Volume 121 Number 5, Part 1
pharynx do not differ substantially in terms of clinical presentation, as confirmed by our findings. A scarlatiniform rash was present in 7 of the 12 children with Ah infection, involving mainly the trunk and less often the extremities. This incidence is high, but it may be spurious because about half of all patients studied had a scarlatiniform rash; probably the presence of a rash in both streptococcus- and Ahinfected children caused parents to take the children to the hospital. The rash is reported as a frequent manifestation of Ah throat infection in the United Kingdom and the United States but is rare in tropical countries.l 1, 12 Frequency of the rash is higher in the second decade of life. We conclude that in children with pharyngotonsillitis or a scarlatiniform rash whose throat culture is negative for G A B H S , Ah infection should be sought. Erythromycin may be administered if the organism is resistant to penicillin, but for most patients penicillin is the drug of choice.
REFERENCES 1. MacLean PD, Liebow AA, Rosenberg AA. A herr ~lytic eorynebacterium resembling Corynebaeterium ovis and Corynebacterium pyogenes in man. J Infect Dis 1946;79:6990. 2. Collins MD, Jones D, Schofield GM. Reclassification of Corynebacterium haemolyticum (MacLean, Liebow & Rosenberg) in the genus Areanobacterium gen.nov, as Areanobacterium haemolytieum nom.rev., comb.nov. J Gen Microbiol 1982;128:1279-81. 3. Goudswaard J, van de Merwe DW, van der Sluys P, Doorn H.
Clinical and laboratory observations
737
Corynebacterium haemolyticum septicemia in a girl with mononucleosis infectiosa. Seand J Infect Dis 1988;20:339-40. 4. Jobanputra RS, Swain CP. Septicemia due to Corynebaeterium haemolytieum. J Clin Pathol 1975;28:798-800. 5. Ceilley RI. Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolytieum. Arch Dermatol 1977; l 13:646-7. 6. Worthington MC, Daly BDT, Smith FE. Corynebacterium haemolytieum endocarditis on a native valve. South Med J 1988;78:1261-2. 7. Cowan ST, Steel KJ. Manual for identification of medical bacteria, 2rid ed. Cambridge: Cambridge University Press, 1974. 8. Coyle M, Hollis D, Groman N. Corynebacterium spp and other coryneform organisms. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy H J, eds. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985:193. 9. Banek G, Nyman M. Tonsillitis and rash associated with Corynebaeterium haemolyticum. J Infect Dis 1986; 154:103740. 10. Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985. 11. Fell HWK, Nagington J, Naylor GRE. Corynebaeterium haemolyticum infections in Cambridgeshire. J Hyg (Cambridge) 1977;79:269-74. 12. Miller RA, Brancato F, Holmes KK. Corynebaeterium haemolyticum as a cause of pharyngitis and scarlatiniform rash. Ann Intern Med 1986;105:867-72. 13. Wickremesinghe RSB. Corynebaeterium haemolytieum infections in Sri Lanka. J Hyg (Cambridge) 1981;87:271-7.
Soft tissue swelling and acute skull fractures Paul K. Kleinman, MD, a n d Melissa R. S p e v a k , MD From the Department of Radiology, Universityof Massachusetts Medical Center, Worcester
To determine whether soft tissue swelling, as identified by computed tomography, invariably accompanies acute calvarial fracture, the computed tomography scans of 35 children a g e d 3 months to 8 years with acute skull fractures were evaluated. Bone window settings revealed at least 4 mm of soft tissue swelling in all instances. We conclude that a skull fracture without overlying soft tissue swelling demonstrable by computed tomography is probably inconsistent with an acute injury. (J PEDIATR4992;424:737-9) Although reasonable criteria exist for assessing the age of fractures involving the long bone shafts and the rib arcs, other bony injuries pose problems in accurate dating. 1 The Submitted for publication Feb 26, 1992; accepted June 16, 1992. Reprint requests: Paul K. Kleinman, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Ave., North, Worcester, MA 01655. 9/22/40276
skull is one important region for which reliable criteria for dating injuries are not available. Infants may undergo substantial blunt injury to the head, have no clinically evident soft tissue swelling, and yet have scalp and subgaleal hemorrhage at autopsy. 2 Thus the absence of clinically detectable soft tissue swelling overlying a skull fracture does not necessarily indicate that the fracture is old. Computed tomography provides a more sensitive assessment of the scalp and the subgaleal space, and this technique might therefore
738
Clinical and laboratory observations
The Journal of Pediatrics November 1992
Figure. Four-month-old infant with history of lethargy lasting several hours and high-pitched cry. A, CT scan showing acute hemisphericsubdural hematoma (large arrow) and subtle edema in the right posterior parietal region (small arrows). B, Image with bone windowand level settings demonstrates left parietal skull fracture (arrow). Because no significantsoft tissue swellingis evident, the fracture is presumably old. The mother subsequentlyadmitted to several episodes of inflicting blunt injury to the child's head.
