to a local hospital and treated with prednisone and a topical corticosteriod cream for presumed Stevens-Johnson syndrome. The following day a subclavian vein catheter was inserted on the right side, but it was removed 24 hours later when it became occluded. Over the next two days she remained febrile and the subclavian site drained pus. Cultures of blood and the purulent drainage yielded S. aureus. She was transferred to the University of Utah Medical Center with the tentative diagnosis of staphylococcal- "scaldedskin" syndrome. Nafcillin, 50 mg/kg/day intramuscularly, was started. Cultnres of the blood, subclavian site, and bullae obtained on the day of admission and four days later yielded S. aureus. Each of the isolates had similar antibiotic sensitivity patterns. Minimal inhibitory and bactericidal concentrations of the blood isolate against nafcillin were 0.19 /~g/ml and 0.39 /~g/ml, respectively. The nafcillin dosage was increased to 170 mg/kg/day intravenously. Two days later, superficial veins over the right pectoral region became distended. A venogram of the fight upper extremity demonstrated occlusion of the subclavian vein with increased collateral circulation (Fig. 1). Heparin therapy was begun to prevent extension of the thrombus and continued for ten days. She did not develop evidence of embolization. Subsequent blood cultures were negative and she was discharged after two weeks of intravenous nafcillin therapy. Follow-up examination, three months later, demonstrated persistent collateral circulation. DISCUSSION Subclavian vein thrombosis may occur either spontaneously or result secondarily to an irritative agent such as a catheter: Clues to the diagnosis include swelling of the extremity and the appearance of collateral circulation. In our patient the ap-
Fig. 1. Venogram demonstrating subclavian vein occlusion.