EXPERIENCE AND REASON 463
Figure. Roentgenography of chest showing bilateral
hilar adenopathy and interstitial infiltration.
diagnosis of scrotal masses in adolescents and
chil-dren.
JANIS SCHAEFFER, MD
MICHAEL NUSSBAUM, MD
SANDY MEYERSFIELD, MD
Department of Pediatrics
Division of Adolescent Medicine
Long Island Jewish-Hifiside Medical Center
New Hyde Park, New York, and
Health Sciences Center
State University of New York at Stony Brook
Stony Brook, New York
REFERENCES
1. Kendig E: The clinical picture of sarcoidosis in children.
Pediatrics 54:289, 1974
2. Jasper P, Dennz F: Sarcoidosis in children. JPediatr 73:499, 1968
3. Gerstenhaber, B., Green, R., and Sachs, F.: Epididymal sarcoidosis: A report of two cases and a review of the litera-ture. Yale J Biol Med 50:669, 1977
4. Mikhail J, Mitchell D, Dyson J, et al: Sarcoidosis with genital involvement. Am Rev Respir Dis 106:465, 1972 5. Singer E, Hensler N, Flynn P: Sarcoidosis: Analysis of 45
cases in a large military hospital. Am J Med 26:364, 1959
6. Ricker W, Clarke M: Sarcoidosis. A clinico-pathologic review of 300 cases including 22 autopsies. Am J Clin Pathol 19:
725, 1949
7. Engle RL Jr: Sarcoid and sarcoid-like granulomas: A study of twenty-two autopsies. Am J Clin Pat/wI 29:53, 1953
8. Opal S, Pittman D, Hofeldt F: Testicular sarcoidosis. Am J Med 67:147, 1979
9. Rudin L, Megalli M, Messa-Tijader A: Genital sarcoidosis.
Urology 3:750, 1974
Excellent
Outcome
of
Bacteroides
Meningitis
in a
Newborn
Treated
with
Metron
idazole
Hydrocephalus has developed in all three
re-ported cases of Bacteroides fragilis meningitis in
newborns.’3 One author suggested this
complica-tion was related to the documented persistence of
Bacteroides in the CSF despite chioramphenicol
therapy.3 In two of the cases metronidazole was
tried late in the course, followed by prompt clinical
and bacteriologic resolution.”3 We report a newborn
Reprint requests to (M.I.M.) Department of Pediatric Infectious Diseases, University of Oklahoma Health Sciences Center, P0 Box 26901, Oklahoma City, OK 73190.
PEDIATRICS (ISSN 0031 4005). Copyright © 1980 by the
American Academy of Pediatrics.
with B fragilis meningitis in whom metronidazole
was used early, with rapid sterilization of the CSF, clinical cure, and no sequelae after 12 months of follow-up.
CASE REPORT
A 2,020-gm white male infant was delivered vaginally at 32 weeks gestation to a healthy primigravida, 52 hours after premature rupture of membranes. During labor, the
mother remained afebrile and received no antibiotics. A
scalp electrode was used to monitor fetal well-being.
Apgar scores were 4 and 8 at one and five minutes, respectively.
The baby was transferred to the Montreal Children’s Hospital because ofan imperforate anus. Additional prob-lems included moderate respiratory distress and a small
scalp laceration secondary to the electrode. Because of
prolonged rupture of membranes, cultures were obtained
and cloxacillin and gentamicin were prescribed.
(Antibi-otic dosages and laboratory data are shown in the Figure.)
