Pediatric Rounds
Special Feature
By Philip R. Fischer, MD, DTM&H
Travel medicine practitioners and infectious disease specialists are often asked to evaluate returned travelers, immigrants, and other individuals with unusual findings. A recent issue of The Pediatric Infectious Disease Journal included reports of several interesting cases. Considered sequentially, these cases make for an excellent session of "pediatric rounds," and they inform and remind physicians of points to consider when caring for children with unusual findings.
Donovanosis: An Unusual Presentation1
A 5-month-old Aboriginal boy from a remote area of northern Australia presented with a one-month history of left-sided cervical lymphadenopathy; initially, there had been purulent ear drainage that decreased with antibiotic therapy. Mycobacterial skin tests and melioidosis serology were negative. The boy was treated with intravenous, then oral, antibiotics. Two months later, the child presented with persisting adenopathy and poor growth. He had purulent drainage from his left ear canal and had a mass on the left eardrum. Additional history revealed that the mother had untreated genital donovanosis. A cervical node was excised from the child. Donovan bodies were noted in cytoplasmic vacuoles, and a PCR assay was positive for Calymmatobacterium granulomatis. The child was treated with a macrolide, and the adenopathy resolved. Literature review revealed four other infants with donovanosis involving the umbilicus, the labia, and the external ears.
Donovanosis, also called granuloma inguinale, is rare in North America but is seen in several tropical regions including parts of India, Africa, Papua, New Guinea, and the Caribbean. It is usually sexually transmitted, but it may be spread to children by contact with infected secretions. Genital lesions include subcutaneous nodules that progress to form painless, granulomatous ulcers. More distant lesions are rare. Treatment with tetracycline and cotrimoxazole (neither of which the child in this case report received) seems effective, and macrolides are also useful for curative therapy.
What lessons does this case teach us? First, the history of travel and exposures is important, even when the "travel" of note was "only" through an infected birth canal. Delayed diagnosis in this case might have been avoided with a more detailed maternal/exposure history. Second, unusual infections can occur. Mycobacterial infection and cat scratch disease are well known to cause cervical adenopathy, but we must also keep our minds open to unusual causes of enlarged lymph nodes.
Diphtheria: An Unusual Localization2
An 8-year-old boy presented to a Boston hospital with a two-week history of malaise and intermittent abdominal pain along with a three-day history of fever and diarrhea. Eleven days later, after treatment for "viral enteritis," he presented again with progressive foot pain; he had been bedridden since the previous visit. He had fever, a murmur, leukocytosis, and thrombocytopenia. Further evaluation revealed aortic and mitral vegetations and cerebral infarcts. Within 12 hours, blood cultures were growing Corynebacterium diphtheriae. Despite aggressive therapy, the child has remained neurologically impaired.
The usual clinical concerns with diphtheria involve either local airway obstruction or more distant, toxin-mediated effects on the heart. This disease has become rare since the use of vaccination with a toxoid vaccine, but diphtheria has re-emerged due to vaccination deficiency in the former Soviet Union. Nontoxigenic strains of C. diphtheriae, as illustrated by this case, can indeed produce clinical illness. Endocarditis caused by this organism is most common in previously healthy patients younger than 40 years of age. Valvular vegetations are often large, and central nervous system complications are not uncommon.
How does the report of this unfortunate child help us? First, it reminds us that history is still relevant. Just because vaccination has removed much of the lay fear of diphtheria, we must not forget that corynebacteria can still cause devastating disease, even in "developed" countries. Second, it reminds us of the need for close follow-up. Despite the challenges of finding adequate access to medical care, we should try to ensure that children receive appropriate follow-up evaluation. This is especially true when symptoms exceed the expectation for a reasonable initial diagnosis (viral enteritis, in this case).
Mefloquine: An Unusual Reaction3
A 7-year-old boy was hospitalized in India with fever, vomiting, and seizures. Cerebral malaria was diagnosed. Symptoms responded to therapy with quinine (dosing details not presented), but the child became ill again one week later with fever and anemia. He was treated with mefloquine. He then began having hallucinations of insects crawling on and around him, and he "started dancing." Symptoms of psychosis subsided within 24 hours of stopping the mefloquine.
Mefloquine has been associated with psychiatric complications in adults, and notable reactions are more likely with therapeutic than with prophylactic doses. This is apparently the first report of a psychotic reaction (presumably) to mefloquine in a child.
Teaching points? Sure! First, we must remember to ask about risk factors that might contraindicate the use of mefloquine in children even as we do in adults. Usually the relevant risk factors would include psychiatric difficulties, seizures, and cardiac rhythm abnormalities. Second, we can be reassured that this child, despite the adverse reaction, recovered completely. Any patient given mefloquine should probably know how to find help in the event that a complication occurs but can be reassured that adverse reactions are usually reversible. However, this agent has a long half-life—measured in weeks—and the response may not be as rapid as described above.
Cholera: An Unusual Cause of Neonatal Sepsis4
A girl was born in India following an uneventful 37-week gestation. The child was breastfed and went home after an uncomplicated neonatal hospitalization. Interestingly, however, caretakers looking after this child in the hospital were also caring for an adult with Vibrio cholerae O:139 gastroenteritis. Fifteen hours after discharge, the child was readmitted moribund with bluish limbs and face and severe dehydration (weight down 25% since the birth three days earlier). The baby died five hours later despite therapy. A blood culture was positive for V. cholerae O:139.
Non-O:1 strains of V. cholerae are more likely than O:1 strains to be associated with extra-intestinal manifestations. Choleral septicemia is usually associated with underlying medical problems, but it might be assumed that this 37-week newborn was immunologically immature.
Tragedy happens. Even in nosocomial disasters, however, we are reminded to remain vigilant about handwashing. Doctors are notorious for incomplete compliance with handwashing policies, and we must not become cavalier. Travelers can also be encouraged to seek needed medical care in settings where cleanliness and hygiene are established and where the risk of nosocomial infection is minimal.
References
1. Bowden FJ, et al. Donovanosis causing cervical lymphadenopathy in a five-month-old boy. Pediatr Infect Dis J 2000;19:167-169.
2. Belko J, et al. Endocarditis caused by Corynebacterium diphtheriae: Case report and review of the literature. Pediatr Infect Dis J 2000;19:159-163.
3. Havaldar PV, Mogale KD. Mefloquine-induced psychosis. Pediatr Infect Dis J 2000;19:166-167.
4. Bose A, et al. Neonatal septicemia caused by Vibrio cholerae O:139. Pediatr Infect Dis J 2000;19:166.
Which of the following is true?
a. Cervical adenopathy is a common presentation of donovanosis.
b. Diphtherial endocarditis is due to the effects of diphtheria toxin.
c. Mefloquine has been associated with psychosis in a child.
d. Dehydration with cholera develops slowly in breastfed infants.
e. Siezure history is not a contraindication to the use of mefloquine on a weekly basis.
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