Neonatal ascariasis

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nursing mothers tested is considerably at variance with t h e findings w h i c h a p p a r e n t l y resulted in the d r u g w a r n i n g for nursing mothers. T h e literature indicates t h a t the m a x i m u m concentration of chlorothiazide in serum is a m e a n of 2.3 /~g p e r milliliter at 2.3 hours in n o r m a l volunteers. 2 W e r e one to use 1,000 c.e. of milk p e r d a y as an average daily intake for one of these infants, a level of 0.1 mg. p e r 100 ml. w o u l d transfer only 1 mg. of chlorothiazide to the i n f a n t p e r day. Since chlorothiazide is used in infants w i t h h e a r t disease at a dose of 20 rag. p e r kilog r a m p e r day, a the a m o u n t of d r u g potentially transferred in breast milk is extremely small. CONCLUSION T h e risk of a nursing infant acquiring toxic or even significant doses of chlorothiazide

Neonatal ascariasis Wen-Genn Chu, M.D., Pin-Mei Chen, M.D., Chin-Chiang Huang, M.D.,* and Chen-Tien Hsu, M . D . , Talpei, Talwan, Republic of China

R E I, o I~ T s of n e o n a t a l h e l m i n t h i c infections are rare. This p a p e r is a r e p o r t of a n infant with neonatal ascariasis, born to a m o t h e r w h o also h a d intestinal a n d p l a c e n t a l ascariasis.

CASE REPORT A male infant was delivered by cesarean section at 8 months' gestation to a 26-year-old para

From the Children's Medical Service and the Department of Obstetrics and Gynecology, Municipal Chung-Hsin Hospital of Taipei. *Reprint address: Children's Medical Service, Municipal Chung-Hsln Hospital of Talpel, 145, Cheng Chow Rd., Talpez, Talwan, Republic oI CMna.

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t h r o u g h breast milk is quite remote. Chlorothiazide appears to be a safe diuretic for ingestion by the nursing m o t h e r requiring such medication. The authors of this study wish to thank Mr. Cornell Allen, Mrs. Judy Thompson, R.N., and Miss Fran Barnaby, R.N., for their technical assistance, and special thanks to Parent and Child Incorporated whose members made this project successful.

REFERENCES 1. Baer, J. E., Leidy, H. L., Brooks, A. V., et al.: The physiological disposition of chlorothiazide {Diuril) in the dog, J. Pharmacol. Exp. Ther. 125: 295, 1959. 2. Brettell, H. R., Aikawa, J. K., and Gordon, G. $2: Studies with ehlorothiazide tagged with radioactive carbon (C a~) in human beings, Arch. Intern. Med. 106: 57, 1960. 3. Rowe, R. D., and Mehrizi, A.: The neonate with congenital heart disease, Philadelphia, 1968, W. B. Saunders Company, p. 404.

2, gravida 3 farm woman. The mother was never examined antenatally. She had a history of occasional vague abdominal pain which lasted for about 10 to 30 minutes without nausea, vomiting, or diarrhea. She was admitted to the hospital on April 3, 1970, because of early rupture of the membranes and prolonged labor. Cesarean section was performed soon after admission as a result of the fetal distress and prolonged labor. Before cesarean section one living Ascaris lumbricoides worm passed from the vagina to the outside and another living adult worm was discovered in the vagina during vaginal douche in preparation for the operation, An adhesion between the small intestine and the uterus was found. After extirpation of the placenta, two living mature male worms and eight living mature female worms were found on the maternal side of the placenta (Fig. 1 ). At delivery, the infant weighed 2,010 Gm., measured 45 cm., and was in fair condition. The Apgar score a t five minutes was 10. The baby appeared well on the second day when he was observed to pass a live female Ascaris Iumbricoides, 30 cm. in length. On the sixth day, he passed another live mature female worm 28 era. in length. Piperazine citrate (50 mg. per kilogram per day) was given to the baby on the sixth and seventh day of life. How-

