Volume 90 Number 2
Letters to the Editor
32 !
obvious and again raises the question: "Should ampicillin be abandoned for treatment of Haemophilus influenzae disease? .... W. L. Albritton, M.D., Ph.D. G. Hammond, M.D. S. Hoban, A.R.T. A. R. Ronald, M.D, Departments of Pediatrics and Medical Microbiology 700 William Ave. Winnipeg, Manitoba, Canada R3E OZ3 REFERENCES 1. American Academy of Pediatrics, Committee on Infectious Disease: Ampicillin-resistant strains of Hemophilus influenzae type B. Pediatrics 55:145, 1975. 2. Thornsberry C, and Kirven LA: Antimicrobial susceptibility of Haemophilus influenzae, Antimicrob Agents Chemother 6:620, 1974. 3. Thornsberry C, and Kirven LA: Ampicillin resistance in Haemophilus influenzae as determined by a rapid test for/~lactamase production, Antimicrob Agents Chemother 6:653, 1974. 4. Echeverria P, et al: Apparent emergence of aminoglycosideresistant Escherichia coli during neonatal meningitis, N Engl J Med 293:913, 1975. 5. Khan W, et al: Haemophilus influenzae type b resistant to ampicillin: A report of two cases. JAMA 229:298, 1974. 6. Nelson JD: Should ampicillin be abandoned for treatment of Haemophilus influenzae disease? J A M A 229:322, 1974.
Suppurative thyroiditis with gas formation due to mixed anaerobic infection To the Editor: Suppurative thyroiditis is rare, and anaerobic infections in otherwise healthy children are uncommon. A 12-year-old boy is presented who was initially treated as having nonsuppurative thyroiditis, but who deteriorated clinically. At operation, he was found to have suppurative thyroiditis, ultimately proved to be due to a mixed aerobic-anaerobic infection. This case demonstrates the value of radiographic studies of the neck and the need for aerobic and ahaerobic cultures at the time of drainage. It also suggests that thyroiditis, with organisms that normally reside in the pharynx, may be due to persistent thyroglossal duct remnants. CASE REPORT A 12-year-old boy was admitted to St. Louis Children's Hospital because of a 4-day history of sore throat, cough, neck swelling, and fever. The left lobe of the thyroid was mildly tender and enlarged to 5 cm and the temperature was 40.4 ~ C. Physical examination was otherwise unremarkable, and he appeared euthyroid and nontoxic. Serum concentrations of T4, PBI, and TSH were normal. White blood cell count was 22,500/mm :~with
Fig. 1. Lateral projection of neck showing collections of gas in region of thyroid gland.
73% polymorphonuclear leukocytes, 15% lymphocytes, and 11% monocytes. Blood cultures were sterile and throat cultures grew normal flora. After three days of aspirin and two days of prednisone therapy his condition changed dramatically. The anterior neck became swollen, erythematous, and tender with extension of the swelling laterally and down to the sternum. Lateral neck roentgenograms (Fig. 1) revealed gas dissection in the soft tissues of the neck. Intravenous gentamycin and clindamycin therapy was initiated. At operation, a large thyroidal and prethyroidal abscess was drained of foul-smelling purulent material. Bacteroides fragilis, peptococcus magnus, and beta hemolytic streptococci (not groups A or B) were grown in culture. Postoperatively the patient was treated with clindamycin and made a rapid recovery. Serum concentrations of T4 and TSH were normal. DISCUSSION The most common organisms associated with a thyroid abscess have been the streptococci, staphylococci, and pneumococci, although recent reports have indicated a variety of unusual organisms including Baeteroides melaninogenicus, Aspergillus
322
Letters to the Editor
fumigatus, and Mycobacterium chelonei. 1--' The presence of a mixed, anaerobic infection with organisms that are known flora of the mouth lead us to suspect that the origin of the infection in this case was the throat. Persistence of remnants of the thyroglossal duct are not unusual and can provide a direct condiut for throat flora into the thyroid. This case emphasizes the need for continued close observation of patients believed to have nonsuppurative thyroiditis and for prompt and appropriate treatment of suppurative complications. Lateral neck roentgenograms indicated the presence o f infection with gas-forming organisms and helped in choosing appropriate antibiotic therapy. Yvonne C. Bussman, M,D. Michael L. Wong, M.D. Martin J. Bell, M.D. Julio V. Santiago, M.D. Divisions of Endocrinology, Metabolism, and Infectious Disease Edward Mallinckrodt Department of Pediatrics Division of Pediatric Surge(y Department of Surgery' Washington Universi(y School of Medicine and St. Louis Children's Hospital St. Louis, Mo. 63110
The Journal o f Pediatrics Februarv 1977
Fig. !. Case 1: A larval fragment (arrows) lies twisted in the center of a myocardial granuloma. (Original magnification x 950.)
