EOSINOPHILIA AND KAWASAKI DISEASE A 17-month-old previously healthy male presented to a referral hospital for evaluation of fever, vomiting and diarrhea of 2 days duration. Physical examination revealed moderate dehydration, bilateral conjunctivitis and an erythematous urticarial rash on the chest, abdomen and cheeks. His CBC showed 18,800 WBC/cu mm with 46% polymorphonuclear cells, 10% band-forms and 16% eosinophils. Because of continued fever, emesis and a repeat CBC of 27,800 WBC/cu mm with 37% eosinophils the patient was transferred to Children’s Medical Center, Dallas (CMCD). He was noted to be very fussy although consolable by his mother. An erythematous rash was noted on the cheeks bilaterally and he had mild edema of the hands and feet, mild conjunctivitis and bilateral cervical lymphadenopathy. He had a white blood cell count of 24,400 WBC per cu mm, with 39% eosinophils. CRP was 19.6 mg/dL and ESR was 48mm/hr. His illness was consistent with atypical Kawasaki disease. He was given 2 g/kg IVIG and commenced on aspirin therapy. Echocardiogram showed a mildly dilated left ventricle and coronary arteries without evidence of aneurysm. Within 24 hours of receiving IVIG he was afebrile, considerably less fussy and his rash and edema were greatly improved. At the time of discharge his repeat CBC had 12,600 WBC per cu mm with 40% eosinophils. Approximately 6 weeks after discharge he was well and his WBC was 14,500 per cu mm with 17% eosinophilia and 674,000 platelets per cu mm. He had a normal echocardiogram. Mild to moderate eosinophilia can be observed in acute Kawasaki disease and eosinophils are known to accumulate in coronary microvessels (Pediatr Infect Dis J 2002; 21:777). Prolonged eosinophilia can indicate IVIG resistance, but not in our case.
WATCHFUL WAITING REVISITED In 2004 the American Academy of Pediatrics issued recommendations for the management of acute otitis media (AOM) in infants and children. A no treatment option was offered for most patients older than 6 months who had mild, uncomplicated middle ear disease. According to the academy this approach likely contributed to the reduction in offi ce visits from 950 to 634 per 1000 and in the number of prescriptions written from 760 to 484 per 1000 infants and children with AOM in the periods 1995-6 and 2005-6, respectively (Pediatrics 2013;131:e964). The diagnosis of AOM should be considered in patients with moderate to severe tympanic membrane bulging, with new onset of otorrhea not associated with otitis externa or in those with only mild bulging and ear pain for less than 48 hours. Middle ear fl uid can be consistently demonstrated by either tympanometry or pneumatic otoscopy in patients with AOM. When therapy is indicated amoxicillin, 90 mg/ kg/day in 2 divided doses is the preferred agent unless the child has received it within 30 days, in which case, amoxicillin-clavulanate, 90 mg/kg/ day in 2 divided doses or a cephalosporin, either cefdinir orally or ceftriaxone intramuscularly, can be given.
C. EVERETT KOOP, MD On February 25, 2013 Dr C. Everett Koop died at the age of 96 years. Many Americans will remember him as an extremely infl uential and effective Surgeon General of the United States from 1982 to 1989. Before being appointed Surgeon General he was the surgeon-in-chief at the Children’s Hospital of Philadelphia where he established the nation’s fi rst neonatal surgical intensive care unit in 1956 and was among the fi rst to separate conjoined twins. As Surgeon General he will be best remembered for his vigorous stand against smoking and his role in educating Americans on the dire consequences of HIV infection. He overcame strong criticism from some in Congress and many in the tobacco industry for his aggressive stand against smoking by pointing out its adverse effects on the lung and cardiovascular system. Before his tenure and since few Americans could name the surgeon general, but during his term he was a household name and was held in high respect. That says a lot!
NOROVIRUS IS THE NEW ROTAVIRUS Until recently the focus on norovirus infections has been outbreaks of diarrhea, but things are changing for two reasons. First, rotavirus is no longer a prominent cause of childhood diarrhea where rotavirus vaccines are widely used. Secondly, candidate norovirus vaccines are being tested. For these reasons it is necessary to get good information about the exact role of noroviruses in all diarrheal illnesses that prompt parents to seek medical help for their children. The Centers for Disease Control organized a superb 2 year long (2009 and 2010) study of 3 medical venues (hospital admissions, outpatient clinics and emergency rooms) in 3 geographic locations (Rochester NY, Nashville TN and Cincinnati OH) that was reported in the March 21, 2013 issue of The New England Journal of Medicine (NEJM 2013; 368:1121). Investigators enrolled children younger than 5 years who had acute diarrhea within 10 days of onset of illness along with appropriately selected control children. Stool samples were tested for presence of rotavirus and norovirus. Overall, norovirus was found in 21% and rotavirus in 12% of children with diarrhea. Norovirus was present in 4% of control children. Rotavirus cases were almost exclusively in winter months while norovirus cases occurred throughout the year but with a predominance in the winter. Nearly half (47%) of norovirus cases were infants from 6-18 months of age (mean 17 months; median 14 months). If the children in the 3 locales studied are representative of all U.S. children, we can conclude that norovirus has replaced rotavirus as the most common cause of acute diarrhea in infants and young children. The authors calculated the annual rates for U.S. children younger than 5 years with norovirus acute diarrhea to be 14,000 hospitalizations, 281,000 emergency room visits and 627,000 outpatient visits with 273 million dollar costs. Those numbers will figure prominently in assessing costs and benefits of a norovirus vaccine.
THE FDA AND FOOD SAFETY Microbial contamination of food causes uncounted numbers of illnesses in consumers. The numbers are uncounted because there is no conceivable way of acquiring such numbers, but they are huge. On January 4, 2013 the Food and Drug Administration proposed two new rules intended to prevent contamination of produce and processed foods. The first rule would require manufacturers of processed food to develop ways to reduce the risk of contamination, have a plan to correct problems and keep records suitable for government audit. The second rule, related to harvest and processing of fruits and vegetables, would require standards for purity of water that touches plants or reaches their roots. Prevention measures cost money, of course, but businesses save money if the measures work and they avoid monetary losses from product recalls, damage law suits, etc. There is a 120 day period for public comment on these proposed rules. That period ends the first week of May. We can expect finalized rules after that.
THE CURRENT STATUS OF DELOUSING Chosidow and Giraudeau write about the frustrating situation of treating head lice in an editorial (NEJM 2012; 367:1750). Pyrethrins and malathion are losing their effectiveness because of resistance of lice to the drugs in many areas. Orally administered ivermectin given twice at a 7 day interval is quite effective, and topical application of ivermectin has produced good results. The lotion is applied to dry hair for 10 minutes and then rinsed off with water. The authors recommend first trying 1% permethrin or pyrethrin insecticide. If lice persist, try malathion. They reserve oral or topical ivermectin as a last resort, presumably because of concerns that widespread use would lead to drug resistance. We suspect that many parents and doctors will opt for topical ivermectin lotion because of its simplicity.