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Fig. 1. Ascarls lumbricoides worms in the placenta. ever, no other worm was found during the following weeks, and Ascaris lumbricoides ova were not seen after the eleventh day of llfe. No eosinophilic leukocytes were seen in peripheral blood of the baby or the mother. Fertilized A. lumbricoides ova were found in the mother's stool, in the amniotic fluid, and in the baby's feces. DISCUSSION

T h e infant described had not had an opportunity to ingest food contaminated with fertilized A. Iurnbrlcoides eggs. His infection presumably resulted from transplacental migration of A. lumbricoides larvae or adult worms. T h e migration of mature Ascaris worms to m a n y organs is well known, but reports of urogenital migration of the parasite are rare? T h e first case of placental bilharziasis was reported by Sutherland and associates ~ in 1965, and the presence of T a e n i a proglottid was first reported in the h u m a n uterus by Schacher and Hajj s in 1970. Enterobius vermicularis has been recorded on a n u m b e r of occasions in the urogenital system, including the uterus. 4 I n 1949, Ochsner and associates ~ reported a case of A. lumbricoides migration to the heart. I n 1965, P h u a c and Schmauss G reported embolism by a grown A. lumbrieoides in the femoral artery. T h e y stated that the worm in this case could only have reached the femoral artery via the bile duct ---> liver abscess --> hepatic vein --> vena cava ---> right heart ---> foramen ovale --->left heart ---> aorta ---> femoral artery. I n individuals exposed to

The Journal of Pediatrics October 1972

m a n y infective stage eggs, some of the larvae m a y pass through the p u l m o n a r y capillaries into the left heart and systemic circulation and may be filtered out in various organs and tissues of the body, as in lymph nodes, thyroid, thymus, spleen, brain, and spinal cord. T h e y m a y also accumulate in the kidneys and be passed in the urine, or they may rarely pass the placental filter and reach the fetus? T h e pathway of placental ascariasis in the present case can be postulated in two possible ways. T h e first is direct invasion of the w o r m from intestine to uterus and placenta, and we did find an adhesion between the small intestine and the uterus at the time of surgery. T h e second possibility is the migration of larvae into the placenta, where they developed to maturity. There m a y be three possible pathways for neonatal ascariasis. T h e first is direct invasion of A. Iurnbricoides from the mother's intestine to the placenta and amniotic cavity, to be swallowed by the fetus. T h e second possible route is as follows: infected Ascaris eggs ---> Ascaris larvae ---> lodged in the lung ---> some larvae reach left heart ----> placenta ---> umbilical vein ---> fetal circulation ---> ductus venosus ---> inferior vena cava --> right heart --->lung --> alveoli --> bronchioles --->trachea --> pharynx ---> esophagus --> stomach ----> small intestine --> mature worm. T h e third possibility is that the fertiliz6d Ascaris eggs are produced by ovipositing female worms in the placenta. These fertilized eggs become infective in the placenta and amniotic cavity by an intracorporeal hatching process, s The infective eggs are swallowed by the fetus and develop into mature worms in the small intestine. We wish to express our gratitude to Dr. J. tI. Cross, Parasitologist, United States NAMRU2, for reviewing the manuscript, and confirming the identification of Ascarls lumbricoides. REFERENCES

I. Arean, V. M., and Crandall, C. A.: Ascariasis, in Pathology of protozoal and helminthic disease with cIinical correIation, ed. 1, Baltimore, 1971, The Williams & Wilkins Company, p. 793. 2. Sutherland, J. C., Berry, A., Hy/id, M., and

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Proctor, N. S. F. : Placental bilharzlasls. Report of a case, S. Afr. J. Obstet. Gynecol. 3: 76, 1965. 3. Schacher, J. F., and Hajj, S. N.: Taenla proglottid in the human uterus, Am. J. Trop. Med. Hyg. 19. 626, 1970. 4. Symmers, W. St. C.: PathoIogy of oxyurlasls with special reference to the presence of oxyuris vermicularis and its ova in the tissue, Arch. Pathol. 50: 475, 1950. 5. Ochsner, A., Debakey, E., and Dixon, L.: Complication of ascariasis requiring surgical treatment, Am. J, Dis. Child. 77: 389, 1949.

