Rare Infection Led to Amputation of Girl’s Limbs

The streptococcus infection that invaded the body of a young girl with chickenpox, causing a toxic shock reaction that led to the amputation of her arms and legs, is the first time such bacteria have been detected in a child in the United States, doctors at Children’s Hospital said Wednesday.

“This is exceedingly rare,” said Dr. John Bradley, director of the division of infectious diseases at Children’s, where 6-year-old Jessica Lynn Esquivel was admitted April 1 with what was first believed to be a routine case of chickenpox.

Shortly after being seen in the emergency room of the adjacent Sharp Memorial Hospital, the girl suffered a bloating of the ankles, a rise in temperature to 104 degrees and, doctors said, the loss of circulation to her arms and legs.

The onset of toxic shock caused what Bradley termed “full cardiac arrest,” in addition to kidney, liver and respiratory failure, before infusions of penicillin began to minimize the effects of the streptococcus bacteria. On April 18, feeling that the chance of an amputation-related infection was minimal, doctors chose to sever her legs at the knee, and her arms at the elbow.

Bradley, whose specialties include the study of antibiotics for bacterial infections, said the strain of streptococcus bacteria that infected Jessica--after entering through one of the pox-caused lesions on her body--has not been found in a child in San Diego or in any documented case anywhere in the country. However, the strain, which has occurred in “dozens” of cases involving adults, is fatal “about 30%” of the time, Bradley said.

He emphasized that Jessica would not have incurred the bacteria without first having had the chickenpox. He pointed out, however, that streptococcus infections as an adjunct to chickenpox are not uncommon.

“In 99.9% of the cases, chickenpox in children is very mild,” Bradley said.

Officials at Children’s said Wednesday that the hospital switchboard had been flooded with calls since the Jessica story was first reported in the news Tuesday, with most inquiries coming from parents whose children have chickenpox.

Sharon Ross, a spokeswoman for Children’s, said the hospital has been instructed to tell callers that Jessica’s is a “very unusual case” and that her almost-fatal complications were believed to be derived, not from the chickenpox, but from the secondary infection that triggered toxic shock syndrome.

Ross said Jessica, a kindergarten student at Oneonta Elementary School in Imperial Beach, remains in critical condition.

Dr. Brad Peterson, director of critical care service at Children’s and the physician in charge of Jessica’s care, said Wednesday that he expects her to have full liver, kidney and respiratory recovery. Peterson said a psychiatrist has been appointed to work with Jessica and her family, and Ross said a trust fund has been established to help pay for the child’s care and long-term recovery.

Lisa Esquivel, 25, said she and her husband, Felix, 27, the girl’s parents, are devastated by the turn of events. Lisa Esquivel said that, on March 30 and 31, she took Jessica to Scripps Memorial Hospital in Chula Vista, where doctors diagnosed the illness as “a simple case of chickenpox” but failed to take the girl’s blood pressure or listen to her heart.

A spokeswoman for the hospital in Chula Vista, Diane Yohe, said Wednesday, “It would not be prudent or ethical for us to comment on the specifics of a patient’s care at this point in time.”

However, Bradley of Children’s said Wednesday that most doctors would not automatically check blood pressure. Given that the blood pressure was low when she went to Sharp (on April 1)--but still within normal range--it’s unlikely it would have been different” two days earlier.

“With regard to the heart rate, any time the fever goes up, the heart rate goes up, too,” he said. “So, had the heart rate been up, it would not have been an abnormal condition.”

Bradley said that, when Jessica was taken to Scripps Memorial in Chula Vista, if there was “no sign of infection and she was (breathing) appropriately, and the symptoms were chickenpox and a fever, standard medical procedure would not have mandated that more be done.”

He said that, even at the time she entered the Sharp emergency room, “It looked like a normal case of chickenpox. I can’t say for sure without having seen her (on March 30 and 31) that we would have done anything differently.”

