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Treatment of children at risk for bacteremia
Volume 110 Number 2
Editorial correspondence
33 1
T a b l e . Titers of IgG, IgM, and IgA antibodies against Coxiella burnetii (immunofluorescence) in a 7-year-old boy IgG
Day of admission 10 days later 6 weeks later
IgM
IgA
Phase I
Phase II
PhaSe II
Phase I
Phase II
512 1024 *
256 8192 16384
256 >4096 512
2048 * 2048
256 * 512
*Not enough serum available.
preexisting heart disease. Our patient was a 7-year-old previously healthy boy, who was admitted to our hospital with a history of high fever (temperature 39.3 ~ C), exanthem, and myalgia for 2 days. On physical examination, other than signs of meningeal irritation and the exanthem, no abnormalities were found. No cardiac murmur was present; nor splenomegaly. Laboratory investigations showed a high sedimentation rate (56 mm/hr), leukocytosis (13.4 • 109/L), and thrombocytopenia (87 • 109/L). Kidney and liver function tests yielded normal results. Initially the patient was given amoxicillin and gentamicin intravenously because of suspected septicemia. Bacterial cultures of blood, cerebrospinal fluid, urine, and nose and throat swabs were sterile. Five days after admission, a soft systolic murmur was heard, with maximal intensity at the third left intercostal space. An echocardiogram showed echodense structures resembling vegetations on one of the three cusps of the aortic valve, lgM antibodies to C. burnetii were found, and a rising titer of slJecific IgG antibodies with immunofluorescence against phase I and phase 1I antigens (Table). The therapy was changed to doxycycline intravenously. Because of the clinical presentation, the laboratory findings, and the echocardiogram, the diagnosis of endocarditis caused by C. burnetii was made. Later we found further support when lgA antibodies to C. burnetii (immunoftuorescence against phase I antigen titer 1:2048) were found; this type of antibody is not present in patients with an uncomplicated form of Q fever, but is present in patients with endocarditis,z After 4 weeks of intravenously administered therapy, the murmur had disappeared and there were no more echocardiographic abnormalities. Doxycyeline was given orally for 6 months. A year later the patient is well. The source of infection in our patient is uncertain. When he was 2 years old he spent several months in Israel, where Q fever is endemic. Eight months before the acute illness he had sheep wool in his bedroom, and in the 2 months preceding his illness he had twice visited zoologic gardens. He regularly ate shoarma (meat of sheep). The serologic reactions did not help us to determine the time of exposure. G. C. M. Beaufort-Krol, M.D. C. J. Storm, M.D. Department o f Pediatrics and Cardiology Zuiderziekenhuis Rotterdam, The Netherlands
2.
Peacock MG, Philip RN, Williams JC, Faulkner RS. Serological evaluation of Q fever in humans: enhanced phase I titers of immunoglobulins G and A are diagnostic for Q fever endocarditis. Infect Immun 1983;4l:1089-98.
Treatment of children at risk for bacteremia To the Editor." Drs. McLellan and Giebink1conclude that presumptive therapy for children at risk for occult bacteremla is not warranted. I, and others,2 believe that in children between 6 and 24 months of age, with hyperpyrexia (temperature >_40~ C) but without symptoms or focus of infection, with either leukocyte count >15,000/#L or erythrocyte sedimentation rate >30 mm/hr, a blood culture should be performed, treatment for presumed bacteremia administered~ and close observation carried out. Carroll et al? concluded that "expectant therapy" was efficacious. Two of five children with bacteremia in the untreated group were not simply "unimproved," but bacterial meningitis developed. Those randomized to receive immediate treatment were given 50,000 U/kg CR-Bicillin, followed by 100 mg/kg/day Pen VK, pending culture results. They did not, as related by McLellan and Giebink, receive benzathine penicillin. The procaine moiety may have been responsible for prompt clinical resolution and eradication of bacteremia. Jonathan 1. Singer, M.D. Wright State University School of Medicine P.O. Box 927 Dayton, OH 45401-0927 REFERENCES 1. 2.
3.
McLellan D, Giebink SG. Perspectives on occult bacteremia in children. J PEDIATR1986;109:1-8. Crocker P J, Quick G. Occult bacteremia in the emergency department: diagnostic criteria for the young febrile child. Ann Emerg Med 1985;14:1172-7. Carroll WL, Farrell MK, Singer JI, et al. Treatment of occult bacteremia: a prospective randomized clinical trial. Pediatrics 1983;72:608-12.
Reply REFERENCES
1.
Laufer D, Lew PD, Oberhansli I, Cox JN, Longson M. Chronic Q fever endocarditis with massive splenomegaly in childhood. J PEDIATR 1986;108:535-9.