J
CT
Computedtomography
J
be of value in assessing the age of calvarial injury. This study was performed to determine whether acute skull fractures demonstrated by CT are invariably accompanied by overlying soft tissue swelling. METHODS A retrospective examination of the CT scans of 35 consecutive acute accidental skull fractures was performed. The CT scans were obtained within 24 hours of head injury. All injuries were deemed by the examining physician to be accidental. Cases of suspected abuse were excluded. Patient ages ranged from 3 months to 8 years, with a mean of 35 months and a median of 36 months. Fractures involved all regions of the skull, but as expected the majority occurred in the parietal bones. Depressed and compound fractures were excluded. Skull radiographs-were generally not obtained. The CT scans were obtained with a General Electric model 9800 scanner, usually with 5 mm thick contiguous slices in infants and 10 mm thick contiguous slices in older children. The maximal soft tissue swelling overlying the re-
gion of fracture was measured with calipers and compared with the soft tissues overlying the contralateral normal region. Soft tissues were measured from the outer table of the skull to the surface of the scalp on images filmed with bone window settings. Soft tissue swelling was defined as the difference between the thickness of the normal side and that of the affected side. RESULTS ~ Soft tissue swelling overlay all fractures. For all patients, the thickness of soft tissue swelling ranged from 4 to 15 mm (mean, 7.9 mm). The patients were divided into two groups: patients 24 months of age or younger and patients older than 24 months of age. In the younger group (14 patients), the mean thickness (_+ SD) of soft tissue swelling was 8 _+ 2.9 mrri. In the older patients (21 patients), the mean thickness Was 7.9 _+ 3.4 ram. The thickness of the soft tissue swelling in these two groups was not significantly different (t test, p = 0.896). DISCUSSION The results of this study could be anticipated, and one might argue that the conclusions are so obvious as to pre-
Volume 121 Number 5, Part 1
clude the need for analysis. However, workers in the field of child abuse recognize that some of the most accepted and self-evident concepts in assessing the nature and age of inflicted physical injuries have come under increased scrutiny by a sophisticated legal community. What may constitute a clear medical diagnosis of abuse may fall short of the medicolegal requirements. Furthermore, substantiation of abuse rests not only on the medical data but also on the credibility of witness testimony. Determining the age of a skull fracture may be critical in assessing the chronology of injury provided by caretakers. Establishing prior injury in the form of an old skull fracture may be crucial in documenting a pattern of physical assault (Figure).
Clinical and laboratory observations
739
This study supports the view that soft tissue swelling of 4 mm or more is a usual concomitant of an acute skull fracture. A skull fracture showing no significant overlying soft tissue swelling on CT scan probably is not an acute injury.
REFERENCES
1. O'Connor JF, Cohen J. Dating fractures. In: Kleinman PK. Diagnostic imaging of child abuse. Baltimore: Williams & Wilkins, 1987:103-13. 2. Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome: a clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409-15.
