ORNITHOSIS IN INFANCY

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ORNITHOSIS

IN

INFANCY

By Shimon Berman, M.D.,* Emil Freundlich, M.D., Kurt Glaser, M.D., Abraham

Abrahamov, M.D., Erela Ephrati-Elizur, Ph.D., and Hans Bernkopf, M.D.

752

P

RIMARY atypical pneumonia may be caused by a variety of agents, among

them rickettsias and viruses. Of the known

viruses there are members belonging to the

psittacosis-lymphogranuloma group. They

were first isolated from parrots, but then were found distributed throughout the ani-mal kingdom in a variety of wild and do-inesticated birds, and in some mammals

(

cats, mice and cattle).

These viruses are endemic in many

spe-cies of birds. Man contracts the disease

usu-ally by intimate contact with birds, or

through inhalation of dust containing virus

particles from their excreta.1’ The infected

bird may not show signs of disease but still be a healthy carrier. Human-to-human transmission is also known to exist, and

“humanized” strains of these viruses were

reported during some epidemics.4’

The name psittacosis is usually reserved for the disease transmitted by parrots or

parakeets. Ornithosis is the term proposed

by Meyer” 2 for virus strains infecting other

species of birds. These strains are generally thought to he less virulent to man.46

Children are believed to be much less

susceptible to ornithosis than adults.1, ‘S

Reports on ornithosis in children are very scarce, and no case report in a child

younger than 13 years has been found in

the literature. From 1 1 1 cases of ornithosis,

(liagnosed at the Hooper Foundation of the

University of California, not a single case

was discovered under the age of 10 years.3

A l)rother and sister aged 5 and 8 years

with interstitial pneumonia and a

3-year-From tile I)epartment of Pediatrics, Hadassah

Ilebrew University Ilospital, and the Virus Labora.

tory, hebrew University Hadassab Medical School, Jerusalem, Israel.

(Submitted for publication I)ecemher 7, 1954;

revision accepted February 1, 1955.)

0 ADDRESS: P.O.B. 499, Jerusal(.ul1, Israel.

old child with pleuropneumonia were

re-ported from Germany and Holland

respec-tively.8’ The youngest patient found with

ornithosis was an 18-month-old infant from Italy.1#{176} Recently 37 cases were reported

from a rural area in Illinois; only 2 of them

were children, aged 7 and 9 years.’1 The

diagnosis of omithosis in all these cases

was based on serological evidence only. Ornithosis viruses were suggested as a possible etiological agent of interstitial pneumonias in Israel when Komarow and Goldsmit isolated an ornithosis virus from

sick pigeons.” A human case of ornithosis in Israel was reported by Valero in an aduht.’ The diagnosis was established by a positive complement-fixation test and

con-tact with infected pigeons was

demon-strated in this case. Five cases of fatal inter-stitial giant cell pneumonia were previously

reported in infants in Israel by Wolman and others.14 The disease was suggested to be of a virus origin but serological and cultural studies for the identification of the virus were not performed.

This article deals with ornithosis in in-fants hospitalized in the Children

Depart-ment of the Hadassah Hebrew University

Hospital, Jerusalem, Israel.

In late winter of 1953 an infant died in our department of a severe pulmonary

in-fection that did not respond to antibiotic

treatment (Case 1 of our series). At about the same time a 1-month-old infant died suddenly at home without signs of previous illness (this infant was not hospitalized and

is not included in our series). A virus

be-longing to the psittacosis-lymphogranuloma

group was isolated from the lung tissue in

both cases.’5 These cases directed our at-tention to the possibility of more frequent occurrence of ornithosis in infants.

There-fore, we started to examine sera of infants and children in our department with

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METHODS

ISOLATION OF THE AGENT. Whole blood or serum, taken at the beginning of the illness and/or lung and spleen suspensions from fatal cases were inoculated amniotically into 12 to

13-day-old developing chick embryos. Penicillin

and streptomycin were added to the inocuhum.

The eggs were incubated for 4 additional days and tile virus was then passed to eggs, by the

amniotic and yolk sac routes and to mice by the

intracerebral and intranasal routes.

COMPLEMENT-FIXATION TEST. The antigen for complement-fixation test was prepared from

ahlantoic fluid with the virus isolated from Case

1. At the beginning of this study all sera were

tested in the dilution of 1 :8 or more. Later,

lower dilutions, 1:2 and 1:4, were also tested.

Normal allantoic fluid served as control antigen.

