Letters to the Editor
Statements appearing here are those of the writers and do not represent the official position of the American Academy of Pediatrics, Inc. or its Committees. Comments on any topic, including the contents ofPediatrics,are invited from all members of the profession: those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.
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Letters should be submitted in duplicate in double-spaced typing on plain white paper with name and address of sender(s) on the letter. Send them to Jerold F. Lucey, MD, Editor, Pediatrics Editorial Office, Fletcher Allen Health Care, Burlington, VT 05401.
Varicella Causes Skin Pits and Keloids—More
Reasons for the Varicella Vaccine
To the Editor.—
Since 1995, the American Academy of Pediatrics and the Ad-visory Committee on Immunization Practices have recommended the varicella vaccine.1Nevertheless, in one study,⬍50% of pedi-atricians recommended universal varicella vaccination.2The
vac-cine’s benefits are manifold. It has been shown to decrease fever, rash, pneumonia, and encephalitis; however, preventing derma-tologic sequelae of varicella has received little attention. These sequelae include cutaneous pits and keloids, particularly among individuals with darkly pigmented skins.3,4 In our experience, keloidal scars are especially common in children and adults of Asian (Fig 1) and African ancestry (Fig 2, see page 161), respec-tively, as well as Hispanics of partial African ancestry. Keloids are disfiguring and may be painful, pruritic, and/or restrict range of motion.5
Virtually all keloid treatments have shortcomings. Radiation is carcinogenic, laser treatment is costly, and scalpel surgery typi-cally delays the recurrence of keloids without being truly ablative. Although efficacious, intralesional corticosteroids are impractical for the pediatric age group because most youngsters are fearful of injections. A noninvasive therapy that holds promise for children is silicone gel sheeting.6Unfortunately, we have found this mo-dality disappointing. Therefore, given the inherent risk of scarring for individuals with darkly pigmented skins, vaccination is the optimal preventive approach to varicella-induced pitting and ke-loid formation.
These complications should be included among the sequelae of varicella and added to the indications for vaccination, especially among children at risk.
Noah Scheinfeld, JD, MD Steven R. Cohen, MD, MPH
Beth Israel Medical Center/Jacobi Medical Center Albert Einstein College of Medicine
New York, NY 10003 REFERENCES
1. Arvin AM. The varicella vaccine. Curr Clin Top Infect Dis.1997;17: 110 –146
2. Newman RD, Taylor JA. Reactions of pediatricians to the recommen-dation for universal varicella vaccination. Arch Pediatr Adolesc Med. 1998;152:792–796
3. Alhady SM, Sivanantharajah K. Keloids in various races. A review of 175 cases.Plast Reconstr Surg.1969;44:564 –566
4. Laude TA. Skin disorders in black children.Curr Opin Pediatr.1996;8: 381–385
5. Alster TS, West TB. Treatment of scars: a review. Ann Plast Surg. 1997;39:418 – 432. See comments.
6. Wong TW, Chiu HC, Chen JS, Lin LJ, Chang CC. Symptomatic keloids in two children. Dramatic improvement with silicone cream occlusive dressing.Arch Dermatol.1995;131:775–777
Underreading of the Tuberculin Skin Test
Reaction
To the Editor.—
In the September 1998 issue ofPediatrics,an abstract fromChest
regarding underreading of the tuberculin skin test reaction by 107 health care professionals, mainly pediatricians and pediatric house officers, was published. The original article stated that only 2 readers chose the ballpoint pen technique for test reading com-pared with 105 who chose the palpation method.1
In our practice, we see significant numbers of patients with induration after tuberculin skin testing caused by previous BCG immunization. We use the ballpoint method to determine the size of the reaction. The ballpoint method has been compared with palpation and determined to be comparable or superior2– 4when performed by experienced or well-trained examiners. The ball-point method is reported to be easier and more quickly learned.2,5 Although imperfect, the tuberculin test is still the best method to screen for tuberculous exposure. There exists a need to teach medical students and residents to accurately read tuberculin skin tests. We endorse the ballpoint technique because it is easy to perform, easy to teach, and learn. It is important to emphasize proper administration of the test and the use of clinical judgement in the interpretation.
