Herpes zoster (HZ), a varicella-zoster virus reactivation, frequently complicates hematopoietic stem cell transplantation (HSCT). Its incidence, complications, and associated risk factors in 310 children undergoing HSCT were reviewed. In all, 61 of 201(32%) patients who had undergone allogeneic and 10 of 109 (9%) patients who had undergone autologous HSCT developed HZ. Of 90 VZV seropositive allogeneic patients, 50 (53%) developed HZ. Seven (17%) of 41 VZV seropositive autologous patients developed HZ. Although a substantial number of patients develop HZ in the early post-HSCT period, risk for HZ persists and HZ can occur up to 5 years post-HSCT. Risk factors for HZ included age 410 years (Po0.0001), allogeneic HSCT (Po0.001), and total body irradiation (TBI) (Po0.059) in allogeneic recipients. Of 37, 22 (59%) patients experienced an elevated alanine aminotransferase (ALT), unassociated with GVHD, in the month preceding HZ. Of the 48/64 patients (75%) hospitalized for treatment (median stay, 6 days; range, 2-39), length of stay was unaffected by donor type but increased by cutaneous dissemination and visceral involvement (P ¼ 0.023 and 0.034, respectively) in allogeneic patients. Consideration of HZ infection particularly in patients 410 years of age with elevated ALT after TBIconditioned allogeneic HSCT may permit earlier diagnosis and therapeutic intervention.

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Learning Objectives 5 Know the common clinical presentations for otitis, sinusitis, and mastoiditis. 5 Identify common and uncommon microbiologic causes of otitis, sinusitis, and mastoiditis. 5 Understand the distinguishing characteristics for acute, recurrent, and chronic clinical courses of each disease. 5 List the important risk factors for developing severe infections of the paranasal sinuses. 5 Outline the approach to diagnosis, including signs and symptoms that warrant laboratory or imaging evaluations. 5 Describe the indications for medical and surgical treatment of otitis, sinusitis, and mastoiditis. 4.1 Otitis 4.1.1 Introduction The term "otitis" encompasses pathology of both the middle and outer ear. It is generally divided into two categoriesotitis media and otitis externa. Otitis media can present either as an acute infectious process of the middle ear (acute otitis media) or as a serous noninfectious process (otitis media with effusion). Otitis externa is an infectious inflammatory condition of the external auditory canal (EAC). Approaches to the diagnosis and treatment of acute otitis media have evolved over the last several decades as new immunizations, and more antibiotic choices have become available. 4.2 Definitions Otitis media with effusion (OME)-A collection of serous fluid in the middle ear space without signs of acute inflammation. OME is not an infectious process. Chronic otitis media with effusion (COME)-A collection of serous fluid in the middle ear space that persists for more than 3 months Acute otitis media (AOM)-An acute infection of the middle ear with signs and symptoms of acute inflammation. An effusion is also present. Recurrent AOM-Three or more episodes of AOM in a 6-month period or 4 or more episodes of AOM in a 12-month period Otorrhea-The presence of a discharge from the ear Chronic suppurative otitis media (CSOM)-The presence of a purulent middle ear effusion associated with otorrhea, secondary to chronic tympanic membrane perforation, for more than 6 weeks in the setting of antibiotic treatment Otitis externa (OE)-An infection of the external auditory canal 4.3 Basic Concepts 4.3.1 Otitis Externa. Fig. 4.1 Normal tympanic membrane.

To determine the pattern and degree of hepatic transaminitis experienced by children undergoing autologous transplantation for neuroblastoma. Sixty-four children with high-risk neuroblastoma received an autologous transplant with cyclophosphamide, etoposide, and carboplatin conditioning. Forty-eight went on to receive a second transplant with M and TBI conditioning. Charts were reviewed for evidence of hepatic regimen-related toxicity. A high rate of transaminitis was observed after both regimens. In each transplant, there was an early period of transaminitis during conditioning, from which patients recovered, followed by a second period of transaminase elevation. The degree of elevation was not associated with age, whether the administered dose was calculated based on a per kg or per M(2) basis or the presence of regimen-related severe mucositis. Elevated transaminases at admission were not associated with maximal hepatotoxicity during the first transplant although there was an association in the second transplant. However, the magnitude of transaminase elevation was less in the second transplant. VOD occurred in one and three patients in transplants 1 and 2, respectively. Both conditioning regimens were associated with an early and late elevation of transaminases without significant cholestasis. This biphasic pattern of transaminitis has not been reported previously. The high prevalence of transaminase elevation at time of both transplants was not associated with an increased incidence of VOD. We conclude that elevated transaminases should not preclude proceeding to a first or second autologous transplant with these regimens.

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