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1/91. Multiple intestinal ulcerations and perforations secondary to methicillin-resistant staphylococcus aureus enteritis in infants.

    PURPOSE: The aim of this study was to define a distinctive clinical entity of multiple intestinal ulcerations and perforations in infants. methods: Two infants underwent abdominal exploration for surgical abdomen and were noted to have multiple intestinal ulcerations and perforations. A peculiar and unique surgical finding, numerous transverse linear ulcerations scattered along the entire small intestine, prompted us to search for similar instances. Five similar cases were additionally identified by members of the Korean association of Pediatric Surgeons. The clinical courses, the surgical findings, and the results of bacterial cultures were reviewed. As well, the tissues of resected intestines were examined histopathologically. RESULTS: The characteristics of this entity are as follows. (1) It usually occurs in infants who have been treated with broad-spectrum antibiotics. (2) Despite broad-spectrum antibiotic treatment, diarrhea and abdominal distension developed progressively and deteriorated. (3) Histological evaluation showed mucosal ulcers with neutrophil infiltration, submucosal microabscesses, and colonies of gram-positive cocci. (4) methicillin-resistant staphylococcus aureus (MRSA) was the predominant organism cultured from the body fluid. (5) Only two cases, the completely resected one and the one immediately treated postoperatively with vancomycin, survived. CONCLUSIONS: This entity is caused by multiple intestinal ulcerations and perforations secondary to MRSA enteritis in infants. It has a high mortality rate because of its difficult diagnosis. However, early recognition of this entity can lead to successful treatment. ( info)

2/91. transillumination for the diagnosis of pneumoperitoneum.

    transillumination of the abdomen with a cold fibreoptic light source was used for the rapid diagnosis of pneumoperitoneum in a sick premature infant with necrotising enterocolitis. The diagnosis was confirmed at laparotomy. The neonate survived the surgical procedure of resection and anastomosis of the perforated gut. Although additional diagnostic investigations such as x-rays and paracentesis of the abdomen were also positive in this case, transillumination of the abdomen proved to be a useful tool for early diagnosis. transillumination thus is a valuable modality for early diagnosis of pneumoperitoneum, especially where facilities for in-house x-rays are not available. ( info)

3/91. incidence and outcome of a 10-fold indomethacin overdose in premature infants.

    We reviewed the incidence and morbidity of a 10-fold medication error among all premature infants treated with indomethacin. We detected 4 incidents among 1059 indomethacin doses given to infants weighing less than 1000 g. None of the infants had intracranial hemorrhage, necrotizing enterocolitis, or significant deterioration of renal function. ( info)

4/91. Spontaneous biliary perforation and necrotizing enterocolitis.

    A case of spontaneous bile-duct perforation in a 5-month-old boy with a history of necrotizing enterocolitis in his 1st week of life is reported. To our knowledge, this is the second case reported with such an antecedent, supporting a vascular etiology for some cases of spontaneous biliary perforation. ( info)

5/91. Profuse lower gastrointestinal haemorrhage as an indication for surgery in necrotising enterocolitis.

    An infant developed massive lower gastrointestinal haemorrhage secondary to necrotising enterocolitis after cardiac surgery. The haemorrhage was only controlled following a colectomy. ( info)

6/91. Necrotizing enterocolitis in omphalopagus conjoined twins.

    female omphalopagus twins underwent laparotomy on the second day of life after an antenatally diagnosed high jejunal bowel obstruction. Bowel resection and choldocho-enterostomies were performed. Despite recovery from laparotomy, the development of severe necrotizing enterocolitis (NEC) in one twin led to rapid deterioration and the death of both infants on day 34. The elucidation of the combined biliary tree, the dilemma of NEC in conjoined twins, and the possibilities of emergency separation are discussed. Consideration should be given to emergency separation of conjoined twins in the event of potentially lethal complications. ( info)

7/91. aeromonas sobria infection with severe soft tissue damage and segmental necrotizing gastroenteritis in a patient with alcoholic liver cirrhosis.

    A 49-year-old man, who had a 3-year history of liver dysfunction but had not been treated, was admitted to the hospital with a sudden onset of fever and generalized muscle pain. He subsequently developed generalized purpura with scattered hemorrhagic bullae of the skin and massive bloody stools. aeromonas sobria was proven by culture of both blood and bullous fluid. In spite of the extensive treatment with antibiotics and other medications in the intensive care unit (ICU), the patient went into septic shock and died 2 days after admission. Pathological examination on autopsy revealed segmental necrotizing gastroenteritis with bacterial colonies and alcoholic liver cirrhosis, in addition to extensive severe soft tissue damage involving cellulitis and rhabdomyolysis and epidermolysis. Although the prognosis for vibrio vulnificus infection with severe soft tissue damage in patients with liver cirrhosis, malignancy, diabetes mellitus or other pre-existing diseases is poor, the unfavorable progression of aeromonas species, especially A. sobria infection is rare. This is thought to be the first report of an autopsied case. ( info)

8/91. Progressive perinatal bowel obstruction--a rare cause of short-bowel syndrome.

    A girl was born after an uneventful pregnancy of 36 weeks. Prenatally, distended bowel loops had been seen on ultrasound. Multiple small-bowel atresia was diagnosed and treated surgically. In the course of the next eleven weeks, previously patent segments of small bowel became obstructed. In 4 separate operative sessions, several segments of jejunum and ileum were resected, leaving 23 cm of ileum with the ileocecal valve in place. On microscopic examination of all resected material, necrosis of the mucosa was found consistent with ischemia. The child survived and tolerated full enteral feeding at the age of 8.5 months. The origin of the progressive obliterating process remains unknown. ( info)

9/91. klebsiella pneumoniae with extended spectrum beta-lactamase activity associated with a necrotizing enterocolitis outbreak.

    BACKGROUND: Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in newborn infants, affecting primarily premature neonates. Clustering of cases in epidemics is well-described; many are associated with an identifiable pathogen. patients AND methods: case reports are presented of six neonates seen with NEC during a 2-month period in 1998. All bacterial isolates were subjected to antibiotic testing, determination of MIC and molecular fingerprinting. RESULTS: klebsiella pneumoniae with extended spectrum beta-lactamase production was isolated from blood cultures of all six patients. In five patients the isolate appeared to be a single clone. The onset of NEC in the patients was earlier, more rapid and more severe than usual. Four of the six required surgery and five required mechanical ventilation. Two of the six patients died, but only one was directly related to a complication of NEC. All of the patients developed severe thrombocytopenia (platelet count <20 x 10(9)/l), and three developed hepatitis. The K. pneumoniae proved difficult to eradicate. Extended courses of multiple antibiotics were administered and measures were introduced to reduce overcrowding and improve infection control. CONCLUSION: The isolation of a single clone of K. pneumoniae with extended spectrum of beta-lactamase activity during an NEC outbreak highlights the need for strict infection control. This organism caused significant morbidity and was difficult to treat. ( info)

10/91. Oral gastrografin in neonates: a note of caution.

    Hyperosmolar feeds are known to increase gastrointestinal permeability, predisposing to absorption of toxins. They are also associated with necrotising enterocolitis (NEC) in neonates. A case of a neonate with suspected NEC who died following Gram-negative septicaemia possibly related to oral gastrografin is reported. Hyperosmolarity of gastrografin may have caused complete loss of mucosal integrity in the compromised bowel leading to Gram-negative septicaemia. ( info)
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