Infantile cortical hyperostosis of the scapula presenting as an ipsilaterat Erb's palsy David Holtzman, M.D., Ph.D., * Bronx, N. t'.

I N F A N T I L E cortical hyperostosis, first described by Caffey a n d Silverman, 1 is a syndrome, in infants less t h a n five m o n t h s of age, characterized by the s u d d e n a p p e a r a n c e of soft tissue swellings, fever, a n d irritability, with subsequent x-ray evidence of periosteal new bone formation. 2, s O n e o r m o r e bones m a y be affected; the scapula is involved in about 10 p e r cent of cases. 4, ~ W e r e p o r t four patients with Caffey's disease in t h e s c a p u l a with dysfunction of the ipsilateral u p p e r braehial plexus. E a c h of the patients presented with an a p p a r e n t E r b ' s palsy. E a c h subsequently developed clinical a n d then r a d i o g r a p h i c findings confirming the diagnosis of infantile cortical hyperostosis, b u t n o t

From the Saul R. Korey Department o[ Neurology, Albert Einstein College o[ Medicine o[ Yeshiva University. Reprint address: Saul R. Korey Department o[ Neurology, Albert Einstein College of Medicine, 1300 Morris Park Ave., Bronx, N. Y. 10461. *Natlonal Institutes o[ Neurologlc Diseases and Stroke Special Fellow in Pediatric Neurology (Grant No. 2 Fll NS02262-02).

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6. Phuae, V. It. H., and Schmauss, A. K.: Emboll elnes ausgewachsenen Ascaris lumbricoides in die Arterie Femoralls, Aus der Chirug. Univ-Klinik im Krankenhaus der Vietnamesisch-Deutschen Freudschaft in Hanoi, NMW 31, 1965. 7. Faust, E. C., Russel, P. F., and Jung, R. C.: Ascariasls. Clinical parsitology, ed. 8, Philadelphia, 1970, Lea & Febiger, Publishers, p. 338. 8. Phan, T.: Eclosion larvaire intracorporelle des oeufs d'ascaris erratiques chez un garcon de 4 arts, Pathol. Microbiol. 28: 443, 1965.

before other diagnoses, some surgically treatabte, h a d been considered. I n each case, the paralysis of the u p p e r extremity resolved completely.

CASE REPORTS Case 1. Patient R. C., a 2-month-old boy, was the product of an uncomplicated pregnancy and delivery. No abnormalities were noted at birth. At one month he received a diphtheria-pertussistetanus injection in the right deltoid. One week later he would not move his arm, and the diagnosis of an Erb's palsy was made. Movement of the arm improved and two weeks later a mild wrist drop was the only deficit. One week later it was again noted that he was not moving his right arm. During the next two days, a swelling appeared over the right shoulder, and he was admitted to the hospital On admission he was febrile (100 ~ F.). A soft tissue swelling, overlying the right scapula, extended laterally to the posterior axillary llne. The overlying skin was not warm or discolored. He had a right upper brachial plexus palsy, including absence of biceps and triceps reflexes. The rest of the examination was normal. Laboratory data were normal except for an erythrocyte sedimentation rate of 39 ram. and a white blood count of 16,000 per cubic millimeter with 70 per cent lymphocytes. An x-ray of the right scapula showed periosteal thickening (Fig. 1). The differential diagnosis included myositis ossificans, neoplasm, and Caffey's disease. During eight days in the hospital, there was no change in signs or symptoms. He returned one week later with a swelling over the right mandible. The diagnosis of Caffey's disease was confirmed radiographically by the presence of bony