REFERENCES
1. Sharma RK, and Rapkin RH: Acute suppurative thyroiditis caused by Bacteroides melaninogenicus, JAMA 229:1470, 1974 2. Halazan JF, Anast CS, and Lukens JN: Thyrotoxicosis associated with aspergillus thyroiditis in chronic granulomatous disease, J PEDIATR 80:106, 1972. 3. Gutman S, Handwerger S, Zwady KP, Abranowsky CR, and Rodgers M: Thyroiditis due to myobacterium chelonei, Rev Resp Dis 110:807, 1974. 4. Jaffe N, and Schamroth L: Gas-forming infection of the thyroid gland, Clin Radiol 17:95, 1966. 5. Gaafar H, and E1-Garem F: Acute thyroiditis with gas formation, J Laryngol Otol 89:323, 1975.
Myocarditis due to visceral larva migrans To the Editor: Visceral larva migrans (VLM) occurs frequently in children who eat dirt contaminated by the ova of the common dog roundworm, Toxocara canis. 1 ' Though most often clinically benign,' ~ VLM has occasionally been reported to cause myocarditis.'-" We have observed myoearditis associated with VLM in three children. The diagnoses of VLM were based on histories of Supported in part by Grant No. HL-5756 from the National Institutes of Health United States Public Health Service and by USPH Grant RR-OO188 from the General Clinical Research Branch National Institutes of Health.
Fig. 2. Case 3: Eosinophils, lymphocytes, and plasma cells form a dense infiltrate in the myocardial interstitium. (Original magnification x 460.)
pica and profound eosinophilia; they were confirmed by finding VLM granulomas on microscopic sections of biopsy or autopsy material. In the two children who died, myocarditis was histologically documented at autopsy. In one child it was the cause of death and. in the other, it was an incidental autopsy finding. In the third child, myocarditis was diagnosed by its clinical manifestations. CASE REPORTS Case 1. An asymptomatic 2-year-old boy was seen at Texas Children's Hospital for evaluation of eosinophilia. VLM was diagnosed, and he was discharged. Three months later he died from a volvulus around the Meckel diverticulum. At autopsy, characteristic VLM granulomas were present in the myocardium. A remnant of a Toxocara larva was found within one granuloma (Fig. 1). Approximately 10% of the
Letters to the Editor
32 !
obvious and again raises the question: "Should ampicillin be abandoned for treatment of Haemophilus influenzae disease? .... W. L. Albritton, M.D., Ph.D. G. Hammond, M.D. S. Hoban, A.R.T. A. R. Ronald, M.D, Departments of Pediatrics and Medical Microbiology 700 William Ave. Winnipeg, Manitoba, Canada R3E OZ3 REFERENCES 1. American Academy of Pediatrics, Committee on Infectious Disease: Ampicillin-resistant strains of Hemophilus influenzae type B. Pediatrics 55:145, 1975. 2. Thornsberry C, and Kirven LA: Antimicrobial susceptibility of Haemophilus influenzae, Antimicrob Agents Chemother 6:620, 1974. 3. Thornsberry C, and Kirven LA: Ampicillin resistance in Haemophilus influenzae as determined by a rapid test for/~lactamase production, Antimicrob Agents Chemother 6:653, 1974. 4. Echeverria P, et al: Apparent emergence of aminoglycosideresistant Escherichia coli during neonatal meningitis, N Engl J Med 293:913, 1975. 5. Khan W, et al: Haemophilus influenzae type b resistant to ampicillin: A report of two cases. JAMA 229:298, 1974. 6. Nelson JD: Should ampicillin be abandoned for treatment of Haemophilus influenzae disease? J A M A 229:322, 1974.
Suppurative thyroiditis with gas formation due to mixed anaerobic infection To the Editor: Suppurative thyroiditis is rare, and anaerobic infections in otherwise healthy children are uncommon. A 12-year-old boy is presented who was initially treated as having nonsuppurative thyroiditis, but who deteriorated clinically. At operation, he was found to have suppurative thyroiditis, ultimately proved to be due to a mixed aerobic-anaerobic infection. This case demonstrates the value of radiographic studies of the neck and the need for aerobic and ahaerobic cultures at the time of drainage. It also suggests that thyroiditis, with organisms that normally reside in the pharynx, may be due to persistent thyroglossal duct remnants. CASE REPORT A 12-year-old boy was admitted to St. Louis Children's Hospital because of a 4-day history of sore throat, cough, neck swelling, and fever. The left lobe of the thyroid was mildly tender and enlarged to 5 cm and the temperature was 40.4 ~ C. Physical examination was otherwise unremarkable, and he appeared euthyroid and nontoxic. Serum concentrations of T4, PBI, and TSH were normal. White blood cell count was 22,500/mm :~with
Fig. 1. Lateral projection of neck showing collections of gas in region of thyroid gland.
