August 2001

---In Memory of Col. James Willis Bass, MD "The Chief" 25 May 1930 – 12 June 2001. He would have liked this one.

A previously healthy 1-year-old boy was admitted to the hospital for evaluation and treatment of pneumonia. The history of this illness began 1 week earlier when he was seen in the emergency department for mild respiratory distress with wheezing and fever, and was found to have respiratory syncytial virus (RSV) bronchiolitis. He was given a shot of ceftriaxone (Rocephin, Roche), a prescription for amoxicillin, albuterol syrup and steroids and told to return the next day. He apparently had some improvement and did not come back as instructed, but when seen four days later, he was still wheezing.

He was then started on nebulized albuterol every 4 to 6 hours and kept on amoxicillin. He initially did well with this regimen, but had a fever to 104° F about 48 hours later with a worsening cough. He was brought back to the clinic the next morning and appeared in no distress, but still had fever. A CBC was done revealing a WBC count of 35,100 and a chest radiograph shown in figures 2 & 3. Previous chest films had been normal. He was given another dose of ceftriaxone, and told to return the next day. At that time his fever was down somewhat, but with no improvement in his cough. Because of concern over the radiographs, he was admitted.

His past medical history and family history were unremarkable, and his immunizations were up to date. He was born full-term and seen only for well baby check-ups and acute minor illnesses. He was seen in the ER a month earlier for URI symptoms. He had a normal chest radiograph at that time.

Examination on admission revealed an alert and active infant with a low-grade fever and otherwise normal vital signs, nasal congestion, decreased breath sounds in the left lower chest, and minimal expiratory wheezes. Because of the appearance on plain radiographs, a chest CT scan was done (figures 4 and 5) soon after admission.

What’s Your Diagnosis?

1. RSV pneumonia
2. Secondary bacterial pneumonia
3. Infected sequestration
4. Lung abscess

Answer

The answer is lung abscess. The plain chest films suggest a cavitary lesion with an air-fluid level, and an abscess is essentially confirmed with the CT scan of the chest. A repeat CT scan was done four days later (figures 6 7, & 8) showing enlargement of the abscess in spite of IV antibiotics (ceftriaxone). The third-generation cephalosporin was used for the first few days because it appeared that the patient had a positive clinical response to the two doses he received as an outpatient. However, soon after the second scan, he was switched to vancomycin plus clindamycin (Cleocin, Pharmacia) and taken to surgery to remove the abscess and surrounding necrotic lung tissue (figure 9 & 10). Culture of the abscess fluid grew methicillin-resistant Staphylococcus aureus (MRSA). This was a community-acquired MRSA (CAMRSA) that was sensitive to both clindamycin and erythromycin. He was discharged on hospital day 16 in good condition on oral clindamycin for an additional week. He had an unremarkable recovery.

The fact that the patient had a normal chest radiograph earlier essentially eliminates sequestration from the list, as these are often found by serendipity while looking for other lung pathology. As you may recall, a sequestration is a nonfunctioning segment of lung tissue as a result of a congenital malformation. This tissue has circulation from the systemic circuit, and may or may not communicate with the airway. They may be cystic and associated with other abnormalities of the chest. They may also be found as a site of infection. The definitive treatment is surgical excision.

We knew the patient had an RSV infection. So, answering RSV pneumonia may not be entirely wrong. However, it is not likely that RSV directly caused the abscess shown in the CT scan. And technically, secondary bacterial pneumonia is also correct. But abscess is more correct. Sounds a little bit like boards, doesn’t it?

Points of interest

There are a couple of teaching points with this case. One is that CAMRSA is becoming more and more common, and we need to start thinking about it more, especially with unusual or persistent infections. See last month’s column for more discussion on this issue. Another point is that treating RSV bronchiolitis with broad-spectrum antibiotics may actually predispose the child to developing a secondary bacterial pneumonia. At the very least, it is not going to speed up the recovery (see Caroline Breese Hall’s chapter (185), in Feigin & Cherry’s Textbook of Pediatric Infectious Diseases, 4^th Ed, 1998, specifically page 2100).

“The Chief”

---Jim Bass, MD, his wife Beverly, and Dr. Gerald Merenstein (center) from Denver, one of many visiting professors Jim hosted at TAMC.

In last month’s column, I announced the death of Jim Bass, MD. I noted at the beginning of this column that he would have liked this case. The Staphylococcus was one of his many special interests. In November 1982, Dr. Bass published the best clinical review of staphylococcal diseases with color pictures I have ever seen, in Postgraduate Medicine (Vol. 72/number 5), titled “The spectrum of staphylococcal disease; from Job’s boils to toxic shock.” In fact, I was in my first year of fellowship with Jim when this came out. Between Dr. Bass and Dr. Marian E. Melish at the University of Hawaii, this small island state had two of the leading staph experts in the business. I always had the sense that there was friendly competition between Drs. Bass and Melish, but always tempered with respect and mutual admiration. Dr. Melish wrote the chapters on Kawasaki disease, bacterial skin infections, and coagulase-positive staphylococcal infections in Feigin and Cherry’s, Textbook of Pediatric Infectious Diseases. Jim also had a special interest in group A streptococcal diseases and often spoke the praises of people like Drs. Breese (the father of Caroline Breese Hall referenced above), Stillerman, Denny and Wannamaker, who had influenced him along the way. However, it was pertussis that was his first area of interest. And it was cat scratch disease that was his last.