Bradley said the flares that alerted doctors at Sharp and Children’s that Jessica’s was a different case were “decreased urine output” and a “bluing of the extremities.”

He said a blood culture was taken “to look for bacteria, and what started growing out of it was this rare streptococcus infection.”

“At that point, we admitted her for observation,” Bradley said. “Those were clues that something wasn’t right. Then the toxic shock hit very hard, dramatically . . . and everything shut down.”

Lisa Esquivel declined to say Wednesday whether she and her husband will take legal action.

“We’re not supposed to talk about that,” she said.

She said she was “angry with the people at Scripps because they did not want to deal with her. They didn’t check my daughter’s heart or her blood pressure. They only checked her temperature.”

Lisa Esquivel said the treatment at Sharp differed, in that doctors immediately tested her daughter’s blood, and gave her Tylenol and codeine as pain suppressants. She said she and her husband believe that doctors at Sharp and Children’s saved their daughter’s life.

She said the doctor on duty at Scripps Memorial--whom Scripps officials identified Wednesday as Dr. David Vandenberg--”told me I worried too much.”

“Yeah, he told my wife that she worried too much,” said Felix Esquivel, an auto mechanic. “He said, ‘You worry too much.’ But now my daughter doesn’t have hands or feet . . . and it’s hard.”

Vandenberg was unavailable for comment.

Yohe, the spokeswoman for Scripps Memorial, said Jessica and her mother went to the hospital about 9 p.m. March 30, and the child showed “the normal symptoms” of chickenpox.

“We told her that, if she was concerned, she should come back,” Yohe said.

Lisa Esquivel and her daughter returned to the hospital several hours later, about 1 a.m. March 31. Lisa Esquivel said she originally took her daughter to the hospital because she was hallucinating, a condition believed to have been caused by Benedryl, an antihistamine used to lessen the discomfort from allergies and the kind of itching common with chickenpox. She said that, when she returned to the hospital around 1 a.m. on the 31st, Jessica’s fever had dropped, but her hallucinations hadn’t stopped.

Yohe said doctors at Scripps Memorial spoke with doctors at Children’s on Wednesday about the case, but she declined to elaborate.

“It was a full 24 hours later before the girl was seen at Sharp, and of course, by that time, they were seeing a totally different set of symptoms,” Yohe said.

Lisa Esquivel said she and her husband and their two children, Jessica and 4-year-old Felix Jr., who contracted the chickenpox just before his sister caught it, moved to San Diego County from Miami in May. She said she was born and grew up in Imperial Beach, where they now share a home with her parents. Lisa Esquivel, a housewife, said her husband grew up on the Yucatan Peninsula of Mexico.

She said that, after getting no sleep after leaving Scripps Memorial on the morning of the 31st, she took her daughter to a walk-in clinic run by a pediatrician in Imperial Beach.

“He looked at her ankle, which was badly swollen, and said that, if she hadn’t fallen on it, that I shouldn’t worry about it,” Lisa Esquivel said. “He acted nervous, like he didn’t want my daughter in there. I think he was afraid of her infecting the other kids.”

Lisa Esquivel said she uses a pediatrician for the care of her children, but that doctor was out of town in the early morning hours of April 1--a Sunday--when Jessica’s symptoms began to worsen. She said she phoned the doctor filling in for the pediatrician, and he urged her to meet him at noon April 1. But, as the symptoms grew worse, and her daughter’s condition caused her even graver concern, she said, she drove to the Sharp emergency room.

“This has been very difficult for us,” she said, “and I don’t feel very good right now. But we are so happy and grateful that she’s alive. We just hope she gets better little by little.”

She said she and her husband have not begun to discuss the use of artificial limbs with Jessica’s doctors, but, “I hope one day that she can do the things that she’s always loved to do--draw pictures and color, even dance.

“All my friends tell me she’s the sweetest little girl they ever met. She’s been a little star, in ballet, tap dancing, gymnastics and the Girl Scouts. And she’d have to be a strong girl, and very special, to have survived what she’s survived.”