[Community-acquired pleuropneumonia in children: bacteriological and therapeutic challenges]

Background: Community-acquired pleuropneumonia [CPP] is a common complication of pneumonia in children. It is serious given its high morbidity and significant mortality

Aim: To study clinical and paraclinical features of CPP in children and to establish a common therapeutic strategy

Methods: Our retrospective study included patients who were hospitalized for CPP between 2004 and 2012. All data were collected from patients' medical files. Statistical analysis was made by Epi-Info 6

Results: One hundred and sixty four patients were registered. The mean age was 32 months [15 days - 14.5 years]. The hospital incidence of CPP doubled between 2004 and 2012. The symptomatology was dominated by fever [93.9%], cough [56.7%] and dyspnea [48.1%]. The pleural effusion was frequently moderately abundant and loculated. Pleural sample, performed in 53.6% of cases, was the most beneficial bacteriological examination [p=10-6 ]. The bacteriological confirmation was attained in 44.5% of cases with the predominance of Staphylococcus aureus [59%] followed by Streptococcus pneumoniae [26%]. The S. aureus occurred basically in most young infants [p=0.04] and was responsible for the most severe cases [p=0.01]. The CPP management included heterogeneous intravenous antibiotics associated with a pleural drainage in 40% of cases. The quarter of our patients were transferred to an intensive care unit. Six patients died

Conclusion: The bacteriological confirmation is difficult. Pleural aspiration is the key tool. S. aureus is the first microorganism followed by S. pneumoniae. A therapeutic strategy is proposed based on large spectrum intravenous antibiotics. The pleural drainage indication is limited

first hour resuscitation of pediatric septic shock

The pediatric septic shock mortality in Tunisia remains high [50%] and was markedly higher than in western countries [10%]. The decrease in septic shock mortality has been obtained with the advent of the early goal directed therapy. The aim of this paper is to propose to the first line practitioners in Tunisia, during the first hour after establishing the diagnosis of septic shock practical clinical guidelines based on earlier consensus recommendations. Literature review. Septic shock must be rapidly suspected and early recognized. Adequate oxygenation and prompt correction of hemodynamic derangements has been shown to improve outcome through aggressive volume resuscitation, early empiric antibiotherapy and early initiation of vasopressor agents. Frequent reassessment has been emphasized to ensure appropriate management. This treatment must take into consideration the resources available in our area. We can reasonably hope to decrease mortality of patients with septic shock if the first line physicians keep in mind specific therapeutic goals

Community-acquired methicillin-resistant Staphylococcus aureus infections requiring admission to a Tunisian paediatric intensive care unit

There is limited literature describing severe community acquired methicillin-resistant S aureus [CA-MRSA] in children admitted to an intensive care unit. To review clinical features and outcome of children admitted in a Tunisian pediatric intensive care with CA-MRSA. Retrospective chart review of patients coded for CAMRSA over 10 years. There were 14 [0.32% of all admissions] patients identified with severe CA-MRSA. The median age was 3 months [range, 0.5-156 months]. All patients had pulmonary involvement. Six children [42.8%] developed septic shock. Two [14.3%] patients had multifocal infection with deep venous thrombosis. Two [14.3%] patients died. Severe CA-MRSA pneumonia dominated presentation. The mortality of CA-MRSA infection in our series is lower than reported in the literature

[Neonatal respiratory morbidity after elective caesarean section at term]

