Pediatric Infectious Disease Journal:
McCracken, George H. M.D.; Nelson, John D. M.D.
ASEPTIC MENINGITIS IN THE UNITED STATES Fewer infants and children with bacterial meningitis are diagnosed and managed today than was the case before the availability of the polysaccharide conjugate vaccines. What about the frequency of aseptic meningitis that should not be impacted by these vaccines or by changes in physicians’ diagnostic acumen? To address this question Nigrovic and colleagues (Pediatrics 2013; 131:670) performed a review of children evaluated in 41 pediatric emergency departments of tertiary-care hospitals participating in the Pediatric Health Information System in the 6 years between January 1, 2005 to December 31, 2011. Although the authors classifi ed their patients as having viral meningitis, we believe a diagnosis of aseptic or non-bacterial meningitis would have been more appropriate because cultures and PCR for viruses were not performed to ascertain etiology. More than 7600 children with aseptic meningitis were identifi ed, representing 0.05% emergency department visits. The number of ED cases declined almost 75% during the 6 year study period. 85% of the children with aseptic meningitis were hospitalized and 91% received antibiotic therapy. Although most children with aseptic meningitis do well the concern of missing the diagnosis of bacterial meningitis and the young age of the patients explains why treatment was often given.
NON-TREATMENT OPTION IN AOM We heard from Dr Stan Block of Bardstown, KY regarding an item in the Newsletter. “Therapeutic Nihilists: Lend Me Your Ears…” (Pediatric Annals 2002; 31:784-791) As a simple practicing pediatrician and leading researcher in the world of AOM, I personally have had to distinguish between AOM, OME and normal TMs in 20 to 30 patients daily for the past 34 years. The diagnostic pitfalls and clinical decision making is extremely complex. In the May 2013 Newsletter I am afraid you have misconstrued the initial AAP/AAFP guidelines on AOM from 2004 regarding the use of the non-treatment option for a “diagnosed” case of AOM. You stated that this option “was offered for MOST patients older than 6 months who had mild, uncomplicated middle ear disease.” This has only recently become an “option” in 2013 guidelines. Actually the non-treatment option in 2004 included only children older than 24 months who had a diagnosed non-severe AOM (fever < 39C; mild pain or less), consent from the caregiver and good follow up. For those 6 to 24 months of age either an observation option or an antibiotic treatment option was allowed for uncertain AOM diagnosis rarely seen by most general pediatricians. In addition, the reasons for the declining rates of AOM had little to do with uptake of the non-treatment option. This was confi rmed in two separate physician surveys performed by Vernacchio et al (Pediatrics 2007, 120:281-287) and by Coco et al (Pediatrics 2010, 125:214-220). Rather, most of the reduction in AOM is likely a result of the widespread uptake of PCV7 (and now PCV13) and an impressive increasing infl uenza vaccine rate in infants and young children. Other factors include better physician accuracy in diagnosis, increasing insurance co-payments and provider quality assurance issues. Furthermore, the 2004 guidelines provided minimal guidance to help the clinician distinguish AOM from OME, as the diagnosis of AOM was then based equally on non-specifi c symptoms (not just pus or bulging) when a child had a middle ear effusion. (Contemporary Pediatrics 2005; 22:S3-S8.) Diagnosis of AOM in the 2013 guidelines is based on examination and is more precise.
PARVOVIRUS MYOCARDITIS We are currently managing a 10 year old boy with severe myocarditis. His illness started with fever, upper respiratory symptoms, an acral maculopapular rash and cervical lymphadenopathy. He had neutropenia and thrombocytopenia and was admitted to Children’s Medical Center Dallas. Soon after admission he had a cardiac arrest and was successfully resuscitated and is currently receiving continuous veno-venous hemodialysis for severe cardiac dysfunction. His diagnostic workup was negative for enteroviruses, adenovirus and Mycoplasma pneumoniae and positive for parvovirus B19 by PCR in blood. He received two doses of IVIG. Whereas other viruses target the cardiomyocyes, parvoviruses infect the coronary endothelium resulting in myocardial ischemia and severe dysfunction. Molina and associates (Pediatr Cardiol 2013; 34:390) reviewed their experience with 19 patients with parvovirus myocarditis managed at four children’s hospitals in the United States. All required inotropic support, 9 required mechanical support, 5 died and 8 eventually required a cardiac transplant as will our patient.
MORE ABOUT SYNDEMICS We heard from Professor Andrew Fretzayas, M.D., Ph.D., who is Chairman of Pediatrics at the University of Athens School of Medicine in Greece: I read with great interest your comments on the history of the term “syndemic” that appeared in the January Newsletter of The Pediatric Infectious Disease Journal. Searching the PubMed database I found that the term has been used in the title of at least 40 publications. Many authors tended to explain the term in their publications and they referred directly or indirectly to the definition of the CDC. CDC defined syndemics as “synergistically interacting epidemics” ( www.cdc.gov/nchhstp/programintegration/definitions.htm) (accessed April 29, 2013). Accordingly, S.P. Kutz defines “syndemic—a set of mutually reinforcing epidemics” (J. Psychoactive Drugs 40(4):13-21, 2008). In the case of the article of MMWR, it was stated that “TB and HIV act synergistically within a population to cause excess morbidity and mortality”. I think that the etymologic origin of this term could be sought in the treasure of the Greek language, ancient and modern. It seems to be a combination of “syn”, which is a Greek preposition, and “epidemic”. Epidemic is also a Greek word which according to the OED means “a disease affecting many people at the same time in the same place for a short period of time”. The preposition “syn”, according to the highly respected scientific Greek dictionary edited by G. D. Babiniotis (ISBN 960-86190-0-9), means that something contributes to the appearance of the second component of the word (in our case epidemic). However, although both components of the term “syndemic” are of Greek origin there is not such a word in the Greek language and the term syndemic is not included in the OED. Therefore, I think that it should be considered as a neologism. We accept Professor Fretzayas’ comments as the final word of the subject.
HIS OWN MOTHER? REALLY? We read the obituary of Susumu Hotta, Professor Emeritus of Kobe University in Japan who died November 17, 2011 at 93 years of age (Emerg Infect Dis 2013; 19:843). Dr. Hotta spent decades studying dengue virus. He first isolated the virus in 1943 by inoculating blood from a patient named Mochizuki into brains of suckling mice. Dengue fever had been introduced into Japan by soldiers returning from tropical zones during World War II. The obituary contains the following astonishing vignette: In a country at war, preserving isolated virus strains was difficult because he did not have a freeze dryer and freezers were useless because of frequent power failures. Because of shortages of everything in his economically devastated country, he had to feed laboratory mice with a portion of his own food ration. At one time, when the supply of mice was low, his mother volunteered to keep the Mochizuki strain infectious. After injecting her with the strain, Dr. Hotta published a clinical report of the dengue syndrome in his mother.
INTERNATIONAL TRAVEL We received in late May the invaluable book from the CDC, CDC Health Information for International Travel 2014. It is published by Oxford University Press ( www.oup.com). The book is superbly organized to make it easy to seek all of the information you need related to international travel.