Mirzada Pasic Kurbasic, MD, MSc J. Thomas Badgett, PhD, MD
Division of General Pediatrics Department of Pediatrics School of Medicine University of Louisville Louisville, KY 40292
REFERENCES
1. Kendig EL, Kirkpatrick BV, Carter WH, et al. Underreading of the tuberculin skin test reaction.Chest.1998;113:1175–1177.
2. Sokal JE. Measurement of delayed skin-test responses.N Engl J Med. 1975;293:501–502
3. Jordan TJ, Sunderam G, Thomas L, et al. Tuberculin reaction size measurement by the pen method compared to traditional palpation. Chest.1987;92:234 –236
4. Pouchot J, Grasland A, Collet C, et al. Reliability of tuberculin skin test measurement.Ann Intern Med.1997;126:210 –214
5. Longfield JN, Margileth AM, Golden SM, et al. Interobserver and method variability in tuberculin skin testing.Pediatr Infect Dis.1984: 323–326
“Damned If the Parents Cry, Damned If They
Don’t” by the Nurses! Dilemma of a
Neonatologist
To the Editor.—
With rapid advances in technology, neonatologists are increas-ingly faced with extremely complex discussions regarding critical illness, prolongation of life, and withdrawal of life support in neonates. Such discussions/decisions are often complicated by social and cultural influences. Working overseas for nearly a de-cade, I have consistently observed a peculiar response from the nursing staff after parents of critically ill neonates have had a talk with the neonatologist. If the parents had tears flooding their eyes, “the bad news was not conveyed appropriately.” If the parents did not cry or did not look shattered, “they were not explained to or did not understand the gravity of their baby’s illness.” In either case, “the parents needed more expert counseling or needed to be explained things more clearly.”
I remember the teaching of my wise, old professor of pediatrics in India: “If the night is dark, even a single, lonely star will help them go through it. Never underestimate the ability of the parents to understand the severity of illness of their child. They know when the inevitable is nearby. These are the times when they will be searching for that star of hope. You may have to help them if they cannot find it. You may point out things in black and white maybe once, but more than that you will be taking away that single, lonely star. The night will then be unbearable; the spirit will be crushed.”
For years I have been trying to support the parents under such circumstances by trying to find that single, lonely star—any rea-sonable ray of hope that will help them to cope with the situation till they recover, able to participate in the decision making involv-ing their child. Even under the worst possible circumstances, I have always found some ground for a ray of hope making the journey toward the inevitable less painful for the parents. I believe Fig 2. Nineteen-year-old African American woman with keloidal nodules 3 to 4 years after varicella infection: (a) right angle of jaw; (b) upper aspect of posterior trunk (base of neck).
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a gradually fading ray of hope is less crushing to the spirit com-pared with sudden darkness ushered in by “brutal honesty.” Fortunately the need for such abrupt, brutal honesty is very in-frequent. If it exists, most probably a meeting with the parents was long overdue before the end was deemed to be inevitable so suddenly.
Whether the reactions of nursing staff are related to cultural differences, medicolegal fears, or to their perceived lack of in-volvement as a team member in such matters is difficult to prove or disprove.1,2I believe it is most probably a combination of both, cultural differences and medicolegal fears overriding the need to search for that single, lonely star as another form of compassion. Until others try to search for it, I will continue to be damned if the parents cry and damned if they don’t.
Sanjay Patole, MD
Kirwan Hospital for Women Department of Neonatology
Thuringowa Central QLD 4817 Australia
REFERENCES
1. Martin DA. Nurses’ involvement in ethical decision-making with se-verely ill newborns.Iss Compr Paediatr Nurs.1989;12:463– 473 2. Holly C. Critical care nurses’ participation in ethical decision-making.J
N Y State Nurses Assoc.1989;20:9 –12
Spin Dryer Injuries
To the Editor.—
A 9-year-old girl presented with arm pain and tenderness after putting her arm into a clothes dryer. The dryer was an old type without automatic shut-off for the drum. Her arm became entan-gled in the clothing, which then twisted her arm. A radiograph showed a mid-diaphysis incomplete spiral radius fracture. She was referred to orthopedics and casted in an above-elbow cast.