PROPERTIES OF ISOLATED AGENTS. Virus was

isolated from 5 cases by inoculating serum,

l)lOod or organ suspensions from fatal cases into fertilized eggs. Chick embryos died 4 to 5 days

following yolk sac inoculation. Mice inoculated

intracerebrally died within 3 to 6 days. Pigeons died within 7 to 10 days following intracerebral

inoculation. Organs of infected mice and egg material were found to be sterile by ordinary bacteriological methods.

Identification of the isolated agents as

orni-thosis virus was based on the following criteria: 1. Macchiaveiho stained smears from ma-terial of infected eggs and mice showed

dc-mentary and inclusion bodies typical of the

psittacosis-lymphogranuloma group.

2. Fatal infection was produced in mice by the intracerebral route only, in contradistinc-tion to psittacosis virus which produces fatal

infection in mice by both intraperitoneal and

intracerel)ral routes.

3. Fatal infection was produced in pigeons

following intracerebral inoculation, a property attributed to ornithosis virus mainly.

4. A cross immunization test carried out

with the isolated virus and a strain of

orni-thosis virus isolated from sick pigeons in

Israel, did not reveal any immunological

dif-ferences.

A detailed description of the biological and serological properties of the isolated viruses

will be published.’6

CASE REPORTS AND RESULTS

The cases which are reported will be

di-vided in 2 groups according to the

corn-pheteness of the laboratory data. The first

group (Cases 1 to 6, Table I) includes cases in which the diagnosis of ornithosis is con-sidered certain, based on the isolation of a

virus of the psittacosis-lymphogranuhoma

group, or on an increasing antibody titer

in the serum during the illness. The second group (Cases 7 to 9, Table II) includes pa-tients in whom a diagnosis of ornithosis

could not be made with certainty because of incomplete data. In no case was isolation

of the virus attempted. In these cases, the early ones in this series, the only blood

sample examined gave a positive comple-ment-fixation test. A second sample either

was not obtained, or did not reach the

laboratory in good condition.

First Group (Cases 1 -6, Table I)

CASE 1. B. M. A 2-year-old girl was ad-mitted February 9, 1953, because of a corneal

ulcer. The infant was malnourished but no

other abnormal findings were revealed on physical examination. The corneal ulcer

im-proved after 2 weeks of local treatment, but

at this time a severe cough with fever

ap-peared. Coarse rales could be heard over both lungs. Her condition deteriorated; she became

dyspneic and cyanotic, and developed severe

diarrhea with signs of dehydration. Parenteral fluid therapy, oxygen, penicillin, Aureomycinit,

and streptomvcin did not improve her

condi-tion and the infant died 5 days after the

ap-pearance of the first signs of respiratory

dis-ease.

On post-mortem examination interstitial pneumonia with areas of atelectasis was found.

A virus belonging to the psittacosis-lympho-granuloma group was isolated from the lung

tissue.

CASE 2. A.J. A 19-month-old boy was

ad-mitted on April 21, 1954. He suffered from

coughing for 1 month before admission. A few days before he entered the hospital his

condition deteriorated and on admission he

was severely cyanotic and dyspneic. Coarse

rales were heard over both lungs. The liver was enlarged, palpable 3 cm. below the costal

margin, and the spleen was just palpable. A

roentgenogram revealed accentuation of the lower branches of the bronchi and increased hilar markings on both sides, especially the

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lung field, possibly atelectasis of the right

lower lobe. The heart was slightly enlarged in

all directions.

The infant received antibiotics and oxygen

but his condition got worse. Diarrhea occurred on the 9th day and signs of paralytic ileus ap-peared 3 days later. In spite of treatment with parenteral fluids, blood transfusion, panto-theme acid, penicillin, Aureomycin#{174}, and streptomycin the infant died on the 14th day of hospitalization.

A virus belonging to the psittacosis-hympho-granuloma group was isolated from the blood

on the 14th day of hospitalization. The corn-plement-fixation test was negative in a 1:8 titer from the same blood specimen. On post-mortem examination foci of

bronchopneu-monia and interstitial myocarditis were found.

Comment on Cases 1 and 2. These 2

cases were the only deaths in our series.

In both cases virus isolation was successful.

The clinical picture was that of a severe

pulmonary infection which did not respond

to antibiotic therapy. Both infants were malnourished and developed a severe

gastroenteritis with dehydration in the hos-pital and in Case 2, paralytic ileus.