Recurrent juvenile dermatomyositis and cutaneous necrotizing arteritis with molecular mimicry between streptococcal type 5 M protein and human skeletal myosin A l b e r t o M a r t i n i , MD, A n g e l o Ravelli, MD, S a l v a t o r e A l b a n i , MD, S t e f a n i a V i o l a , MD, M. S e r e n e l l a S c o t t a , MD, U m b e r t o M a g r i n i , MD, a n d G. R o b e r t o Burgio, MD From the Clinica Pediatrica and Dipartimento di Patologia Umana ed Ereditaria, UniversitO di Pavia, Istituto di Ricovero e Cura a Carattere Scientifico S. Matteo, Pavia, Italy, and the Department of Medicine, University of California, San Diego, La Jolla, California
An adult patient had a syndrome associating the features of juvenile dermatomyositis and cutaneous polyarteritis nodosa that followed a cyclic course from childhood; recurrences were always associated with a rise of serum antistreptococcal antibodies. Regions of homology between streptococcal type 5 M protein and skeletal myosin were found. These findings suggest that streptoc o c c a l infection, possibly through a molecular mimicry mechanism, p l a y e d a role in the pathogenesis of the disease in our patient. (J PEDIATR1992;121:73942) Juvenile dermatomyositis is a chronic multisystem inflammatory disease that involves primarily skin and muscles.l, 2 Although the cause is unknown, occasional reports have suggested a relationship of juvenile dermatomyositis with various infections, including coxsackievirus group B and Supported in part by IRCCS S. Matteo, Pavia, Italy. Submitted for publication Aug. 9, 1991; accepted May 27, 1992. Reprint requests: Alberto Martini, MD, Clinica Pediatrica dell'Universifft di Pavia, Istituto di Ricovero e Cura a Carattere Scientifico S. Matteo, P. le Golgi 2, 27100 Pavia, Italy. 9/22/39712
Toxoplasma gondii. 1,2 Cutaneous polyarteritis nodosa is an inflammatory disease in which vascular involvement is seen most prominently in the skin) It has been suggested recently that cutaneous PAN may be related to a previous streptococcal infection.3, 4 We describe a patient who had a syndrome associating the features of juvenile dermatomyositis and cutaneous PAN. The disease followed a cyclic course, and recurrences were invariably associated with serologic evidence suggesting recent streptococcal infection. By computer search, we found the presence of regions of homology between streptococcal type 5 M protein and skeletal myosin.
pharynx do not differ substantially in terms of clinical presentation, as confirmed by our findings. A scarlatiniform rash was present in 7 of the 12 children with Ah infection, involving mainly the trunk and less often the extremities. This incidence is high, but it may be spurious because about half of all patients studied had a scarlatiniform rash; probably the presence of a rash in both streptococcus- and Ahinfected children caused parents to take the children to the hospital. The rash is reported as a frequent manifestation of Ah throat infection in the United Kingdom and the United States but is rare in tropical countries.l 1, 12 Frequency of the rash is higher in the second decade of life. We conclude that in children with pharyngotonsillitis or a scarlatiniform rash whose throat culture is negative for G A B H S , Ah infection should be sought. Erythromycin may be administered if the organism is resistant to penicillin, but for most patients penicillin is the drug of choice.
REFERENCES 1. MacLean PD, Liebow AA, Rosenberg AA. A herr ~lytic eorynebacterium resembling Corynebaeterium ovis and Corynebacterium pyogenes in man. J Infect Dis 1946;79:6990. 2. Collins MD, Jones D, Schofield GM. Reclassification of Corynebacterium haemolyticum (MacLean, Liebow & Rosenberg) in the genus Areanobacterium gen.nov, as Areanobacterium haemolytieum nom.rev., comb.nov. J Gen Microbiol 1982;128:1279-81. 3. Goudswaard J, van de Merwe DW, van der Sluys P, Doorn H.