Blood and urine cultures were sterile, whereas the gastric
aspirate and swabs of eye, ear, nose, and throat grew
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I f , I If f f t f f I 1
1195 209 663 118 22 0 41 11 10
(79) (13) (46) (41) (0) (44) (0) (0)
240 220 283 395 139 157 170 198 180
25 24 23 71 30 41 35 38 38
(61 1 (79) [631 12291 1671 1941 (1 18) [56] 99
+ + + - - -
-intravenous
___(OOJ oral
() 1 J
L (3#{176}) Y//J/////////A vI/IllIlIlIIIIIIlJIJ
c’<2 32,2 %2 <2,
32/2 /2 32,, M2 <2
(1) (1) (1) (2) (24)
. . I . . , I I I
1,0 5 20 25 30 35 40 45 50 55
464
PEDIATRICS
Vol.66
No. 3 September
1980
LUMBAR csF WBC (% PMN) PROTEIN (mg/dO SUGAR (mg/d$) BLOOD SUGAR CULTURE ANTIBIOTIC THERAPY mg/Ig day CLOXACILLIN GENTAMICIN AMPICILUN CHLORAMPHENICOL ME TRONIDAZOL( INHIBITORY/KILLING POWER
reciprocal of t#{232}ter
SERUM
CSF
5 10 15 20 25 30 35 40 45 50 55
AGE (daysj
Figure. Sequential antibiotic therapy and laboratory
data in a newborn with B fragilis meningitis. Asterisk
indicates interval (hours) between receiving antibiotic
Escherichia coli. The imperforate anus was due to a thin
covering membrane which was perforated digitally,
fol-lowed by daily anal dilations. The scalp laceration was
washed daily with 3% hexachlorophene and covered with
sterile dressings. The respiratory distress resolved rapidly
and by day 7 antibiotics and supplemental oxygen were
discontinued and the patient was bottle-feeding. At this
time a scalp abscess was noted at the electrode site.
Cultures of the purulent exudate grew E coli, B fragilis,
and anaereobic streptococci. Local treatment with
de-bridement and repeated hexachlorophene washes was
prescribed.
On day 10 the baby suddenly developed periodic breathing and cyanotic spells. WBC was 33,000/cu mm
with 53% polymorphonuclear (PMN) cells, 8% band cells,
and 24% lymphocytes. CSF showed 266 red cells, 1,175
white cells (79% PMN), protein of 240 mg/100 ml, and
sugar of 25 mg/100 ml (blood sugar of 61 mg/100 ml);
Gram stain was negative. Therapy with Ampicillin and
gentamicin therapy was started. Over the next three days
the baby remained critically ill with recurrent seizures,
despite anticonvulsant therapy. On day 14, B fragilis was
isolated from the initial CSF while cultures of blood and
urine remained sterile. By tube dilution method, the
minimal inhibitory concentration (MIC)/minimal
bacte-ricidal concentration (MBC) was 32/64 units/nil for
pen-icillin and 2/128 .tg/m1 for chloramphenicol. Antibiotic
therapy was changed to intravenous chioramphenicol at
a dose of25 mg/kg every 12 hours. There was no
improve-ment over the next 36 hours, and in view of the reported
failure ofchloramphemcol to sterilize CSF despite in vitro
sensitivitofB fragilis,’3 the drug was discontinued and intravenous metromdazole was started (30 mg/kg/day in
two divided doses). The CSF culture obtained after three
doses of chloramphemcol grew B fragilis. After 48 hours
of metronidazole therapy the CSF was sterile and the baby, having shown marked clinical improvement, did
dose and sampling of blood or CSF. Inhibitory and killing
powers were determined by tube dilution method using
the patient’s serum and CSF isolate of B fragilis.
well for the remainder of his hospital stay. Computed
tomography showed normal sized ventricles with no
evi-dence of ventriculitis or focal abscess. Metronidazole was
discontinued after a three-week course; however a repeat
lumbar puncture three days later showed an increase in
PMNs and a low sugar leveL The Gram stain and culture
were negative. Although his clinical condition was good,
oral metromdazole (in the same dosage regimen as given
intravenously) was continued for one more week.
Subse-quently, the CSF improved except for a persistently low
sugar level. At the time of this report, the baby is 12
months old, in good health, and developing normally for
his age.
DISCUSSION
This report documents the development of local
and invasive Bacteroides fragilis infection
proba-bly due to the fetal monitoring scalp electrode.
Local abscesses have been reported to occur in 4.5%
of babies monitored with scalp electrodes; however,
B
fragilis infection has not been documented andinvasive disease is rare.4 This is also the first
re-ported case of Bacteroides meningitis in a newborn
with no sequelae. We feel the early use of
metroni-dazole with rapid sterilization of the cerebrospinal
fluid was critical in this patient’s remarkable
recov-ely.
