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Shigellosis in infancy and childhood
784
Brie[ clinical and laboratory observations
May 1963
Fig. 3. (From Davis: Pedlat, Radiol. 15: 152, 1961, Williams & Wilkins Company.)
Fig. 4.
Physical examination showed him to be normal and in good health with the exception of limitation of pronation and supination of the right forearm. The family refused surgery. CONCLUSION A rare complication of infantile cortical hyperostosis with bony fusion of the radius and ulna and dislocation of the radius at the elbow is reported with ultimate resolu-
tion. There was residual limitation of the movement of the forearm at 4 ~ years. REFERENCES 1. Caffey, J.: Late skeletal changes in chronic infantile hyperostosis, Radiology 39" 651, 1952. 2. Caffey, J.: Infantile cortical hyperostosis, a review of the clinical and radiographic features, Proc. Roy. Soc. Med. 50" 347, 1957. 3. Caffey, J.: Personal communication, 1962. 4. Caffey, J.: Personal communication, 1958.
Sl'gellosis in infamy and childhood Clinical and cerebrospinalfluid findings S h y a m a l K u m a r Sanyal, M.D., Walter T. Hughes, M.D., and F r a n k Falkner, M.R.C.P. ~ LOUISVILLE~
KY.
T I~I E clinical differentiation between bacterial and nonbacterial gastroenteritis is sometimes difficult and parallels similar problems in the upper respiratory tract. Although the
From the Depar of Pediatrics, The University o[ Louisville Medical School, Louisville, Ky.
vast majority of infections in both instances are of viral etiology, constant attention must be given to the less frequently encountered cases of bacterial etiology for which antibiotic "~Address Chairman, DetJartment o[ Pediatrics, University o[ Louisville School of Medicine, Children s Hospital, Louisville 2, K y . Markle Scholar in Medical Science.
Volume 62 Number 5
Brie[ clinical and laboratory observations
triad of bloody diarrhea, high fever, and abdominal pain, and the blood picture is of little diagnostic help in infants. 3. Shigella sonnei and Shigella flexneri are equally common etiologic agents in our series, and there is very little difference in the clinical picture caused by either S. sonnei or S. flexneri except that abnormal neurologic manifestations are more common with S.
therapy may be indicated. We have been impressed, and discouraged, by the frequent occurrence of shigellosis in patients in whom the classic manifestations of bloody diarrhea, high fever, leukocytosis, and abdominal pain were lacking. T h e records of 100 infants and children admitted with shigellosis to the Pediatric Service of the Louisville General Hospital and Children's Hospital from 1942 to 1962 were studied. The age range was 1 week to 14 years. Only cases in which an organism could be cultured from the stool were ineluded i n this survey. A minimum of 3 stool cultures was obtained from all patients as soon after admission as possible. A hemogram in 96 patients, blood culture in 26 patients, and a lumbar puncture in 23 patients were also obtained. The spinal fluid was examined for total and differential white blood cell count, protein, and sugar, and was cultured. Fig. 1 summarizes the clinical and laboratory observations. From study of this sample we conclude, that : 1. Shigellosis is not uncommon below 6 months of age. 2. The majority of patients in infancy and childhood do not present with the classical
TOTAL NUki~ER r
IP~
16
9
&8
I
II
(
)
sonnei. 4. Fatality is more common during infancy. 5. We were interested by the findings in the cerebrospinal fluid. Twenty-three of the patients had 1 or more convulsions (60 per cent cases were due to S. sonnei) and had lumbar punctures. Five cases had definite pleocytosis (more than 15 white blood cells per cubic millimeter). Two of these five had elevated protein. Thus it appears actual meningeal pathology, as reflected by elevated protein and marked pleocytosis is not very common. Cerebrospinal fluid sugar was within normal range in all cases. From the five cases with pleocytosis, S. sonnei was cultured from the stools of 4. All cultures for other bacteria were negative.
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Fig, 1. Clinical manifestations of shigellosis in different age groups.
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,
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Brie[ clinical and laboratory observations
May 1963
Fig. 3. (From Davis: Pedlat, Radiol. 15: 152, 1961, Williams & Wilkins Company.)