---The big catch: A lover of photography, Jim Bass inspired Jim Brien to begin taking clinical pictures.

I almost referred to pertussis as his first love. That would have been wrong. Jim’s first (and last) love would be his wife, Beverly, whom he married in 1951, and was at his side when he died. Jim and Bev raised two daughters, Paulet and Brian, and have three grandchildren. His second true love would, of course, be pediatrics and infectious diseases.

Jim was a 1957 graduate of the LSU School of Medicine in New Orleans. He did his Pediatric training at Brooke Army Medical Center in San Antonio under Col. Leo Geppert, who about 11 years earlier had started the first Army Pediatric Residency training program at BAMC in 1946. Dr. Geppert was also a very accomplished pediatrician and veteran of World War II, but many people don’t know that one of his children is the singer, songwriter and musician, Christopher Cross.

---During his career, Jim Bass trained 22 ID fellows and 155 pediatricians.

Dr. Bass went on to Army assignments at Ft. Detrick, Maryland and Madigan Army Medical Center in Tacoma, Wash. Following these assignments, he did his infectious disease training at Tulane in New Orleans with Margaret Smith, MD, from 1966-1968. He then found his third true love, Hawaii, when he was assigned there at Tripler Army Medical Center from 1968-1975 (as department chief from 1969-1975). He was then called back East to be the chief of the department of pediatrics at Walter Reed Army Medical Center and consultant in pediatrics to the U.S. Army Surgeon General. While there, he was also the founding chairman and professor, department of pediatrics at the Uniformed Services University of the Health Sciences in Bethesda, Md. However, the lure back to Hawaii was more than he could stand, and he moved back to his true home in 1981. He remained chief of pediatrics at Tripler until 1994. After more than 40 years of active duty, Jim was medically retired in 1997. At that time, Jim Bass was the senior colonel in the U.S. Army.

---When Jim came to town, people came together for a good time.

During his career, Dr. Bass trained 22 infectious disease fellows and 155 pediatricians. My Scott & White colleague, Ed Fajardo, Capt, U.S. Navy (ret), and I were two of those fellows from 1982-84. Eduardo speaks with a bit of a Peruvian accent that Jim had trouble understanding, so I often volunteered to translate Ed’s comments into Texan. Being from Louisiana, Jim understood Texan fairly well.

The housestaff and staff who served under Jim affectionately referred to him as “The Chief.” He could be a father figure or a brother figure, depending on whether you needed your butt kicked or someone to sit down and share a beer and some sushi. He could move seamlessly between these roles. While he was busy rearing generations of pediatricians and ID specialists, Jim published more than 200 papers, abstracts and book chapters, and received numerous awards recognizing his accomplishments. Some of his more noteworthy awards include the prestigious Lewis Aspey Malogne Award for Academic Excellence from the Surgeon General of the Army in 1990, the Outstanding Service Award from the Section on Uniformed Services of the American Academy of Pediatrics in 1992, the first Burtis Burr Breese Award from the Pediatric Infectious Diseases Society in 1999, and the Distinguished Physician Award from the PIDS the following year (see The Pediatric Infectious Disease Journal, 2000; 19:815-818). This is the most prestigious award given by his peers. It’s like the Academy Award for best actor.

Col. Bass was directly responsible for starting me on my career of taking clinical pictures. Our mutual love of photography and sense of humor provided hundreds of opportunities to capture funny and sometimes-embarrassing moments. We often joked that Jim’s picture with his swordfish caught in the Hawaiian waters as being staged. Of course it was not, but he was always ready to pose for whatever the occasion, especially for a laugh. On Fridays after work, Jim could be found holding court with his residents and fellows at the Tripler Army Medical Center Officers Club, or driving home a point with some of the nurses. Of course, he always held himself to a two beer limit, and always left to be home before dark (Beverly’s rule).

The Uniformed Services Section of the AAP has honored distinguished military pediatricians by naming various competitions after them. Howard Johnson, Col, USAF (ret), Ogden Bruton, Col, USA (ret), and Andrew Margileth, Capt., USN (ret), and Leo Geppert have various research competitions named in their honor. Jim Bass was honored in 1995 by having the annual college bowl competition named after him, the James W. Bass Challenge Bowl, at the annual Uniformed Services Pediatric Seminar. The original “Challenge Bowl” concept for the USPS was developed by James E. Shira, Col, USA (ret) in 1986. For those of you interested in the history of military pediatrics, an excellent, concise review was published by Callahan, Bass, Person and Shira in Pediatrics, vol. 103(6):1298-1303, June 1999.

I could fill this magazine with Jim Bass stories and pictures, but I don’t think that would be allowed. The Army Medical Corps has lost one of its truly legendary figures, and I will conclude this tribute by just saying that the world I live in is less interesting, less entertaining, less educational, and less fun now that Jim is gone. I and many others whose lives were changed by knowing Jim Bass feel that we have lost a mentor, instantly available consultant, brother, father and friend. Eduardo says “Farewell, Chief, ’til we meet again.”

For Your Information:

• James H. Brien, DO, Pediatric Infectious Disease, Scott and White's Children's Health Center and Texas A&M University, College of Medicine, Temple, Texas. E-mail: jhbriend@aol.com