In Reply.— Our recent study of children with fever and petechiae included all children admitted to the Emergency Department during the 1 year of the study. Therefore, the 7% incidence of meningococcemia is a true incidence of meningococcemia in children admitted to an emergency facility with fever and petechiae. Although we agree that including the patients in whom an organism was not documented would have enhanced the statistical power of our results, we chose to exclude them due to the wide spectrum of illness represented in this group, both in severity of illness (ranging from viral syndrome to partially treated, presumed bacterial meningitis) and in presumed organism (viral versus bacterial).
A prospective study of patients with fever and petechiae was performed. Of 190 patients enrolled in the 1-year study, 13 (7%) had meningococcal disease. The most common bacterial association was Streptococcus pyogenes (19 patients). Viral infections were documented in 28 patients. Patients with invasive bacterial disease (group I) appeared more sick, were more likely to have signs of meningeal irritation, and were more likely to have petechiae on the lower extremities than those with less serious, nonbacteremic disease (group II). No patient in group I had petechiae only above the nipple line. Patients in group I had a significantly higher peripheral white blood cell count and absolute band form count. Although no laboratory test or physical finding was sufficiently sensitive to detect all patients with serious disease, the patient with abnormal cerebrospinal fluid, elevated white blood cell count, or elevated absolute band form count was at increased risk for invasive, bacterial disease. Conversely, the risk of serious disease was small if all of these values were in the normal range in the nonill-appearing child or if sore throat and clinical pharyngitis were present in the patient older than 3 years of age.
A prospective study of the effects of fever reduction on the clinical appearance of infants at risk for occult bacteremia was undertaken to study the hypothesis that infants with bacteremic illness fail to improve clinically following defervescence compared with infants with benign viral illness. A total of 154 children were enrolled in the study, including 19 with bacteremia: 13 with occult Streptococcus pneumoniae bacteremia, two with occult Haemophilus influenzae, type b bacteremia, and four with Haemophilus meningitis and bacteremia. There were no differences in degree of temperature reduction with acetaminophen between the bacteremic and nonbacteremic groups of infants. Among infants with bacteremia but without meningitis, differences from nonbacteremic children were detected in clinical appearance prior to fever reduction but not following defervescence. All patients with meningitis appeared seriously ill before and after defervescence. It was concluded that clinical improvement with defervescence is not a reliable indicator of the presence of occult bacteremia. Lack of clinical improvement with defervescence may be a reliable indicator for the presence of meningitis. Because there were differences in clinical appearance prior to fever reduction, routine administration of acetaminophen may interfere with the clinical evaluation by the physician.
To the Editor.— We wish to describe a previously unreported type of injury that we have encountered recently at the Children's Hospital Medical Center in Cincinnati, during this year of the 17-year locust, more properly termed cicada. Twelve children have come to the emergency department within a 1-month period with injuries related to activities involving catching, killing, or dodging these defenseless insects. The city of Cincinnati was invaded with an estimated 100 million of these insects during the late spring/early summer of this year.