January 2004

A 5-year-old female was admitted to the hospital for evaluation and treatment of left upper lobe pneumonia. She had the onset of cough and fever about five days earlier. She was first evaluated in the emergency department (ED) two days after that and treated with azithromycin (Zithromax, Pfizer). However, her fever persisted and her cough worsened and a rash soon developed under her right eye. She received a shot of ceftriaxone (Rocephin, Roche) prior to leaving the ED for the ward.

Her past medical history is unremarkable and her immunizations are up to date, but she has not received pneumococcal conjugate vaccine (Prevnar, Wyeth). Her family history is positive for a younger brother currently in the pediatric intensive care unit (PICU) on a ventilator with pneumococcal pneumonia with an empyema caused by a macrolide-resistant and penicillin-intermediate Streptococcus pneumoniae.

Examination revealed a fever of 102.8° F, respiratory rate of 36. Her lungs had some rales and rhonchi. A rash was noted below the right eye consisting of a raised erythematous base with some small pustules and denuded areas (figure 1), which was initially thought to be erysipelas. Her chest radiograph is shown in figures 2 & 3. She was continued on intravenous ceftriaxone. Over the next few days her fever and pneumonia improved, and the rash changed as shown in figures 4 & 5.

Lab tests on admission revealed a white blood count of 26,000. Cultures of blood and rash are pending.

What is wrong with this patient? Pick all that apply.

1. Resistant pneumococcal pneumonia
2. Erysipelas
3. Cutaneous herpes simplex
4. Cellulitis
5. Impetigo

Answer

This is a case of simultaneous infections. The pneumococcus isolated from her brother in the pediatric intensive care unit (PICU) was penicillin-intermediate and resistant to macrolides. It is reasonable to assume the same organism caused this patient’s pneumonia, and indeed, grew from the culture of the rash. The blood culture was negative (on therapy). A viral culture of the rash was also positive for herpes simplex virus (HSV). The only way to know whether this is HSV or zoster is with a culture, as there is frequently overlap in appearance (figures 6–8, a different patient with zoster). The patient had intravenous acyclovir empirically added on hospital day 2. Remember that if treating with oral acyclovir for cutaneous infections, the dose is higher for zoster than for HSV (80 mg/kg/day vs. 30mg/kg/day). Therefore, I recommend doing viral cultures on all suspicious primary lesions. An ophthalmology consult was obtained to rule out eye infection with HSV. If there had been (figure 9), topical trifluoridine would be added. Lastly, it is unlikely that she also had impetigo or cellulitis, but co-infection is possible as seen in figure 10 & 11, that of a child with culture-proven HSV of a lesion on the forehead that was also infected with Staphylococcus aureus causing a cellulitis.

I hope your new year is off to a great start. I have received several very positive messages regarding my comments about supporting the military in various dangerous spots around the world. I think this is fairly natural. We all want to see an end to this conflict as soon as possible. I would be particularly interested in knowing how many pediatricians are deployed to these areas of the world, especially Iraq and Afghanistan.

So if you know of an active duty, reserve or National Guard pediatrician in these areas, please e-mail me at jhbrien@aol.com. Civilian pediatricians on missionary trips in these areas should also be included. I don’t know yet what we will do with the information, but I am sure many of you, like me, would like to know how many and who they are. I would also be interested in knowing about family physicians in these areas who are involved in pediatric medicine there.

For more information:

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