Incidence of elective caesareans at term is increasing these last decades with an associated increase of neonatal respiratory morbidity. To analyse the influence of elective Caesarean delivery at term on the incidence of neonatal respiratory distress in order to propose an effective strategy of prevention. It is an analytical study compiling all births resulting from elective Caesarean at term [gestationnel age ranging between 37 and 41+6 GA], reported over two years period at the Charles Nicolle hospital [Tunis-Tunisia]. We compared 250 live births, without maternel risk factors, delivered by elective Caesarean to 250 births delivered by vaginal way. Frequency of the elective Caesarean at term was of 3.6% live births; it was mainly indicated in the presence of a cicatricial uterus. The incidence of respiratory morbidity was 6% [15/250] in the group exposed to the elective caesarean versus 1.6% [4/250cas] in the reference group, OR = 3.9; 95%CI: [1, 28-11, 99] p<0.01. Before the term of 39 GA, OR = 5.22; 95%CI: [1.14-23.87] p=0.01. After 39 GA, the risk of respiratory distress decreased: OR = 1.86 95%CI: [0.30, 11.35] NS. The principal etiology of respiratory distress in the exposed group was the transitory tachypnea of the newborn. Incidence of respiratory distress was higher at newborn babies born from elective Caesarean with a significant reduction in this incidence after the term of 39 GA

[Sternal clefit, a rare congenital anomaly. Report of the first Tunisian case]

Sternal cleft is an uncommon visually dramatic congenital anomaly of the chest wall. It is resulting of failure of the two lateral mesodermal sternal bars fusion by the eight weeks of gestation. Superior defects are the commonest forms, usually isolated. Clinical and surgical aspects of stemal cleft are presented. The advantages of early surgery in the neonatal period are developed. We report the first Tunisian case of a superior sternal cleft associated to haemangioma in a newborn boy. Scanning shows non-appearance of manubrium at the upper part of sternum. Sternal bars showing a U-shaped incomplete sternal cleft. Surgical repair consisted of reconstructing a new sternum from sternal bars and resection of haemangioma. The patient had good aesthetic and functional results. The appearance of a child with its heart bulging through its chest wall is very disturbing to parents. Early surgery is most easy and most comforting

[Current management of acute bronchiolitis in Tunisia]

The purpose of this study was to assess the current management practices of acute bronchiolitis by Tunisian paediatricians. A questionnaire was sent by mail to all Tunisian paediatricians, about the most widely used drugs during the first stage of acute bronchiolitis. The answers were sent to us by mail in pre-stamped envelopes. Out of total of 420 questionnaires sent, 180 [42,8%] were returned, out of which 177[42%] were analysed. Of the respondents, 117 [66%] were working in hospitals and, 60[34%] were working in the private sector. Bronchodilators were used by 93,3% of peadiatricians either routinely [35,6%] or occasionally [44,1%]. Steroids were used by 88.7% of pediatricians either routinely [28.8%] or occasionally [43.5%] Nasal drops, were prescribed routinely by 80,2% of the pediatricians. Physiotherapy was performed routinely or occasionally in 91.5% of the cases. Oxygen and antibiotics were respectively used by 92% and 70% of the paediatricians. A comparaison between the practices of the hospital paediatricians and their private sector conterparts showed that private practitioners, statistically, prescribe more bronchodilatators [42,7% vs 21,7%] [p < 0.05] and corticosteroids [36.8% vs 13.3%][p < 0.05] than their hospital colleagues. Hospital physicians, more than the private sector ones, tend to never prescribe bronchodilatators, 2 [15% vs 2,6%] [p < 0.05] and steroids [25% vs4,3][p<0,05]. Despite the absence of the scientific evidence showing a beneficial effect of the pharmaceutical agents, most paediatricians, during the initial phase of acute bronchiolitis, resort to prescribing bronchodilators [93,3%] and corticosteroids [88,7%]. There is a great variety of therapeutic practices among hospital paediatricians and private practitioners .National guidelines could be helpful in reducing this disparity

Management of purpura fulminans about 21 cases: diagnostic delay and therapeutic problems