Fig. 4.
Physical examination showed him to be normal and in good health with the exception of limitation of pronation and supination of the right forearm. The family refused surgery. CONCLUSION A rare complication of infantile cortical hyperostosis with bony fusion of the radius and ulna and dislocation of the radius at the elbow is reported with ultimate resolu-
tion. There was residual limitation of the movement of the forearm at 4 ~ years. REFERENCES 1. Caffey, J.: Late skeletal changes in chronic infantile hyperostosis, Radiology 39" 651, 1952. 2. Caffey, J.: Infantile cortical hyperostosis, a review of the clinical and radiographic features, Proc. Roy. Soc. Med. 50" 347, 1957. 3. Caffey, J.: Personal communication, 1962. 4. Caffey, J.: Personal communication, 1958.
Sl'gellosis in infamy and childhood Clinical and cerebrospinalfluid findings S h y a m a l K u m a r Sanyal, M.D., Walter T. Hughes, M.D., and F r a n k Falkner, M.R.C.P. ~ LOUISVILLE~
KY.
T I~I E clinical differentiation between bacterial and nonbacterial gastroenteritis is sometimes difficult and parallels similar problems in the upper respiratory tract. Although the
From the Depar of Pediatrics, The University o[ Louisville Medical School, Louisville, Ky.
vast majority of infections in both instances are of viral etiology, constant attention must be given to the less frequently encountered cases of bacterial etiology for which antibiotic "~Address Chairman, DetJartment o[ Pediatrics, University o[ Louisville School of Medicine, Children s Hospital, Louisville 2, K y . Markle Scholar in Medical Science.
Volume 62 Number 5
Brie[ clinical and laboratory observations
triad of bloody diarrhea, high fever, and abdominal pain, and the blood picture is of little diagnostic help in infants. 3. Shigella sonnei and Shigella flexneri are equally common etiologic agents in our series, and there is very little difference in the clinical picture caused by either S. sonnei or S. flexneri except that abnormal neurologic manifestations are more common with S.
therapy may be indicated. We have been impressed, and discouraged, by the frequent occurrence of shigellosis in patients in whom the classic manifestations of bloody diarrhea, high fever, leukocytosis, and abdominal pain were lacking. T h e records of 100 infants and children admitted with shigellosis to the Pediatric Service of the Louisville General Hospital and Children's Hospital from 1942 to 1962 were studied. The age range was 1 week to 14 years. Only cases in which an organism could be cultured from the stool were ineluded i n this survey. A minimum of 3 stool cultures was obtained from all patients as soon after admission as possible. A hemogram in 96 patients, blood culture in 26 patients, and a lumbar puncture in 23 patients were also obtained. The spinal fluid was examined for total and differential white blood cell count, protein, and sugar, and was cultured. Fig. 1 summarizes the clinical and laboratory observations. From study of this sample we conclude, that : 1. Shigellosis is not uncommon below 6 months of age. 2. The majority of patients in infancy and childhood do not present with the classical
TOTAL NUki~ER r
IP~
16
9
&8
I
II
(
)
sonnei. 4. Fatality is more common during infancy. 5. We were interested by the findings in the cerebrospinal fluid. Twenty-three of the patients had 1 or more convulsions (60 per cent cases were due to S. sonnei) and had lumbar punctures. Five cases had definite pleocytosis (more than 15 white blood cells per cubic millimeter). Two of these five had elevated protein. Thus it appears actual meningeal pathology, as reflected by elevated protein and marked pleocytosis is not very common. Cerebrospinal fluid sugar was within normal range in all cases. From the five cases with pleocytosis, S. sonnei was cultured from the stools of 4. All cultures for other bacteria were negative.
~
~;
l
n
[]
9
2
2
m
[]
[]
[]
~ L
,
rll
;~
;~
~ L
l
n
SIGNS
7 85
m
1
m
. . . . . . .
~ & , ,~' ,' ,~,'cz Aoc
IN
y~A~S
Fig, 1. Clinical manifestations of shigellosis in different age groups.
,:,,= ,%
,
,
,
,,,_m_,_