Volume 81
Number 4
nursing mothers tested is considerably at
variance with t h e findings w h i c h a p p a r e n t l y
resulted in the d r u g w a r n i n g for nursing
mothers. T h e literature indicates t h a t the
m a x i m u m concentration of chlorothiazide in
serum is a m e a n of 2.3 /~g p e r milliliter at
2.3 hours in n o r m a l volunteers. 2 W e r e one to
use 1,000 c.e. of milk p e r d a y as an average
daily intake for one of these infants, a level of
0.1 mg. p e r 100 ml. w o u l d transfer only
1 mg. of chlorothiazide to the i n f a n t p e r day.
Since chlorothiazide is used in infants w i t h
h e a r t disease at a dose of 20 rag. p e r kilo-
g r a m p e r day, a the a m o u n t of d r u g poten-
tially transferred in breast milk is extremely
small.
CONCLUSION
T h e risk of a nursing infant acquiring toxic
or even significant doses of chlorothiazide
Neonatal ascariasis
Wen-Genn Chu, M.D., Pin-Mei Chen,
M.D., Chin-Chiang Huang, M.D.,* and
Chen-Tien Hsu, M . D . , Talpei, Talwan,
Republic of China
R E I, o I~ T s of n e o n a t a l h e l m i n t h i c infec-
tions are rare. This p a p e r is a r e p o r t of a n
infant with neonatal ascariasis, born to a
m o t h e r w h o also h a d intestinal a n d p l a c e n t a l
ascariasis.
CASE REPORT
A male infant was delivered by cesarean sec-
tion at 8 months' gestation to a 26-year-old para
From the Children's Medical Service and the
Department of Obstetrics and Gynecology,
Municipal Chung-Hsin Hospital of Taipei.
*Reprint address: Children's Medical Service, Municipal
Chung-Hsln Hospital of Talpel, 145, Cheng Chow Rd.,
Talpez, Talwan, Republic oI CMna.
Brief clinical and laboratory observations 783
t h r o u g h breast milk is quite remote. Chloro-
thiazide appears to be a safe diuretic for
ingestion by the nursing m o t h e r requiring
such medication.
The authors of this study wish to thank Mr.
Cornell Allen, Mrs. Judy Thompson, R.N., and
Miss Fran Barnaby, R.N., for their technical
assistance, and special thanks to Parent and
Child Incorporated whose members made this
project successful.
REFERENCES
1. Baer, J. E., Leidy, H. L., Brooks, A. V.,
et al.: The physiological disposition of chloro-
thiazide {Diuril) in the dog, J. Pharmacol.
Exp. Ther. 125: 295, 1959.
2. Brettell, H. R., Aikawa, J. K., and Gordon,
G. $2: Studies with ehlorothiazide tagged with
radioactive carbon (C a~) in human beings,
Arch. Intern. Med. 106: 57, 1960.
3. Rowe, R. D., and Mehrizi, A.: The neonate
with congenital heart disease, Philadelphia,
1968, W. B. Saunders Company, p. 404.
2, gravida 3 farm woman. The mother was never
examined antenatally. She had a history of occa-
sional vague abdominal pain which lasted for
about 10 to 30 minutes without nausea, vomiting,
or diarrhea. She was admitted to the hospital
on April 3, 1970, because of early rupture of
the membranes and prolonged labor. Cesarean
section was performed soon after admission as a
result of the fetal distress and prolonged labor.
Before cesarean section one living Ascaris lum-
bricoides worm passed from the vagina to the
outside and another living adult worm was dis-
covered in the vagina during vaginal douche in
preparation for the operation, An adhesion be-
tween the small intestine and the uterus was
found. After extirpation of the placenta, two liv-
ing mature male worms and eight living mature
female worms were found on the maternal side
of the placenta (Fig. 1 ). At delivery, the infant
weighed 2,010 Gm., measured 45 cm., and was
in fair condition. The Apgar score a t five minutes
was 10. The baby appeared well on the second
day when he was observed to pass a live fe-
male Ascaris Iumbricoides, 30 cm. in length. On
the sixth day, he passed another live mature
female worm 28 era. in length. Piperazine citrate
(50 mg. per kilogram per day) was given to the
baby on the sixth and seventh day of life. How-
784 Brief clinical and laboratory observations
Fig. 1. Ascarls lumbricoides worms in the pla-
centa.
ever, no other worm was found during the fol-
lowing weeks, and Ascaris lumbricoides ova were
not seen after the eleventh day of llfe. No
eosinophilic leukocytes were seen in peripheral
blood of the baby or the mother. Fertilized A.
lumbricoides ova were found in the mother's
stool, in the amniotic fluid, and in the baby's
feces.