To evaluate the diagnostic delay and therapeutic insufficiencies delay before the transfer in ICU of the children admitted in the ICU of the children's hospital of Tunis with a purpura fulminans [PF] A retrospective, descriptive study, of children with PF referred between January 2000 and January 2006 to a the paediatric intensive care unit [PICU] of the children's hospital of Tunis. The PF diagnosis was retained in any child presenting a feverish purpura and circulatory insufficiency signs. The optimal diagnostic and therapeutic charge taking was defined in three levels: parental, the first line doctors, and the hospital doctors. The symptoms' duration and the various treatments which were lavished to the patients were taken from the medical observations of the patients transferred in our PICU. Twenty one observations were collected. Twelve patients [57,1%] were addressed by a doctor exerting in a dispensary or by a free practicing doctor, 5 patients [23,8%] were transferred from a regional hospital and 4 children [19,1%] directly consulted the children hospital of Tunis urgencies .delayed parental recognitionoccured in 11 children. The PF diagnosis was not evoked by the first line doctor in 62%. Eleven [52,4%] of the children with meningococcal disease were seen but not admitted by a doctor in the 48 hours before admission. Apart from 2 patients [9,5%] who were hospitalized in reanimation directly of the urgencies, all the other patients forwarded by a general pediatry service. In general pediatry, the PF diagnosis was not evoked in 3 cases [15.8%], 31,6% of patients had unnecessary a lumbar punctures and shock was not recognised or treated in 26,3%. Twelve patients [52,2%] died. The duration of hospitalization in general pediatry is significantly higher among deceased patients [5,5 +/- 6,6 hours] than among the surviving patients [2,6 +/- 1,5 hours]; p<0,5. Suboptimal treatement in PF is due to failure of parents, general practioners and hospital doctors to recognise specific features of the illness. Improvement in outcome could be achieved by public education and better training of clinicians in recognition, resuscitation, and stabilisation of seriously ill children

[Acute respiratory distress syndrome in infants at term and near term about 23 cases]

Aim: to precise the incidence of acute respiratory distress syndrome in infants at term and near term and the clinical characteristics of this disease not yet well recognised

Methods: retrospective study of the medical records of infants admitted in the paediatric intensive care unit for ARDS along a period of 4 years. Diagnosis of ARDS was based on the following criterias: 1] Gestational age >/= 35 weeks of gestation; 2] Severe and immediate respiratory distress requiring mechanical ventilation with PEEP >/=4 cm H2O and FiO[2] >/= 0.5 during at least 6 hours ; 3] Dependence on oxygen >/= 48 hours; 4] Diffuse alveolar damage in the chest radiograph; 5] PaO[2] /= 0.5

Results: During the period of the study, 23 infants [gestational age = 36 +/- 1.1 weeks of gestation; birth weight = 2756 +/- 453 gr] were included in the study. Their mean age at admission was 16.5 +/- 14.6 hours. The majority of infants [91.3%] were born by caesarean section before the onset of labour in 78.3% cases. All infants had a severe acute hypoxemic respiratory failure [D[A- a]O2 = 468 +/- 165; OI = 19 +/- 8.4]. Five infants [21.7%] improved their oxygenation parameters under conventional mechanical ventilation [CMV] [p<0.001; p = 0.002 et p=0.003 respectively for D[A - a] O[2], OI and PaO2/FiO[2]]. Eighteen infants [78.2%] required high frequency oscillatory ventilation [HFOV] with a rapid and persistant improvement of oxygenation parameters. Five patients [21.7%] developed pulmonary air leak

One infant died

Conclusion:ARDS represents 6.8% of etiology of respiratory distress in infants at term and near term. Caesarean section before the onset of labour seems to be a triggering factor. The outcome seems to be favourable [rate of survival = 95.7%] if the management is suitable

[Pulmonary alveolar proteinosis in two siblings. A case report]

Pulmonary alveolar proteinosis [PAP] is a rare disorder in children. This report describes two siblings in whom PAP developed during infancy [three years for the boy and four years two months for the girl]. The girl was admitted for chronic respiratory distress. Chest x-ray showed a reticulonodular pattern. Her brother was asymptomatic. The diagnosis of PAP was confirmed by open lung biopsy for the boy and broncho-alveolar lavage for the girl. Therapeutic broncho-alveolar lavages were performed [six for the girl and two for the boy], the girl lost dependence on oxygen therapy. 6 years later, the brother is still asymptomatic. The sister had two episodes of respiratory distress, after two and four years, that required therapeutic lavages. The last therapeutic broncho-alveolar lavage was performed for the first time by a Tunisian team