Browsing by Author "Pitcher, Richard"

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    Bilateral tuberculous mastoiditis and facial palsy
    (2004) Pitcher, Richard; Thandar, Mohammed A
    This case, only the second of bilateral facial palsy in the literature,1 underscores the tragedy of a fragmented social infrastructure and health care system where multiple factors conspire to ensure an increasing prevalence of tuberculosis (TB). The patient was first seen at Red Cross Children’s Hospital in September 2001, aged 3 years and 2 months. He was living with his unemployed single-parent mother in an informal settlement. He had bilateral suppurative submandibular lymphadenitis, requiring incision and drainage. Two weeks after discharge, pus swabs revealed a positive culture for Mycobacterium tuberculosis. The local TB clinic was notified, but his mother could not be contacted, having relocated to central Cape Town where she had obtained temporary employment. In March 2002 he was seen at Somerset Hospital, Cape Town, with a suppurative discharge from both ears. Pus swabs again cultured M. tuberculosis. Attempts at contact via the local TB clinic faced the same problems as previously and the follow-up outpatient appointment was not kept. The third contact with the health care system was in May 2002, when his aunt, who had taken over his care, brought him to Red Cross Hospital. He had bilateral profuse suppurative discharges from his ears, discharging neck sinuses, facial palsies, profound conduction deafness, microcytic anaemia and kwashiorkor. There was no evidence of exposure to HIV. Pus swabs from the ears and neck yielded mixed bacterial and M. tuberculosis culture. Computed tomography (CT) of the temporal bones demonstrated extensive destruction of the mastoid bone and ossicular chain bilaterally, consistent with tuberculous mastoiditis (Fig. 1).
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    Congenital lung mass in anasymptomatic patient
    (2006) Zar, Heather; McIvor, Bruce; Furlan, Gisella; Jedeikin, Leon; Pitcher, Richard
    A routine 20-week antenatal ultrasound scan showed a congenital lesion of the left fetal lung, measuring approximately 25 mm x 25 mm x 30 mm. The mass showed no sonographic change through the remainder of an uneventful pregnancy. The baby was delivered by elective caesarean section at 38 weeks' gestation, with a birth weight of 2 900 g, and had no postnatal complications. A chest radiograph performed in the early neonatal period was normal, but a contrasted single-slice helical computed tomography (CT) chest scan at age 6 weeks demonstrated the small, oval, solid mass in the left lower lobe, with no associated mediastinal shift (Fig. 1). The vascular supply of the lesion could not be identified on this scan.
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    Extrinsic bronchial compression by primary tuberculous adenopathy, simulating foreign-body aspiration
    (2005) Pitcher, Richard; Hewitson, John
    A 5-month-old boy was well until the day before admission, when he developed a cough. On the morning of admission he was irritable and his mother noticed a blue tinge to his lips during episodes of crying. This prompted her to bring him to the emergency unit at Red Cross Children's Hospital, where he was found to be distressed and cyanosed, with a respiratory rate of 60 beats per minute, a heart rate of 200/minute and alar flaring. His left chest showed decreased air entry, bronchial breathing and dullness to percussion. Oxygen saturation was 66%, improving to 88% on face-mask oxygen. His weight was on the 50th percentile. He was well hydrated, well perfused and had no significant background medical history. A mobile chest radiograph (Fig. 1) showed complete opacification of the left hemithorax, mediastinal deviation to the left and overexpansion of the right lung, which had herniated across the midline. A penetrated anteroposterior (AP) chest radiograph (Fig. 2) showed abrupt 'cut-off' of the left main bronchus.
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    Protean appearance and behaviour of liver hydatids
    (2004) Pitcher, Richard
    A 12-year-old boy was first seen in May 2003 for a tympanoplasty, when a peri-operative chest radiograph showed a calcified granuloma in the right lung (Figs 1a and 1b), but no other abnormality. In September 2003 he was seen again, referred by his rural general practitioner, with a 3-week history of right upper quadrant pain, fever, anorexia and weight loss. He had had a non-productive cough for a week, was pyrexial (37.8°C) and tachypnoeic, with dullness to percussion and decreased breath sounds at the right pulmonary base. He had marked right upper quadrant abdominal tenderness with guarding and a 3 cm hepar, but was not jaundiced. His white cell count was 14.9 x 109 /ml and his erythrocyte sedimentation rate (ESR) 140 mm/hour. Chest radiography revealed a markedly elevated right hemidiaphragm, with loss of clarity in its mid-portion and some right fissural thickening (Figs 2a and 2b). An ultrasound examination showed three mixed echogenicity liver lesions interpreted as abscesses (Fig. 3). One was located in the left lobe (6 cm diameter), and two were in the right lobe, measuring approximately 8 cm and 10 cm in diameter respectively. The abscess in segments 7 - 8 showed transdiaphragmatic rupture into the right pleural space (Fig. 4). During respiratory excursion, ultrasound showed abscess contents moving across this defect. A contrast-enhanced computed tomography (CT) scan of the liver (Figs 5a and 5b) showed thick fluid and septations in the lesion in segments 7 - 8, while homogeneous thick fluid was demonstrated in the other two. The presence of septations in one of the cysts raised the possibility of complicated hydatid disease.
