[ cas de meningite tuberculeuse chez un enfant vaccine]

The tuberculous meningitis stays dangerous because of its high lethality and frequent severe neurological permanent repercussions. Its prognosis is directly in relation with the precocity of its diagnosis. Well, this diagnosis is often difficult. In this work, we report a case of tuberculous meningitis in children aged 13, who is properly vaccinated. The diagnosis was made on clinical and radiological and was confirmed by late positive cultures of CSF on Lowenstein-Jensen highlighting Mycobacterium bovis BCG. TB treatment and steroids were initiated, followed by an improvement in general condition. Unfortunately, a relapse was observed after one year. The occurrence of TB meningitis in our patient leaves have two hypotheses: either an immune deviciency or ineffectiveness of the BCG vaccine. Indeed, the standard rate of immunoglobulins and the absence of recurrent infections were ruled out a deficit of humoral immunity. The study of lymphocyte markers by immunophenotyping excluded an abnormal number and distribution of T lymphocytes. An abnormality of cell proliferation was also excluded given the normal response to various antigens and mitognes. The study of the functionality of the polymorphonuclear neutrophils was normal. These normal immunological explorations showed that our patient has no immune deficiency. Several studies show that there is a genetic susceptibility to tuberculosis and it is polygenic. Hence the study of molecular genetic to research of mutations has been proposed. Others studies have highlighted the protective efficacy of BCG vaccination in children and bring into question the role of revaccination

[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

[Epidemiology profile and mortality factors of the septic shock subordinate to a community infection among children in a developing country]

Goal: To determine the epidemiology profile of the septic shock subordinate to a community infection among children, admitted to an intensive care unit in a developing country, and the factors affecting mortality

Patients and Methods: Retrospective analysis of all the observations of the children, admitted between january 1998 and august 2005, in a children's intensive care unit and among whom septic shock subordinate to a community infection was diagnosed. The criteria adopted to diagnose the septic shock are those of the American College of Critical Care Medecine. The multivisceral deficiency was defined by the simultaneous presence of 2 deficient organs [Wilkinson Criteria]. Babies of less than 7 days old and shock subordinate to a nosocomial infection were excluded from this study. The data taken for every patient was: the age, gender associated pathology, the time duration between the symptoms of circulatory failure, the PRISM score, the other deficient organs, the results of the microbiological tests, the filling volume, the nature, the amount, the duration and the number of the vasoactive drugs used, the use of hydrocortisone and the lack there of, and transfer to an intensive care unit. Forthe survivors, the duration of mecanical ventilation and the duration of stay were noted. The time and cause of death were also precisely noted for the deseased patients

Results: Seventy cases were observed, representing 2,8% of the admittions. The average age patients was 3, 8 +/- 4, 2 years and their PRISM during the first 24 hours was 19,2 +/- 8,4. Thirteen children [18, 6%] had a co-morbidity associated to the septic shock. Sixty-nine children [98, 6%] have a multivisceral deficiency and 60 of them [85,7%] have more than 2 deficient organs. An Acute Respiratory Distress Syndrome [SDRA] was associated to the septic shock in 5,7% of the cases. For 17 patients [24, 3%], the shock state was declared after the admission to the intensive care unit. For the 53 patients who were in a state of shock on admission, the average time between the noting of the first hemodynamic troubles and the admission to intensive care was 9,4 +/- 11,3 hours. The identification of an infection agent was only possible for 27 children [38, 6%]. The most frequently responsible germs were the Staphylocoque Aureus [13%], the Meningocoque [11, 5%] and the Pneumocoque [4, 3%]. Thirty two patients [45, 7%] died after 18 +/- 2 days from the time ressucitation started. For the survivors, the average duration of hospitalization and ventilation was respectively of 7,8 +/- 7 days and 4,3 +/- 3 days. An analysis indentified six factors significantly assciated to the death: the age > 30 month [p = 0,03], an intensive care transfer time > 4 hours [p = 0,03], a failure of more than 2 organs on admission [p < 0,001], a filling volume > 20 ml/kg to days 2 of resus sitation [p = 0,002], the use of epinephrin [p < 0,001], the use of more than 2 vasoactive drugs[p < 0,001].A multivariate analysis revealed 3 independant mortality risk factors: a failure of more than 2 organs on admission [OR, 4,4 ; 95 % CI [2,1 - 9,4]], a filling volume > 20 ml/kg after 2 days of resuscitation [OR , 3,4'; 95 Cl % [1,1 - 10,3]] and the use of more than 2 vasoactive drugs [OR, 3,3 ; 95 CI % [1,2 - 9]]

Conclusions: The septic shock subordinate to a community infection is a frequent cause of admission into children's intensive care unit. The Staphylocoque Aureus and the Meningocoque are the pathological agents the most frequently identified. Mortality is high [45, 7 %]. A failure of more than 2 organs upon admission, a filling volume > 20 ml/kg after 2 days of intensive care and the use of more than 2 vasoactive drugs are independant mortality risk factors