CASE 3. L. R. This male infant was 1 month old on admission April 1, 1954. His mother

re-. ported that she had had a persistent cough

during the last month of pregnancy, without

c fever. His older brother had a mild upper respiratory infection 1 week after the patient’s

. birth. The patient was breast fed

supple-- mented with half skimmed milk and gained

t satisfactorily. At the age of 2 weeks he started

:

to cough and 1 week later developed fever but

nevertheless continued to gain weight.

He was cyanotic on admission but in good

. general condition. There was dullness on

per-cussion over the left lung base. The spleen was palpable 1 cm. below the costal margin. A roentgenogram showed decidely increased

]m hilar markings on both sides, especially on the

‘! left, and pleural effusion along the left chest

. border.

. The infant received penicillin, streptomycin

and chhoramphenicol. His condition improved

slowly; the temperature became normal after

. 1 1 days but the left hilar shadow was still markedly increased in the roentgenogram after

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con-dition when he heft the hospital 25 days after

admission.

A virus of the psittacosis-hymphogranuloma

group was isolated from the infant’s blood on

the 4th hospital day, 2 weeks after the

begin-ning of the disease. The complement-fixation

test was twice negative in the 1 : 8 dilution.

CASE 4. A.

J.

A 1-year-old boy was admitted

OH November 20, 1953, 2 days after his illness

began with cough, high fever and dyspnea.

The infant’s mother had had a cough without

fever 2 weeks before. On admission he was

dyspneic and cyanotic; there was dullness over

the right lung on percussion. A roentgenogram on admission revealed a dense shadow in the

middle lobe (atelectasis?) and a slight pleural

effusion on the right. There were no

patho-logical findings in the left chest.

The infant received penicillin, streptomycin,

Aureomycin#{174}, Terramvcin#{174}, and oxygen. Ten

ml. of clear, bacteria-free fluid were extracted

from the right pleural space. On the 7th day of hospitalization, a roentgenogram showed

marked effusion in the left pleural space and

a round shadow in the right middle hung field. The hilar shadows were markedly increased

on both sides.

There was no improvement during the first 10 days of hospitalization. Afterwards the

temperature became normal and the cyanosis

disappeared ; however, the roentgenological

findings still persisted. The infant was seen

in the outpatient clinic after being discharged

an(l was in excellent condition.

The complement-fixation test on the 6th day of the disease was positive in the 1:8 dilution;

On the 27th (lay the titer rose to 1 :64.

Isola-tion of the virus was not attempted.

Comment on Cases S and 4. These 2

cases represent a moderate to severe

pul-monary infection. The diagnosis was proved

in Case 3 by the isolation of a virus, in

Case 4 by an eight-fold rise of the titer in

the complement-fixation test. Both infants were cyanotic, had fever for nearly 2 weeks

and did not respond to antibiotics. Both had increased hilar markings, a pleural effusion

and persistent roentgenological signs after clinical improvement. The white blood cell count was high in both infants (Table I). The young age of Case 3 is noteworthy.

In both cases the mother had had a

respira-tory infection before the infants’ illness.

CASE 5. 5. C. This infant was admitted on

February 20, 1954, at the age of 40 days. The pregnancy and the birth were normal. He was breast fed and gained satisfactorily. His dis-ease began 3 days before admission with fever, cough, vomiting and diarrhea. On ad-mission, he was in very good condition,

with-out fever. There were no other pathological findings, aside from ronchi and moist rales throughout both lungs. The roentgenogram of

the chest was negative. The infant received penicillin and was discharged after 6 days. A virus belonging to the

psittacosis-lympho-granuloma group was isolated from patient’s

blood on the 5th day of the disease. The com-phement-fixation test was twice negative but was tested in the dilution of 1 : 8 only.

CASE 6. K. E. A 2-year-old boy was admitted on February 20, 1954, with the history of fever for 1 day, cough and respiratory stridor.

The pharynx was mildly inflamed and moist

rales were heard throughout both lungs. A roentgenogram of the chest was negative. The infant received penicillin, streptomycin and Terramycin#{174}, and steam. The temperature became normal the day after admission. He

was discharged after 5 days at his parents’ request though at this time there still were signs and symptoms of a mild upper

respira-tory infection.

A virus was isolated from his blood on the 4th day of the disease. The complement-fixa-tion test was negative in the 1 :8 dilution on

the 4th and 22nd days of the disease; 3 months later it was positive in the 1 :4 dilution.