Anaerobic infections, although uncommon in the
pediatric age group, are being recognized with
in-creased frequency. A recent prospective survey
found that 5.8% of clinically significant bacteremic
episodes in children were due to anaerobes.5 In the
neonatal age group the incidence was 8.7%; 43% of
these isolates were B fragilis which is notable
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EXPERIENCE AND REASON 465
among anaerobes for its frequent resistance to
pen-icillin. Although sensitive in vitro to
chioramphen-icol, clindamycin, and carbenidillin, only
chioram-phenicol reliably achieves CSF concentrations
ex-ceeding the MIC.6 Despite this, chloramphenicol
has not been very effective in sterilizing the CSF,’3
and has failed to cure septic anaerobic infection in
spite of documented sensitivity to the drug, the use
of recommended doses, and adequate surgical
drainage procedures.7 The bacteriostatic activity of
chloramphenicol against B fragilis may account for
some of the reported therapeutic failures.8
Although our patient had received only three
doses of chloramphenicol we considered the
ther-apy a failure in view of his clinical deterioration, an
increasing CSF polymorphonuclear response, and a
persistent low CSF sugar. This was confirmed by
the positive CSF culture, and low serum and CSF
killing powers obtained while the patient was being
treated with chloramphenicol. This was in contrast
to the rapid clinical and bacteriological response,
coupled with excellent serum and CSF killing
pow-ers shortly after starting metronidazole therapy.
Metronidazole has a rapid bactericidal action
against anaerobes9 and is known to achieve
excel-lent CSF concentrations even with oral
administra-3 An injectable form is now available,
al-though its use is stifi experimental. Several recent
reports confirm the remarkable efficacy and low
toxicity of this drug in treating anaerobic
infec-tions.’#{176}The major fear limiting its use comes from
reports of tumors occurring in mice who were fed
life-long diets of metronidazole in high doses.” The
clinical relevance of such data remains to be shown.
There are no pharmacokinetic data on the use of
metronidazole in infants. We chose a regimen based
on that used in two previous reports of neonatal B
fragilis Based on our experience we
recommend early consideration of metronidazole
therapy in similar cases.
ACKNOWLEDGMENTS
Thanks to Mr S. Sorger for technical assistance and to
Dr R. Fontaine of Poulenc Ltd for provision of injectable
metromdazole.
REFERENCES
BARBARA
J.
LAW,MD
MELVIN
I.
MARKS,MD
Montreal Children’s Hospital
Montreal
1. Feldman WE: BacterQides fragilis ventriculitis and menin-gitis. Am J Dis Child 130:880, 1976
2. Dysart NK Jr, Griswold WR, Schanberger JE, et al: Men-ingitis due to Bacteroides fragilis in a newborn infant. J Pediatr 89:509, 1976
3. Berman BW, King FH, Rubenstein DS, et al: Bacteroides
fragilis meningitis in a neonate successfully treated with metronidazole. J Pediatr 93:793, 1978
4. Okada DM, Chow AW, Bruce VT: Neonatal scalp abscess and fetal monitoring: Factors associated with infection, Am J Obstet Gynecol 129:185, 1977
5. Dunkle LM, Brotherton TJ, Feigin RD: Anaerobic infections in children: A prospective study. Pediatrics 57:311, 1976 6. Picardi JL, Lewis HP, Tan JS, et at: Clindamycin
concentra-tions in the central nervous system of primates before and after head trauma. J Neurosurg 43:717, 1975
7. Thadepalli H, Gorbach SL, Bartlett JG: Apparent failure of chloramphenicol in the treatment of anaerobic infections.
Curr Therap Res 22:421, 1977
8. Rahal JJ Jr, Simberkoff MS: Bactericidal and bacteriostatic action of chloramphemcol against meningeal pathogens.
Antimicrob Agents Chemother 16:13, 1979
9. Ralph ED, Kirby WMM: Unique bactericidal action of
met-romdazole against Bacteroides fragilis and Clostridium
per-fringens. Antimicrob Agents Chemother 8:409, 1975 10. Tally FP, Sutter VL, Finegold SM: Treatment of anaerobic
infections with metronidazole. Antimicrob Agents
Chemo-ther 7:672, 1975
11. Roe FJC: Metronidazole: Review of uses and toxicity, J
Antimicrob Chemother 3:205, 1977
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1980;66;463
Pediatrics
Barbara J. Law and Melvin I. Marks
Metronidazole
Meningitis in a Newborn Treated with
Bacteroides
Excellent Outcome of
Services
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1980;66;463
Pediatrics
Barbara J. Law and Melvin I. Marks
Metronidazole
Meningitis in a Newborn Treated with
Bacteroides
Excellent Outcome of
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