Clinical and laboratory observations
737
Corynebacterium haemolyticum septicemia in a girl with mononucleosis infectiosa. Seand J Infect Dis 1988;20:339-40. 4. Jobanputra RS, Swain CP. Septicemia due to Corynebaeterium haemolytieum. J Clin Pathol 1975;28:798-800. 5. Ceilley RI. Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolytieum. Arch Dermatol 1977; l 13:646-7. 6. Worthington MC, Daly BDT, Smith FE. Corynebacterium haemolytieum endocarditis on a native valve. South Med J 1988;78:1261-2. 7. Cowan ST, Steel KJ. Manual for identification of medical bacteria, 2rid ed. Cambridge: Cambridge University Press, 1974. 8. Coyle M, Hollis D, Groman N. Corynebacterium spp and other coryneform organisms. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy H J, eds. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985:193. 9. Banek G, Nyman M. Tonsillitis and rash associated with Corynebaeterium haemolyticum. J Infect Dis 1986; 154:103740. 10. Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985. 11. Fell HWK, Nagington J, Naylor GRE. Corynebaeterium haemolyticum infections in Cambridgeshire. J Hyg (Cambridge) 1977;79:269-74. 12. Miller RA, Brancato F, Holmes KK. Corynebaeterium haemolyticum as a cause of pharyngitis and scarlatiniform rash. Ann Intern Med 1986;105:867-72. 13. Wickremesinghe RSB. Corynebaeterium haemolytieum infections in Sri Lanka. J Hyg (Cambridge) 1981;87:271-7.
Soft tissue swelling and acute skull fractures Paul K. Kleinman, MD, a n d Melissa R. S p e v a k , MD From the Department of Radiology, Universityof Massachusetts Medical Center, Worcester
To determine whether soft tissue swelling, as identified by computed tomography, invariably accompanies acute calvarial fracture, the computed tomography scans of 35 children a g e d 3 months to 8 years with acute skull fractures were evaluated. Bone window settings revealed at least 4 mm of soft tissue swelling in all instances. We conclude that a skull fracture without overlying soft tissue swelling demonstrable by computed tomography is probably inconsistent with an acute injury. (J PEDIATR4992;424:737-9) Although reasonable criteria exist for assessing the age of fractures involving the long bone shafts and the rib arcs, other bony injuries pose problems in accurate dating. 1 The Submitted for publication Feb 26, 1992; accepted June 16, 1992. Reprint requests: Paul K. Kleinman, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Ave., North, Worcester, MA 01655. 9/22/40276
skull is one important region for which reliable criteria for dating injuries are not available. Infants may undergo substantial blunt injury to the head, have no clinically evident soft tissue swelling, and yet have scalp and subgaleal hemorrhage at autopsy. 2 Thus the absence of clinically detectable soft tissue swelling overlying a skull fracture does not necessarily indicate that the fracture is old. Computed tomography provides a more sensitive assessment of the scalp and the subgaleal space, and this technique might therefore
738
Clinical and laboratory observations
The Journal of Pediatrics November 1992
Figure. Four-month-old infant with history of lethargy lasting several hours and high-pitched cry. A, CT scan showing acute hemisphericsubdural hematoma (large arrow) and subtle edema in the right posterior parietal region (small arrows). B, Image with bone windowand level settings demonstrates left parietal skull fracture (arrow). Because no significantsoft tissue swellingis evident, the fracture is presumably old. The mother subsequentlyadmitted to several episodes of inflicting blunt injury to the child's head.
J
CT
Computedtomography
J
be of value in assessing the age of calvarial injury. This study was performed to determine whether acute skull fractures demonstrated by CT are invariably accompanied by overlying soft tissue swelling. METHODS A retrospective examination of the CT scans of 35 consecutive acute accidental skull fractures was performed. The CT scans were obtained within 24 hours of head injury. All injuries were deemed by the examining physician to be accidental. Cases of suspected abuse were excluded. Patient ages ranged from 3 months to 8 years, with a mean of 35 months and a median of 36 months. Fractures involved all regions of the skull, but as expected the majority occurred in the parietal bones. Depressed and compound fractures were excluded. Skull radiographs-were generally not obtained. The CT scans were obtained with a General Electric model 9800 scanner, usually with 5 mm thick contiguous slices in infants and 10 mm thick contiguous slices in older children. The maximal soft tissue swelling overlying the re-
gion of fracture was measured with calipers and compared with the soft tissues overlying the contralateral normal region. Soft tissues were measured from the outer table of the skull to the surface of the scalp on images filmed with bone window settings. Soft tissue swelling was defined as the difference between the thickness of the normal side and that of the affected side. RESULTS ~ Soft tissue swelling overlay all fractures. For all patients, the thickness of soft tissue swelling ranged from 4 to 15 mm (mean, 7.9 mm). The patients were divided into two groups: patients 24 months of age or younger and patients older than 24 months of age. In the younger group (14 patients), the mean thickness (_+ SD) of soft tissue swelling was 8 _+ 2.9 mrri. In the older patients (21 patients), the mean thickness Was 7.9 _+ 3.4 ram. The thickness of the soft tissue swelling in these two groups was not significantly different (t test, p = 0.896). DISCUSSION The results of this study could be anticipated, and one might argue that the conclusions are so obvious as to pre-
Volume 121 Number 5, Part 1
clude the need for analysis. However, workers in the field of child abuse recognize that some of the most accepted and self-evident concepts in assessing the nature and age of inflicted physical injuries have come under increased scrutiny by a sophisticated legal community. What may constitute a clear medical diagnosis of abuse may fall short of the medicolegal requirements. Furthermore, substantiation of abuse rests not only on the medical data but also on the credibility of witness testimony. Determining the age of a skull fracture may be critical in assessing the chronology of injury provided by caretakers. Establishing prior injury in the form of an old skull fracture may be crucial in documenting a pattern of physical assault (Figure).