Comment on Cases 5 and 6. These 2

cases had only a mild upper respiratory

infection with a negative roentgenogram

of the chest. They had mild fever for the first few days of the disease. The infants

were in very good general condition during the illness. The spleen and liver were not enlarged and the white blood cell count was normal. In both cases a virus belonging to

the psittacosis-lymphogranuloma group was isolated from the blood, the

complement-fixation test was negative in the 1 :8

dilu-tion in both cases at first and positive in a

dilution of 1:4 in Case 6 three months after the disease. The young age of Case 5 is

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‘l’ABLE HI

COMPLEMENT-FIXING ANTIBODY TITE1IS IN FAMILY MEMBERS

4 1:16 I.5 months

5.5 uimontlus

ORIGINAL ARTICLES

Second Group (Cases 7-9, Table II)

These are the cases with a single positive

complement-fixation test. The interpretation

of the serologic tests requires some cati-tion because non-specific serological

reac-tions are known to appear in cases with

atypical pneumonia. However, the serum

reactions with normal control antigen were

always negative in our cases. Moreover

taking into consideration the young age

of our patients, it seemed unlikely that the

positive serologic tests could be connected

with a former infection. It was assumed, therefore, that the presence of antibodies

was caused by the present disease.

Comment on Cases 7-9. These cases

rep-resent a mild to moderate pulmonary in-fection. They had a history of cough and

fever for a few days before entering the hospital. On admission they had high fever and were dyspneic but improved clinically

after 1 to 3 days. The physical findings in

the lungs were dullness over part of the

lung or a few rales. The roentgenograms revealed density of part of the lung, pleural

effusion or increased hilar markings. The

white blood cell count was normal or slightly elevated. Additional findings were

diarrhea and malnutrition in Case 7, anemia

and purulent conjunctivitis in Case 8, and

congenital heart disease in Case 9.

Serological Findings in Family Members

Family members of some of our patients

were examined for the presence of

comple-ment-fixing antibodies against ornithosis

viruses. As reported earlier, the history of a

recent respiratory infection was elicited in

Sonic family members.

The results are presented in Table III. It is seen that in 2 cases sera of the

par-ents and, in 1 case the mother’s serum

con-tamed specific complement fixing

anti-bodies. In Case 3 the mother reported

hay-ing had a cough during the last month of

pregnancy and the infant’s older brother

had had an upper respiratory infection 1

week before the patient’s illness began. The

patient was 1 month old at the beginning

(‘ase A1otiiei Father

Time of Ixam. after Patient’s

Disease

1 1:16 1:8 ‘3 months

3 1:10 1:10 1nmonth

*

* Could not he examined because of

anticonlple-unentary reaction.

of the disease. In Case 4 the mother’s serum

showed a titer of 1 : 16 which dropped to 1:2 4 months later, a finding which may be explained on the assumption that the titer observed in the first sample was due to a recent infection. In this case, the mother

had a severe cough some 10 days before the infant’s illness.

The presence of complement-fixing anti-bodies in other members of the family may

be due to an infection from a common source, but the possibility of a human-to-human transmission of the disease should also be considered.

DISCUSSION

The experience with ornithosis which has been described definitely demonstrates that clinical ornithosis occurs in infants and that this disease, far from being rare in this age period, may have a predilection for early childhood. The number of cases reported here probably constitutes the minimum

rather than the true number coming in our department, as no doubt other cases were overlooked, especially in the beginning of

this study.

A number of problems have arisen from

our experience with omithosis:

The clinical course was so varied that one

can easily assume infections occur without

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chil-(Iren in our series may be dtie either to the

mildness of the infection in this age group

or to an immunity, not necessarily of

demonstrable type, resulting from an

un-recognized infection in the past.

The severity and prolonged duration of

SOI1T1 of the cases cannot be ascribed to a

supenmposed bacterial infection; the

in-effectiveness of the antibiotics is against

such an argument.

Three of our cases had a pleural effusion

(3, 4, and 9), bilateral in one (Case 4),

while all pulmonary findings (clinical and

roentgenologicah) were on the right side only. These findings may indicate that in

the course of a viremia the infection lo-cahized directly in the pleura. No attempt

was made to isolate the agent from the

pleural effusion.