To the Editor." Dr, Singer is correct that in the study by Carroll et al. the treatment group received benzathine plus procaine penicillin,
Editorial correspondence
33 1
T a b l e . Titers of IgG, IgM, and IgA antibodies against Coxiella burnetii (immunofluorescence) in a 7-year-old boy IgG
Day of admission 10 days later 6 weeks later
IgM
IgA
Phase I
Phase II
PhaSe II
Phase I
Phase II
512 1024 *
256 8192 16384
256 >4096 512
2048 * 2048
256 * 512
*Not enough serum available.
preexisting heart disease. Our patient was a 7-year-old previously healthy boy, who was admitted to our hospital with a history of high fever (temperature 39.3 ~ C), exanthem, and myalgia for 2 days. On physical examination, other than signs of meningeal irritation and the exanthem, no abnormalities were found. No cardiac murmur was present; nor splenomegaly. Laboratory investigations showed a high sedimentation rate (56 mm/hr), leukocytosis (13.4 • 109/L), and thrombocytopenia (87 • 109/L). Kidney and liver function tests yielded normal results. Initially the patient was given amoxicillin and gentamicin intravenously because of suspected septicemia. Bacterial cultures of blood, cerebrospinal fluid, urine, and nose and throat swabs were sterile. Five days after admission, a soft systolic murmur was heard, with maximal intensity at the third left intercostal space. An echocardiogram showed echodense structures resembling vegetations on one of the three cusps of the aortic valve, lgM antibodies to C. burnetii were found, and a rising titer of slJecific IgG antibodies with immunofluorescence against phase I and phase 1I antigens (Table). The therapy was changed to doxycycline intravenously. Because of the clinical presentation, the laboratory findings, and the echocardiogram, the diagnosis of endocarditis caused by C. burnetii was made. Later we found further support when lgA antibodies to C. burnetii (immunoftuorescence against phase I antigen titer 1:2048) were found; this type of antibody is not present in patients with an uncomplicated form of Q fever, but is present in patients with endocarditis,z After 4 weeks of intravenously administered therapy, the murmur had disappeared and there were no more echocardiographic abnormalities. Doxycyeline was given orally for 6 months. A year later the patient is well. The source of infection in our patient is uncertain. When he was 2 years old he spent several months in Israel, where Q fever is endemic. Eight months before the acute illness he had sheep wool in his bedroom, and in the 2 months preceding his illness he had twice visited zoologic gardens. He regularly ate shoarma (meat of sheep). The serologic reactions did not help us to determine the time of exposure. G. C. M. Beaufort-Krol, M.D. C. J. Storm, M.D. Department o f Pediatrics and Cardiology Zuiderziekenhuis Rotterdam, The Netherlands
2.
Peacock MG, Philip RN, Williams JC, Faulkner RS. Serological evaluation of Q fever in humans: enhanced phase I titers of immunoglobulins G and A are diagnostic for Q fever endocarditis. Infect Immun 1983;4l:1089-98.
Treatment of children at risk for bacteremia To the Editor." Drs. McLellan and Giebink1conclude that presumptive therapy for children at risk for occult bacteremla is not warranted. I, and others,2 believe that in children between 6 and 24 months of age, with hyperpyrexia (temperature >_40~ C) but without symptoms or focus of infection, with either leukocyte count >15,000/#L or erythrocyte sedimentation rate >30 mm/hr, a blood culture should be performed, treatment for presumed bacteremia administered~ and close observation carried out. Carroll et al? concluded that "expectant therapy" was efficacious. Two of five children with bacteremia in the untreated group were not simply "unimproved," but bacterial meningitis developed. Those randomized to receive immediate treatment were given 50,000 U/kg CR-Bicillin, followed by 100 mg/kg/day Pen VK, pending culture results. They did not, as related by McLellan and Giebink, receive benzathine penicillin. The procaine moiety may have been responsible for prompt clinical resolution and eradication of bacteremia. Jonathan 1. Singer, M.D. Wright State University School of Medicine P.O. Box 927 Dayton, OH 45401-0927 REFERENCES 1. 2.
3.
McLellan D, Giebink SG. Perspectives on occult bacteremia in children. J PEDIATR1986;109:1-8. Crocker P J, Quick G. Occult bacteremia in the emergency department: diagnostic criteria for the young febrile child. Ann Emerg Med 1985;14:1172-7. Carroll WL, Farrell MK, Singer JI, et al. Treatment of occult bacteremia: a prospective randomized clinical trial. Pediatrics 1983;72:608-12.
Reply REFERENCES
1.
Laufer D, Lew PD, Oberhansli I, Cox JN, Longson M. Chronic Q fever endocarditis with massive splenomegaly in childhood. J PEDIATR 1986;108:535-9.
To the Editor." Dr, Singer is correct that in the study by Carroll et al. the treatment group received benzathine plus procaine penicillin,