DISCUSSION
T h e infant described had not had an op-
portunity to ingest food contaminated with
fertilized A. Iurnbrlcoides eggs. His infection
presumably resulted from transplacental mi-
gration of A. lumbricoides larvae or adult
worms. T h e migration of mature Ascaris
worms to m a n y organs is well known, but
reports of urogenital migration of the para-
site are rare? T h e first case of placental
bilharziasis was reported by Sutherland and
associates ~ in 1965, and the presence of
T a e n i a proglottid was first reported in the
h u m a n uterus by Schacher and Hajj s in
1970. Enterobius vermicularis has been re-
corded on a n u m b e r of occasions in the
urogenital system, including the uterus. 4 I n
1949, Ochsner and associates ~ reported a
case of A. lumbricoides migration to the
heart. I n 1965, P h u a c and Schmauss G re-
ported embolism by a grown A. lumbrieoides
in the femoral artery. T h e y stated that the
worm in this case could only have reached
the femoral artery via the bile duct ---> liver
abscess --> hepatic vein --> vena cava ---> right
heart ---> foramen ovale --->left heart ---> aorta
---> femoral artery. I n individuals exposed to
The Journal of Pediatrics
October 1972
m a n y infective stage eggs, some of the larvae
m a y pass through the p u l m o n a r y capillaries
into the left heart and systemic circulation
and may be filtered out in various organs and
tissues of the body, as in lymph nodes, thy-
roid, thymus, spleen, brain, and spinal cord.
T h e y m a y also accumulate in the kidneys
and be passed in the urine, or they may
rarely pass the placental filter and reach the
fetus? T h e pathway of placental ascariasis
in the present case can be postulated in two
possible ways. T h e first is direct invasion of
the w o r m from intestine to uterus and pla-
centa, and we did find an adhesion between
the small intestine and the uterus at the time
of surgery. T h e second possibility is the mi-
gration of larvae into the placenta, where
they developed to maturity. There m a y be
three possible pathways for neonatal ascari-
asis. T h e first is direct invasion of A. Iurn-
bricoides from the mother's intestine to the
placenta and amniotic cavity, to be swal-
lowed by the fetus. T h e second possible
route is as follows: infected Ascaris eggs --->
Ascaris larvae ---> lodged in the lung ---> some
larvae reach left heart ----> placenta ---> um-
bilical vein ---> fetal circulation ---> ductus
venosus ---> inferior vena cava --> right heart
--->lung --> alveoli --> bronchioles --->trachea -->
pharynx ---> esophagus --> stomach ----> small
intestine --> mature worm. T h e third possi-
bility is that the fertiliz6d Ascaris eggs are
produced by ovipositing female worms in the
placenta. These fertilized eggs become in-
fective in the placenta and amniotic cavity
by an intracorporeal hatching process, s The
infective eggs are swallowed by the fetus and
develop into mature worms in the small in-
testine.
We wish to express our gratitude to Dr. J.
tI. Cross, Parasitologist, United States NAMRU-
2, for reviewing the manuscript, and confirming
the identification of Ascarls lumbricoides.
REFERENCES
I. Arean, V. M., and Crandall, C. A.: As-
cariasis, in Pathology of protozoal and hel-
minthic disease with cIinical correIation, ed.
1, Baltimore, 1971, The Williams & Wilkins
Company, p. 793.
2. Sutherland, J. C., Berry, A., Hy/id, M., and
Volume 81
Number 4
Proctor, N. S. F. : Placental bilharzlasls. Report
of a case, S. Afr. J. Obstet. Gynecol. 3: 76,
1965.
3. Schacher, J. F., and Hajj, S. N.: Taenla
proglottid in the human uterus, Am. J. Trop.
Med. Hyg. 19. 626, 1970.