Clinical and laboratory observations
739
This study supports the view that soft tissue swelling of 4 mm or more is a usual concomitant of an acute skull fracture. A skull fracture showing no significant overlying soft tissue swelling on CT scan probably is not an acute injury.
REFERENCES
1. O'Connor JF, Cohen J. Dating fractures. In: Kleinman PK. Diagnostic imaging of child abuse. Baltimore: Williams & Wilkins, 1987:103-13. 2. Duhaime AC, Gennarelli TA, Thibault LE, Bruce DA, Margulies SS, Wiser R. The shaken baby syndrome: a clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409-15.
Recurrent juvenile dermatomyositis and cutaneous necrotizing arteritis with molecular mimicry between streptococcal type 5 M protein and human skeletal myosin A l b e r t o M a r t i n i , MD, A n g e l o Ravelli, MD, S a l v a t o r e A l b a n i , MD, S t e f a n i a V i o l a , MD, M. S e r e n e l l a S c o t t a , MD, U m b e r t o M a g r i n i , MD, a n d G. R o b e r t o Burgio, MD From the Clinica Pediatrica and Dipartimento di Patologia Umana ed Ereditaria, UniversitO di Pavia, Istituto di Ricovero e Cura a Carattere Scientifico S. Matteo, Pavia, Italy, and the Department of Medicine, University of California, San Diego, La Jolla, California
An adult patient had a syndrome associating the features of juvenile dermatomyositis and cutaneous polyarteritis nodosa that followed a cyclic course from childhood; recurrences were always associated with a rise of serum antistreptococcal antibodies. Regions of homology between streptococcal type 5 M protein and skeletal myosin were found. These findings suggest that streptoc o c c a l infection, possibly through a molecular mimicry mechanism, p l a y e d a role in the pathogenesis of the disease in our patient. (J PEDIATR1992;121:73942) Juvenile dermatomyositis is a chronic multisystem inflammatory disease that involves primarily skin and muscles.l, 2 Although the cause is unknown, occasional reports have suggested a relationship of juvenile dermatomyositis with various infections, including coxsackievirus group B and Supported in part by IRCCS S. Matteo, Pavia, Italy. Submitted for publication Aug. 9, 1991; accepted May 27, 1992. Reprint requests: Alberto Martini, MD, Clinica Pediatrica dell'Universifft di Pavia, Istituto di Ricovero e Cura a Carattere Scientifico S. Matteo, P. le Golgi 2, 27100 Pavia, Italy. 9/22/39712
Toxoplasma gondii. 1,2 Cutaneous polyarteritis nodosa is an inflammatory disease in which vascular involvement is seen most prominently in the skin) It has been suggested recently that cutaneous PAN may be related to a previous streptococcal infection.3, 4 We describe a patient who had a syndrome associating the features of juvenile dermatomyositis and cutaneous PAN. The disease followed a cyclic course, and recurrences were invariably associated with serologic evidence suggesting recent streptococcal infection. By computer search, we found the presence of regions of homology between streptococcal type 5 M protein and skeletal myosin.