In a disease with such varied clinical

courses, it is difficult to evaluate the effec-tiveness of antibiotic therapy. There is no

basis in any of the cases for ascribing the

termination of the illness to the therapy. Some cases (2, 3, and 4), remained febrile

for 10 or more days and 2 (lied (Cases 1, 2) in spite of antibiotic treatment. This is

contrary to reports in the hiterature’7’#{176}

which claim the broad spectrum antibiotics

have a favorable influence on ornithosis.

On the other hand Aureornycin#{174} in a dose of

1 mg. per egg inhibited completely the mul-tiphication of the strain of ornithosis virus isolated from Case 1.

More should be learned about the evalua-tion of the serological test. The absence of

a rise in the titer of the complement-fixing

antibodies in some of our cases in which

a virus was isolated is not clearly

under-stood; the time of persistence of a positive

complement-fixation test after the disease

has run its course seems to differ from case to case. Two of our youngest patients

(

Cases 3 and 5) showed a very poor serologi-cal response. More study will be necessary before we can attribute this to poor

anti-body production in young infants. The low

titer in the complement-fixation test in those

cases can probably not be explained by

treatment, because in most of these cases

there was no clinical response to antibiotics.

In considering the possibility of

human-to-human infection, pathways of the

excre-tion of the virus should be known. If such infection had taken place in our series, from

the mother to infant, droplet transmission seems probable. Two of the fatal cases had

diarrhea which may have been one of the casual infections so common in malnour-ished children. However, the fecal excre-tion of the viruses would have to be

con-sidered, even without diarrhea, especially in infants in whom virus coughed up was

probably swallowed.

In our small series the cases were

dis-tributed between the months October and April. In none of our patients could

in-timate contact with birds be demonstrated. The children could have easily come in

con-tact with infected pigeons’ droppings as pigeons are found all over Jerusalem and

other places in Israel. Over 25 per cent of more than 100 pigeons examined had a positive complement-fixation test for orni-thosis virus.’6 Here too we do not know how long the complement-fixation test

re-mains positive after the infection, nor do we

know how long an apparently healthy bird

may excrete virus. Virus isolation from

birds’ droppings was not attempted. We can

say that pigeons represent a reservoir of

ornithosis infection in our area although

the importance of this reservoir could not be estimated. Sparrows, starlings, chickens, etc. were not examined.

SUMMARY

This report deals with 6 certain and 3 possible cases of ornithosis in infants. All

cases were under 2% years of age; 2 of them

were 1 month old.

In 5 cases a virus belonging to the

psit-tacosis-lymphogranuloma group was iso-lated and the sixth case showed an eightfold rise of the antibody titer in the complement-fixation test during his illness. In other cases the diagnosis was suggested by a single

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All these infants had manifestations of

respiratory tract infection. There was a

great \rariatjon in the clinical picture; 2

cases were fatal and 2 others suffered

moderate to severe respiratory disease

while the others had only a mild respiratory

infection. In severe cases the broad

spec-trum antibiotics had no obvious effect upon

the course of the disease.

Infected birds may have been the source

of the disease but in some cases

human-to-llunlan transmission appeared possible.

ACKNOWLEDGM ENTS

\Ve wish to express our thanks to Dr.

S. Schorr, X-ray Department of the

Hadas-saIl Hebrew University Hospital, Jerusalem,

for his helpful a(lyice in the evaluation of

the roentgenologic findings.

Our thanks are due to Drs. M. Wolman

and \I. G. Goldberg, Department of

Pathology, Hebrew University Medical

School, who performed the autopsies on

CaSeS 1 and 2.

REFERENCES

1. Meyer, K. F. : The ecology of psittacoSis

.311(1 Ornitllosis. Iedicine, 2 1:175, 1942.

2.

Meyer, K. F., Eddie, B. , and Yanamura,

H. Y.: Ornithosis (Psittacosis) in pigeons

dIl(l its relation to human pneumonitis.

Proc. Soc. Exper. Biol. & Med., 49:609,

1942.

:3. Meyer, K. F., and Eddie, B. : The knowl-edge of human virus infection of animal

Origin. J.A.M.A., 133 : 822, 1947.

4. Bedson, S. P. : Recent work On the viruses

of the psittacosis-lvmphogranuloma

group and its importance with special

reference to primary atypical

pneu-inonia. Irish

J.

M. Sc., 322:385, 1952.

5. Bedson, S. P. : The psittacosis-lympho-granuloma group of viruses. Brit. M. Bull., 9:226, 1953.

6. L#{233}pine, P. R.: L’ornithose (#{233}tiologie,

svmptomatologie et diagnostic). Semaine

hop. Paris, 26:3376, 1950.

