The Pediatric Infectious Disease Journal Newsletter

TIRE FLIPPING CAN BE HAZARDOUS TO YOUR HEALTH We recently evaluated an otherwise healthy 13 year old girl admitted to our hospital with fever, back and flank pain and limp. Active in athletics, her off-season strength training program included flipping large tractor tires. She remembered the back pain starting immediately after one such tire-flipping workout two weeks earlier. Soon thereafter she developed fever and difficulty on ambulation because of pain on movement of the left lower extremity. On evaluation, she had laboratory evidence of systemic inflammation, and a CT scan with intravenous contrast of the abdomen and pelvis revealed an edematous left psoas muscle with a 4.5cm septated fluid collection within the muscle consistent with a psoas abscess. Intravenous clindamycin was begun and subsequently a blood culture grew methicillin-susceptible Staphylococcus aureus. She improved quickly, the repeat blood culture was sterile and she was given oral clindamycin and discharged to continue therapy at home for a minimum of 4 weeks. MRI of the abdomen and pelvis performed 3 days later showed marked improvement in the size of the psoas abscess, and enhancement of the L4 vertebral body on T2-weighted imaging consistent with osteomyelitis. Psoas abscess is uncommon in children and usually arises de novo (i.e. primary infection). Secondary psoas abscess is the result of contiguous spread of infection from a neighboring source such as the vertebrae or appendix. Children are more likely to have primary psoas abscess (Pediatr Infect Dis J. 1990; 9:201-6), whereas in adults the majority have an infected adjacent structure (Medicine 2009; 88:120-30). Staphylococcus aureus causes most cases of primary psoas abscess and of secondary abscess from musculoskeletal sources. Local trauma followed by staphylococcal bacteremia is thought to predispose to primary psoas abscess. In 1905, Miyake showed that dogs injected intravenously with S. aureus developed muscle abscesses at the exact locations of prior inflicted muscle trauma, whereas dogs without preexisting trauma did not form muscle abscesses (Mitt Grenzgeb Med Chir. 1904; 13:155-198). While it is unusual for a prior traumatic event to be linked definitively to the development of a psoas abscess, Meehan et al. presented a case of primary left iliopsoas abscess from S. aureus in a 13 year old girl who had a history of repetitive trauma to her left hip and gluteus due to falls at volleyball practice (J Pediatr Surg. 1995; 30:127-8). Our case highlights the advantages of MRI in the evaluation of a child with muscular infection, as occult bony foci may not be visualized with other imaging modalities (Prepared by Dr. Thomas Fox, a senior fellow in our division). PERTUSSIS IN DALLAS In the first two weeks of April 2012 we managed 8 patients with confirmed pertussis at the Children’s Medical Center Dallas (CMCD) system. Five of the patients were younger than 10 weeks of age; two were siblings. The youngest patient was 32 days of age, required intensive care management, including extracorporeal membrane oxygenation and died. The mother of this infant received Tdap 2 years earlier. Since the introduction of Tdap in Dallas County in 2007, the number of pertussis cases seen at CMCD decreased from 163 in 2008 to 13 in 2011. We anticipate that this cluster of cases will be limited promptly because of the excellent vaccine coverage rates in our area. We are not alone in experiencing a cluster of pertussis cases. Through March 31, 2012 the Washington State Department of Health reported 640 cases of pertussis in 23 counties; this compares with 94 cases diagnosed in the comparable period of 2011. In Marin County, California 171 cases of pertussis were confirmed, of which 132 were in pediatric patients (Clin Infect Dis 2012; PMID:22423127) The number of cases was low in children younger than 6 years and peaked at 12 years of age. The investigators reviewed the electronic medical records for the immunization status of the patients and the population served. They calculated that the effectiveness of pertussis vaccine was 41% and 24% in 2-7 and 8-12 year olds, respectively. It was 79% in those 13-18 years. Immunity to pertussis appears to wane after immunization and suggests that a greater effort should be made to immunize children and adolescents to provide protection to family members (Dr. Jane Siegel provided the CMCD data). HEARING LOSS AND PNEUMOCOCCAL MENINGITIS Hearing loss is common in children who survive pneumococcal meningitis. In a study of adults with pneumococcal meningitis Hackenberg and associates (Clin Microbiol Infect 2011; Sept 6. doi: 10.1111/j) showed that 22% of adult patients who survived pneumococcal meningitis had hearing loss; 53% were classified as mild and the remaining were severe. Unlike in children hearing loss in their patients was significantly associated with the diagnosis of otitis on admission (OR 2.58; 95% CI, 1.66-4.02; p<0.001) and not with the CSF inflammatory indices. ABOLISH THE GOLD STANDARD In financial circles the term “gold standard” means that the basic unit of currency, such as the dollar, is pegged to the value of a given weight of gold. It has nothing to do with excellence, dependability, reliability or other such admirable qualities. The gold standard was abolished in the financial world years ago, but the phrase lives on in medical writing. Almost every manuscript we receive that has anything to do with laboratory diagnostic tests refers to the existing or previous standard diagnostic test as the “gold standard”. Why? It makes no sense. A medical laboratory test, new or old, has nothing to do with gold. And the gold standard as a financial term had nothing to do with a laboratory test; it certainly was not a test to identify gold in a substance. Listen up, authors! If you want to say that a certain test is the acknowledged, standard test, just say “standard”, or at most embellish it with the adjectives “acknowledged”, “accepted” or “definitive”. But never “gold”. This is just one item in our quest to rid medical writing of trite words and phrases. EXPANDED USE OF VARIZIG VariZIG, which is available only from Cangene Corporation in Winnepeg, Canada, is intended for immune compromised persons at risk of severe disease from varicella zoster virus (VZV) who are exposed to the virus. Formerly it was said that it had to be given within 4 days of exposure to be effective in preventing infection. That period has been extended to within 10 days after exposure (MMWR 2012; 61:212). The immunocompromised group includes certain newborn infants. VariZIG should be given after VZV exposure to any premature baby born before 28 weeks of gestation or weighing less than 1,000 grams at birth, and to those born after 28 weeks of gestation whose mothers are not immune to VZV. VariZIG should be given to all neonates, regardless of birth weight, whose mothers develop varicella between 5 days before and 2 days after delivery. These situations are uncommon but potentially dangerous. To obtain VariZIG it is necessary to contact the CDC. MALARIA IN U.S. CHILDREN The CDC recently released the summary about malaria cases in the United States in the year 2010 (MMWR 2012; 61 (SS No. 2): 1-17). The 1691 cases reported in 2010 is the largest annual incidence since 1980. There were 9 fatal cases. We were most interested in the 232 cases in children younger than 18 years; 108 (47%) of these were classified as U. S. citizens with the remainder having foreign resident status. The 108 cases were spread across the childhood age spectrum: 4 were less than 2 years, 10 were 2-4 years, 54 were 5-12 years and 40 were 13-17 years. Most (75%) infections were acquired in Africa, usually on visits to relatives and friends. Information about chemoprophylaxis was known in 85 cases and it is the expected story: 26 children took some type of prophylaxis but in only 5 children was it an appropriate regimen that was adhered to. Without this information one might expect that persons who have family in Africa would be more savvy about the risks of malaria and be more likely to take appropriate prophylaxis, but that is not the case. On the bright side, it appears that the risk of acquiring malaria during usual vacations to malarial areas is very small.

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