73% polymorphonuclear leukocytes, 15% lymphocytes, and 11% monocytes. Blood cultures were sterile and throat cultures grew normal flora. After three days of aspirin and two days of prednisone therapy his condition changed dramatically. The anterior neck became swollen, erythematous, and tender with extension of the swelling laterally and down to the sternum. Lateral neck roentgenograms (Fig. 1) revealed gas dissection in the soft tissues of the neck. Intravenous gentamycin and clindamycin therapy was initiated. At operation, a large thyroidal and prethyroidal abscess was drained of foul-smelling purulent material. Bacteroides fragilis, peptococcus magnus, and beta hemolytic streptococci (not groups A or B) were grown in culture. Postoperatively the patient was treated with clindamycin and made a rapid recovery. Serum concentrations of T4 and TSH were normal. DISCUSSION The most common organisms associated with a thyroid abscess have been the streptococci, staphylococci, and pneumococci, although recent reports have indicated a variety of unusual organisms including Baeteroides melaninogenicus, Aspergillus
322
Letters to the Editor
fumigatus, and Mycobacterium chelonei. 1--' The presence of a mixed, anaerobic infection with organisms that are known flora of the mouth lead us to suspect that the origin of the infection in this case was the throat. Persistence of remnants of the thyroglossal duct are not unusual and can provide a direct condiut for throat flora into the thyroid. This case emphasizes the need for continued close observation of patients believed to have nonsuppurative thyroiditis and for prompt and appropriate treatment of suppurative complications. Lateral neck roentgenograms indicated the presence o f infection with gas-forming organisms and helped in choosing appropriate antibiotic therapy. Yvonne C. Bussman, M,D. Michael L. Wong, M.D. Martin J. Bell, M.D. Julio V. Santiago, M.D. Divisions of Endocrinology, Metabolism, and Infectious Disease Edward Mallinckrodt Department of Pediatrics Division of Pediatric Surge(y Department of Surgery' Washington Universi(y School of Medicine and St. Louis Children's Hospital St. Louis, Mo. 63110
The Journal o f Pediatrics Februarv 1977
Fig. !. Case 1: A larval fragment (arrows) lies twisted in the center of a myocardial granuloma. (Original magnification x 950.)
REFERENCES
1. Sharma RK, and Rapkin RH: Acute suppurative thyroiditis caused by Bacteroides melaninogenicus, JAMA 229:1470, 1974 2. Halazan JF, Anast CS, and Lukens JN: Thyrotoxicosis associated with aspergillus thyroiditis in chronic granulomatous disease, J PEDIATR 80:106, 1972. 3. Gutman S, Handwerger S, Zwady KP, Abranowsky CR, and Rodgers M: Thyroiditis due to myobacterium chelonei, Rev Resp Dis 110:807, 1974. 4. Jaffe N, and Schamroth L: Gas-forming infection of the thyroid gland, Clin Radiol 17:95, 1966. 5. Gaafar H, and E1-Garem F: Acute thyroiditis with gas formation, J Laryngol Otol 89:323, 1975.
Myocarditis due to visceral larva migrans To the Editor: Visceral larva migrans (VLM) occurs frequently in children who eat dirt contaminated by the ova of the common dog roundworm, Toxocara canis. 1 ' Though most often clinically benign,' ~ VLM has occasionally been reported to cause myocarditis.'-" We have observed myoearditis associated with VLM in three children. The diagnoses of VLM were based on histories of Supported in part by Grant No. HL-5756 from the National Institutes of Health United States Public Health Service and by USPH Grant RR-OO188 from the General Clinical Research Branch National Institutes of Health.
Fig. 2. Case 3: Eosinophils, lymphocytes, and plasma cells form a dense infiltrate in the myocardial interstitium. (Original magnification x 460.)
pica and profound eosinophilia; they were confirmed by finding VLM granulomas on microscopic sections of biopsy or autopsy material. In the two children who died, myocarditis was histologically documented at autopsy. In one child it was the cause of death and. in the other, it was an incidental autopsy finding. In the third child, myocarditis was diagnosed by its clinical manifestations. CASE REPORTS Case 1. An asymptomatic 2-year-old boy was seen at Texas Children's Hospital for evaluation of eosinophilia. VLM was diagnosed, and he was discharged. Three months later he died from a volvulus around the Meckel diverticulum. At autopsy, characteristic VLM granulomas were present in the myocardium. A remnant of a Toxocara larva was found within one granuloma (Fig. 1). Approximately 10% of the