An English literature search (“spin dryer injuries”) revealed reports of other such injuries including dislocated fingers, frac-tures of the forearm, fracfrac-tures of the humerus, and avulsion of the arm at the distal humerus.1,2
Parents should be urged to keep children away from these dryers and to replace them as soon as possible.
Steven G. Hammer, MD
Waukesha Medical Center—Barstow Waukesha, WI 53188
REFERENCES
1. Glasko CS. Spin dryer injuries.Br Med J.1972;4:646 2. Vickers PR. Spin dryer injuries.Br Med J.1973;1:175
Diagnostic Performance of Amplified
Mycobacterium Tuberculosis
Direct Test in the
Cerebrospinal Fluid of Children With
Tuberculosis Meningitis
To the Editor.—
Early diagnosis and specific treatment can prevent sequelae or fatal outcome in tuberculous meningitis (TBM).1Extrapulmonary tuberculosis is frequently associated with infection with low num-bers of bacilli, which prompted the adaptation of nucleic amplifi-cation assays to nonrespiratory specimens for early diagnosis.2 Several such amplification tests are available for the detection of
Mycobacterium tuberculosis(MT), but few data describe their use in the diagnosis of TBM.
We performed a prospective study to assess pretreatment and posttreatment cerebrospinal fluid (CSF) specimens of 72 children with highly probable TBM admitted to the University Hospital of Dicle, Diyarbakir, Turkey, from January 1998 through February 1999. Doerr et al’s3criteria were used for diagnosis of TBM in our patients. We used transcription-mediated amplification (Ampli-fied M. Tuberculosis Direct Test [MTD]; Gen-Probe, San Diego, CA) and compared it with Ziehl-Neelsen staining, radiometric
culture (BACTEC) and Lo¨venstein-Jensen medium for MT. MTD was performed with 50L of SDS-NaOH-pretreated specimen with a cutoff value ofⱖ30.000 relative light units according to the instructions of the manufacturer. Of 72 patients included in the study (26 female; 6 months–14 years old, median: 4.6 years), 15 were in stage I, 34 were in stage II, and the remainder were in stage III. The duration of symptoms varied from 7 to 74 days (average: 28 days). Fever (94%) and neck stiffness (74%) were the most common presenting signs and symptoms. All patients re-sponded to treatment clinically. Of 72 CSF pretreatment speci-mens, 24 (33%) were positive by MTD, 7 (10%) by BACTEC, 4 (5%) by growth in Lo¨venstein-Jensen medium, and 2 (3%) by acid-fast staining. On the second CSF examination after the fourth week of treatment, 2 were positive by MTD, and none by culture and direct smear, as expected from previous reports of posttreatment tests.4 TBM presents one of the most difficult diagnostic problems among the extrapulmonary manifestations of TB. Because micros-copy yields positive results in 3% to 37% of first samples only, and culture on solid media—apart from being very slow—is similarly insensitive, with growth observed only 37% to 52% of cases,4 many clinics use Doerr’s criteria,3 as done in our study. Most nucleic acid amplification assays based on amplification of myco-bacterial DNA by polymerase chain reaction are rapid and spe-cific. Nevertheless, reports vary greatly with respect to the ability of polymerase chain reaction to detect MT in clinical specimens.5 Also, many of these protocols require technical equipment and skills not easily available in the setting of a clinical laboratory. Our results support that Gen-Probe MTD, based on the same principles as culture confirmation method (Accuprobe), including a preced-ing enzymatic rRNA amplification step that provides greater sen-sitivity,6overcomes many of the difficulties and drawbacks cited above, and can be a valuable test for rapid diagnosis and therapy of TBM.