7. \Volins, W. : Ornithosis (Psittacosis).

Re-,iew, with report of 8 cases resulting from contact with domestic pekin duck. Am.

J.M.

Sc., 216:551, 1948.

8. Strobel, W. : Beitrag zum Krankheitsbild (her Ornithose im Kindesalter. Deutsche med. Wchnschr., 79: 176, 1954.

9. Prakken, H. H. : Ecu Ceval van Psittacosis

(

Ornithosis). Maandschr. kindergeneesk.,

18:341, 1950.

10. Toscano, F., Angela, C. C., and Di Nola, F. : Pneumopatie da ornitosi nell’infan-zia. Minerva pediat., 5:930, 1953. 1 1. Ward, C. C., Hildinger, A. L., Morrissey,

R. A., and Birge,

J.

P. : Psittacosis-lymphogranuloma venereum virus anti-bodies in man. J.A.M.A., 155:1146, 1954.

12. Komarov, A., and Goldsmit, L. : The isola-tion of the causative agent of ornithosis (psittacosis) in Israel. Harefuah, 43:85,

1952.

13. Valero, A. : Human Ornithosis in Israel. Harefuah, 45:102, 1953.

14. Wolman, M., Izak, G., Freund, E., an(I Shamir, Z. : Studies on interstitial giant cell pneumonia. Am.

J.

Dis. Child., 83:

573, 1952.

15. Ephrati-Elizur, E., Bernkopf, H. and Wol-man, M. : Isolation of virus belonging to the psittacosis-lymphogranuloma group

from two fatal cases of interstitial pneu-monia in children. Harefuah, 45:199, 1953.

16. Ephrati-Elizur, E., and Bernkopf, H. : To be published.

17. Sigel, M. M., Cole, L. S., and Hunter, 0.: Mounting incidence of psittacosis. Am.

J.

Pub. Health, 43:1418, 1953.

18. Wirth,

J.

: L’ornithose. Helvet. med. acta,

19:314, 1952.

19. MacLachlan, W. \V. C., Crum, C. E.,

Kleinschmidt, R. F., and Wehrle, P. F.: Psittacosis. Am.

J.

M. Sc., 226:157, 1953.

20. Horsfall, F. L. : Chemotherapy of respira-tory viral diseases. PEDIATRICS, I 3:593,

1954.

SPANISH ABSTRACT

Ornitosis

en la Infancia

Los virus determinantes de cua(lrOs respi-ratorios son end#{233}micos en muchas especies (IC

ayes; el hombre los adquiere par contacto Intimo con tales ayes o bien por Ia inhalaci#{243}n de polvo contaminado por eh virus de los

cx-creta de las ayes infectadas. Estas adem#{225}s pueden ser simplemente portadores asinto-m#{225}ticos. Se supone que el virus se transmite

tambi#{233}n de hombre a hombre; los 1111105 son

menos susceptibles que los adultos.

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mes de edad, con el objeto de se#{241}alarel hecho de que Ia ornitosis puede ser m#{225}sfrecuente en lactantes y niflos de Jo que comunmente se

supone. A fines de 1953 observaron un nino

it1e muri#{243} con infecci#{243}n pulmonar severa,

resistente a los antibi#{243}ticos; aproximadamente

en Ia misma fecha un lactante de mes de edad falleci#{243} bruscamente en su domicilio sin

mani-festaci#{243}n de enfermedad; en ambos casos se

aisl#{243}del tejido pulmonar un virus del grupo

psitacosis-hinfogranuloma. Desde entonces los autores iniciaron tin estudio del suero de los niflos hospitahizados por infecciones

respira-tori iS.

En cinco de los casos aqul presentados se aisl#{243}el virus; en el sexto los tItulos de aglutinaci#{243}n se encontraron muy elevados y en otros tres ci diagn#{243}stico fue sugerido por una sola prueba de fijaci#{243}n del complemento. Todos presentaron sIntomas y signos de

mIce-ci#{243}nrespiratoria, benigna y higera en algunos y muy grave en otros; 2 fallecieron. En los casos severos no se observ#{243}beneficio sobre el curso de la enfermedad con ci empleo de antibi-#{243}ticosde espectro amphio.

(10)

1955;15;752

Pediatrics

and Hans Bernkopf

Shimon Berman, Emil Freundlich, Kurt Glaser, Abraham Abrahamov, Erela Ephrati-Elizur