Despite being recognised for over two millennia and having an increasing incidence in many countries, the management of childhood empyema remains controversial. This review examines the recent literature on its causes and investigation then focuses on its treatment. Following a trial of appropriate intravenous antibiotics, the evidence would currently support the use of chest drain insertion with urokinase instillation as first line treatment with video-assisted thoracoscopic surgery to be used for failure of medical management. A treatment algorithm is proposed to guide clinical practice.

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are characterized by widespread skin and mucosal blistering and necrosis. The triggers and long-term sequelae in children may differ from those reported for adults. Bronchiolitis obliterans (BO) is an uncommon complication, with only 15 previously reported cases, but can lead to significant long-term morbidity, requiring lung transplantation in some cases. We report three children with nondrug-related SJS (n = 1) and TEN (n = 2) who developed BO. Two were treated with intravenous immunoglobulin therapy (2-2.4 g/kg) and all three survived. We highlight salient learning points from our cases and potential pitfalls in diagnosis of BO, including delayed onset, and we also review the literature.Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, potentially life-threatening conditions, characterized by widespread skin and mucosal necrosis. SJS is defined as < 10% body surface area (BSA) detachment, SJS-TEN overlap as 10-30% BSA detachment and TEN as > 30% detachment. 1 The reported incidence is lower in children than adults: 5.3 vs. 9.3, 0.8 vs. 1.9 and 0.4 vs. 1.6 cases per million per year for SJS, SJS-TEN and TEN, respectively, in the USA. 2,3 Medications are usually culpable, although infections may be implicated, particularly in children. 4 Mortality in childhood is reportedly 0% (SJS), 4% (SJS-TEN) and 16% (TEN), 2 with deaths most frequently due to sepsis and organ failure. 2 However, similarly to adults, increased mortality is noted with higher degrees of epidermal detachment: 60-70% BSA involvement was associated with 37.5% mortality in one study. 5 Intravenous immunoglobulin (IVIG), ciclosporin and/or systemic corticosteroids have been used despite the relative lack of evidence, as summarized in recent guidelines. 6 Bronchiolitis obliterans (BO) is a rarely reported complication, but when present, is associated with significant long-term morbidity. We report three children with nondrug-related SJS/TEN who developed BO. ReportPatient 1 was a previously well 5-year-old boy who presented with a 2-day history of an erythematous maculopapular rash in association with fever and coryza. Overall, the skin changes involved 95% BSA, with 40% epidermal detachment. There were additional bilateral conjunctival defects with confluent superficial punctate epithelial erosions of the cornea. He had severe oral and upper airway ulceration with sloughing. Subsequent development of stridor necessitated intubation.Histological examination of a skin biopsy confirmed TEN, with negative direct immunofluorescence. Chest radiography was unremarkable. Bronchoscopy showed ulceration at the base of insertion of the endotracheal

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Persistent wheezing, poorly responsive to bronchodilator therapy, raises concerns about the progression of cystic fibrosis-related lung disease. We describe 3 infants with such symptoms who were observed to have primary tracheomalacia. The diagnoses were made using flexible bronchoscopy during spontaneous respiration. Early recognition of this etiology can limit unnecessary investigation and the overuse of empirical treatments such as oral and inhaled corticosteroids.

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MEDICBJOURNA 1947, but the mass at the transverse colon was much larger than before and a biopsy only was taken, which showed the presence of anaplastic adenocarcinoma. The patient made a good recovery and was discharged home on December 20, 1947. She attended my follow-up clinic for some years and I last saw her about 10 years ago." On October 2, 1963, the patient was admitted to New Cross Hospital in a confused senile state associated with hypertension, blood-pressure 220/130, and severe bronchopneumonia from which she died on October 7. At necropsy there was an encysted empyema between the middle and lower lobes of the right lung, the lower lobe showing bronchopneumonia. The left lung was congested. The heart weighed 430 g. and the coronary arteries were atheromatous. The gastro-intesti nal tract showed no evidence of growth. The omentum and mesentery appeared normal. No glands were present. Sections were examined from postmortem tissues and no evidence of carcinoma was demonstrated.