Ahmet Yaramis, MD* Selahattin Tekes, PhD‡ Meki Bilici, MD*
*Unit of Pediatric Infectious Diseases ‡Medical Biology and Genetic Department Dicle University Hospital
Diyarbakır, Turkey
REFERENCES
1. Waecker NJ, Connor JD. Central nervous system tuberculosis in children: a review of 30 cases.Pediatr Infect Dis J.1990;9:539 –553 2. Pfyffer GE, Kissling P, Jahn EMI, Welscher HM, Salfinger M, Weber R.
Diagnostic performance of amplified M tuberculosis direct test with cerebrospinal fluid, other nonrespiratory, and respiratory specimens. J Clin Microbiol.1996;34:34 – 41
3. Doerr CA, Starke JR, Ong LT. Clinical and public health aspects of tuberculous meningitis in children.J Pediatr.1995;127:27–33
4. Kennedy DH, Fallon RJ. Tuberculous meningitis. JAMA. 1979;241: 264 –268
5. Soini H, Skurnik M, Liippo K, Tala E, Vilgonen MK. Detection and identification of mycobacteria by amplification of a segment of the gene coding for the 32-kilodalton protein.J Clin Microbiol.1992;30:2025–2028 6. Vlaspolder F, Singer P, Roggeveen C. Diagnostic value of an amplifica-tion method (Gen-Probe) compared with that of culture for diagnosis of tuberculosis.J Clin Microbiol.1995;33:2699 –2703
Precocious Puberty
To the Editor.—
this study give average ages for breast development and pubic hair development in 2 racial groups only—white girls and African American girls. Before introducing new guidelines for evaluation, surely a random population-based study should be performed including all racial groups.
While acknowledging the inadequacy of using Marshall and Tanner’s guidelines3from the 1960s we feel that if new guidelines for evaluation of early puberty are to be introduced in the United Kingdom or other countries, a truly random study should first be carried out within the local community.
Fiona Finlay, MD Rosemary Jones, MD
Bath & West Community NHS Trust Child Health Department
Newbridge Hill
Bath BA 1 3QE, England
REFERENCES
1. Kaplowitz PD, Oberfield SE. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: Implications for evaluation and treatment.Pediatrics.1999;104:936 –941
2. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary char-acteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings Network.Pediatrics1997; 99:505–512
3. Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in girls.Arch Dis Child.1969;44:291–303
In Reply.—
Thank you for giving us the opportunity to reply to the letter of Drs Finlay and Jones. We agree that althoughideally,a random-ized, population-based study including all racial groups would
provide the best way to define the normal range for the age of onset of puberty in young girls, we believe that the paper of Herman-Giddens et al at the present time provides the most useful data, at least for US girls. The large size of the sample and the fact that the subjects were drawn from 65 different practices around the country in large part compensates for the lack of randomiza-tion. In England, where Drs Finlay and Jones work, the trend for earlier onset of puberty may not be as strong, and we encourage them and our colleagues in other parts of the world to either review existing data for their countries or help gather new data to decide if new guidelines for defining precocious puberty are war-ranted. We wish to underscore the point made in our article that whatever guidelines are used for the age at which puberty is precocious, pediatricians need to be aware that there are situations in which girls with signs of early puberty, even at ages that fall within the newly proposed guidelines, still need to be evaluated. These include girls in which 1) the progression of puberty is very rapid; 2) the height coupled with a very advanced bone age suggests a poor adult height prognosis; 3) there is new evidence of central nervous system dysfunction; and 4) there are social or behavioral factors that indicate the child and family would cope poorly with early puberty and menses.
Paul B. Kaplowitz, MD
Department of Pediatrics
Virginia Commonwealth University School of Medicine
Richmond, VA 23298-0140
Sharon E. Oberfield, MD
Department of Pediatrics
Columbia University College of Physicians and Surgeons
New York, NY
LETTERS TO THE EDITOR 163
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DOI: 10.1542/peds.106.1.160-a
2000;106;160
Pediatrics
Mirzada Pasic Kurbasic and J. Thomas Badgett
Underreading of the Tuberculin Skin Test Reaction
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DOI: 10.1542/peds.106.1.160-a
2000;106;160
Pediatrics
Mirzada Pasic Kurbasic and J. Thomas Badgett
Underreading of the Tuberculin Skin Test Reaction
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