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    Proximal oesophageal strictures in a child with HIV disease
    (Health and Medical Publishing Group, 2003) Van der Merwe, William; Pitcher, Richard; Zöllner, Ekkehard W
    The patient and her twin brother were born preterm by caesarean section. Her birth weight was 2 100 g. She had perinatal exposure to HIV, and was therefore bottle-fed with term formula milk.She remained well until the age of 11 months when, weighing 6 880 g, she required hospital admission for a right upper lobe pneumonia, which responded well to oral amoxicillin. No causative organism was isolated. There was no evidence of active tuberculous infection on gastric washings or Mantoux test.
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    Short emergency department length of stay attributed to full-body digital radiography - a review of 3 paediatric cases
    (2006) Koning, Lizanne; Douglas, Tania S; Pitcher, Richard; Van As, A B
    Multiple casualties strain the resources of emergency departments. Two polytraumatised patients arriving simultaneously can overwhelm a small community hospital, while the capacity of a large urban emergency department does not extend beyond the treatment of 3 - 4 severely injured patients at the same time using the routine trauma protocol.1 Emergency department overcrowding because of multiple casualties leads to increased length of stay and can have an adverse effect on patient outcome. Variations from the norm in trauma management, particularly during the initial assessment and resuscitation phase of care, during a multiple casualty incident, has been associated with 10% and 9% incidence of preventable morbidity and mortality, respectively.2 Inadequate evaluation may contribute to up to 30% of early deaths in children with polytrauma.3
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    Short emergency department length of stay attributed to full-body digital radiography - a review of 3 paediatric cases
    (2006) Koning, Lizanne; Douglas, Tania S; Pitcher, Richard; Van As, Sebastian A B
    Multiple casualties strain the resources of emergency departments. Two polytraumatised patients arriving simultaneously can overwhelm a small community hospital, while the capacity of a large urban emergency department does not extend beyond the treatment of 3 - 4 severely injured patients at the same time using the routine trauma protocol.1 Emergency department overcrowding because of multiple casualties leads to increased length of stay and can have an adverse effect on patient outcome. Variations from the norm in trauma management, particularly during the initial assessment and resuscitation phase of care, during a multiple casualty incident, has been associated with 10% and 9% incidence of preventable morbidity and mortality, respectively.2 Inadequate evaluation may contribute to up to 30% of early deaths in children with polytrauma.3
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    Simultaneous ultrasound identification of acute appendicitis, septic thrombophlebitis of the portal vein and pyogenic liver abscess
    (Health and Medical Publishing Group, 2003) Pitcher, Richard; McKenzie, Carey
    A 17-year-old youth from a rural background presented to a secondary hospital with a 3-week history of epigastric pain, constipation and weight loss. He had a temperature of 40°C, marked right upper quadrant tenderness and a white cell count of 21.1 ´ 109/l. The chest and abdominal radiographs were normal, but an abdominal ultrasound scan showed two small areas of low echogenicity in the left lobe of the liver consistent with abscesses (Fig. 1). The main portal vein was distended, measuring 16 mm in diameter, and contained echogenic material indicative of thrombus (Fig. 2). In the right iliac fossa there were features of an inflamed appendix, as demonstrated by an 8 mm diameter tubular, non-compressible, fluid-filled viscus, with a distal blind end and an echogenic focus filling the lumen proximally (Fig. 3). A diagnosis was made of acute appendicitis, complicated by septic thrombophlebitis of the portal vein (pylephlebitis) and pyogenic liver abscesses. Appendicectomy was performed later that day, revealing an inflamed appendix, confirmed histologically. The patient was treated with perioperative intravenous triple antibiotics and commenced on anticoagulants following surgery. Discharge was on the 10th postoperative day. Regular out-patient follow-up documented progressive decrease in the size of the portal vein thrombus and the liver abscesses. The abdominal ultrasound scan 4 months post-surgery demonstrated a completely normal upper abdomen