4. Symmers, W. St. C.: PathoIogy of oxyurlasls
with special reference to the presence of oxy-
uris vermicularis and its ova in the tissue,
Arch. Pathol. 50: 475, 1950.
5. Ochsner, A., Debakey, E., and Dixon, L.:
Complication of ascariasis requiring surgical
treatment, Am. J, Dis. Child. 77: 389, 1949.
Infantile cortical hyperostosis
of the scapula presenting as
an ipsilaterat Erb's palsy
David Holtzman, M.D., Ph.D., *
Bronx, N. t'.
I N F A N T I L E cortical hyperostosis, first de-
scribed by Caffey a n d Silverman, 1 is a syn-
drome, in infants less t h a n five m o n t h s of
age, characterized by the s u d d e n a p p e a r a n c e
of soft tissue swellings, fever, a n d irritability,
with subsequent x-ray evidence of periosteal
new bone formation. 2, s O n e o r m o r e bones
m a y be affected; the scapula is involved in
about 10 p e r cent of cases. 4, ~ W e r e p o r t four
patients with Caffey's disease in t h e s c a p u l a
with dysfunction of the ipsilateral u p p e r
braehial plexus. E a c h of the patients pre-
sented with an a p p a r e n t E r b ' s palsy. E a c h
subsequently developed clinical a n d then
r a d i o g r a p h i c findings confirming the diagno-
sis of infantile cortical hyperostosis, b u t n o t
From the Saul R. Korey Department o[
Neurology, Albert Einstein College o[ Medicine
o[ Yeshiva University.
Reprint address: Saul R. Korey Department o[ Neurology,
Albert Einstein College of Medicine, 1300 Morris Park
Ave., Bronx, N. Y. 10461.
*Natlonal Institutes o[ Neurologlc Diseases and Stroke
Special Fellow in Pediatric Neurology (Grant No. 2 Fll
NS02262-02).
Brie[ clinical .and laboratory observations 785
6. Phuae, V. It. H., and Schmauss, A. K.: Em-
boll elnes ausgewachsenen Ascaris lumbricoides
in die Arterie Femoralls, Aus der Chirug.
Univ-Klinik im Krankenhaus der Vietnam-
esisch-Deutschen Freudschaft in Hanoi, NMW
31, 1965.
7. Faust, E. C., Russel, P. F., and Jung, R. C.:
Ascariasls. Clinical parsitology, ed. 8, Phila-
delphia, 1970, Lea & Febiger, Publishers, p.
338.
8. Phan, T.: Eclosion larvaire intracorporelle des
oeufs d'ascaris erratiques chez un garcon de
4 arts, Pathol. Microbiol. 28: 443, 1965.
before other diagnoses, some surgically treat-
abte, h a d been considered. I n each case, the
paralysis of the u p p e r extremity resolved
completely.
CASE REPORTS
Case 1. Patient R. C., a 2-month-old boy, was
the product of an uncomplicated pregnancy and
delivery. No abnormalities were noted at birth.
At one month he received a diphtheria-pertussis-
tetanus injection in the right deltoid. One week
later he would not move his arm, and the diag-
nosis of an Erb's palsy was made. Movement of
the arm improved and two weeks later a mild
wrist drop was the only deficit. One week later
it was again noted that he was not moving his
right arm. During the next two days, a swelling
appeared over the right shoulder, and he was ad-
mitted to the hospital
On admission he was febrile (100 ~ F.). A soft
tissue swelling, overlying the right scapula, ex-
tended laterally to the posterior axillary llne. The
overlying skin was not warm or discolored. He
had a right upper brachial plexus palsy, including
absence of biceps and triceps reflexes. The rest
of the examination was normal. Laboratory data
were normal except for an erythrocyte sedimen-
tation rate of 39 ram. and a white blood count
of 16,000 per cubic millimeter with 70 per cent
lymphocytes. An x-ray of the right scapula
showed periosteal thickening (Fig. 1). The dif-
ferential diagnosis included myositis ossificans,
neoplasm, and Caffey's disease.
During eight days in the hospital, there was
no change in signs or symptoms. He returned one
week later with a swelling over the right man-
dible. The diagnosis of Caffey's disease was con-
firmed radiographically by the presence of bony