Meningitis tuberculosa: un desafío diagnóstico en pediatría

Resumen La meningitis por Mycobacterium tuberculosis es infrecuente en pediatría y su diagnóstico definitivo representa un desafío clínico. Presentamos el caso de un lactante de dos años, que presentó un cuadro de meningitis crónica. Se logró el diagnóstico tras la sospecha imagenológica y la confirmación tras la búsqueda seriada del complejo M. tuberculosis por RPC en LCR y en biopsia de tejido cerebral. A pesar de sus complicaciones, el paciente respondió favorablemente al tratamiento antituberculoso. En Chile, la tuberculosis es infrecuente en niños y los síntomas son generalmente inespecíficos. Los hallazgos en RM cerebral asociados a alteraciones del LCR permiten sospechar el compromiso meníngeo precozmente. Se recomienda iniciar el tratamiento antituberculoso empírico ante la sospecha, ya que mejora el pronóstico. A pesar de los avances diagnósticos y terapéuticos, la meningitis tuberculosa sigue teniendo una alta tasa de complicaciones y un pronóstico ominoso.

Abstract Mycobacterium tuberculosis meningitis is rare in the pediatric population and its definitive diagnosis represents a clinical challenge. We present the case of a 2-year-old infant with chronic meningitis. Diagnosis was accomplished by suggestive radiological findings and serial search for M. tuberculosis complex by real-time polymerase chain reaction (qPCR) in cerebrospinal fluid (CSF) and in brain tissue. Despite the complications, the patient evolved favorably with the tuberculosis treatment. In Chile, tuberculosis is a rare disease in children and symptoms are generally nonspecific. Brain MRI findings associated with CSF alterations allow early suspicion of MTBC. Start of empirical antituberculosis treatment upon suspicion is recommended given it is associated with better prognosis. Despite diagnostic and therapeutic advances, MTBC continues to have a high complication rate and an ominous prognosis.

Meningitis por Salmonella Enteritidis en un lactante: comunicación de un caso y revisión de la literatura / Salmonella Enteritidis meningitis in an infant: case report and literature review

Resumen La meningitis por Salmonella spp. es infrecuente en pediatría, pero debe sospecharse especialmente en menores de seis meses. Salmonella subespecie enterica es la más frecuente a nivel mundial, siendo el serovar Enteritidis el más importante. Tiene una alta tasa de complicaciones, predominando las colecciones y abscesos, por lo que se recomienda realizar una neuroimagen a todos los pacientes. A pesar que el manejo no está estandarizado, hay consenso en que el tratamiento de elección son las cefalosporinas de tercera generación. La resistencia antimicrobiana es infrecuente pero va en aumento, principalmente en países subdesarrollados. Presentamos el primer caso publicado en Chile de una meningitis por S. Enteritidis en un lactante de 11 meses, que se presentó con fiebre y una convulsión focalizada, con hemocultivos y cultivo de líquido cefalorraquídeo positivos. El paciente completó tratamiento con ceftriaxona y ciprofloxacina por cuatro semanas con buena respuesta.

Abstract Salmonella spp meningitis is rare in pediatrics. However, it should be especially suspected in children younger than 6 months. The enteric subspecies is the most frequent worldwide, with the Enteritidis serovar being the most important. The complication rate is high, with collections and abscesses predominating. For this reason, neuroimaging is currently recommended for all patients. Even though management is not standardized, there is consensus that first line treatment should be with third generation cephalosporins. Antibiotic resistance is infrequent but increasing, mainly in underdeveloped countries. We present the first case reported in Chile of meningitis by Salmonella Enteritidis in an 11-month-old infant presenting with fever and focused epileptic crisis. Blood culture and cerebrospinal fluid culture were positive. The patient completed four weeks of treatment with ceftriaxone and ciprofloxacin with a good response.

Feohifomicosis nasal por Curvularia spicifera en un paciente pediátrico con neutropenia y leucemia mieloide aguda / Nasal phaeohyphomycosis by Curvularia spicifera in pediatric patient with neutropenia and acute myeloid leukemia

There are very few reports of pediatric patients with infections by dematiaceous filamentous fungi. In this publication we report a case of invasive fungal infection of the nasal septum by Curvularia spicifera in a pediatric patient with acute myeloid leukemia. The patient presented with a painful scabby wound in the nasal vestibule. Culture and universal PCR were consistent with Curvularia spicifera. Early management with surgical debridement and bi-associated antifungal therapy achieved complete resolution of the lesions, with no evidence of dissemination and relapses. Clinical management of these fungal infections represents a challenge as the antifungal selection and duration of therapy is not yet well stablished.

Existen pocos reportes de infecciones por hongos dematiáceos en pediatría. Comunicamos el caso de una infección fúngica invasora del tabique nasal en un niño con una leucemia mieloide aguda, que se presentó como una lesión costrosa dolorosa en el vestíbulo nasal. Se realizó desbridamiento quirúrgico precoz y recibió tratamiento antifúngico biasociado, lográndose resolución completa de las lesiones, sin diseminación ni recaídas. El cultivo y la RPC universal fueron compatibles con Curvularia spicifera. El manejo de estas infecciones fúngicas representa un desafío, considerando que la elección del agente antifúngico y la duración de la terapia no están completamente establecidas.

Acceso a colecistectomía en un programa de tamizaje ecográfico de colelitiasis en centros de medicina familiar / Access to cholecystectomy among patients attended at primary family health centers

Background: Cholelithiasis (CL) represents a major health burden in Chile, with rates of cholecystectomy (CCT) of ~40.000 per year. The explicit health care guaranties (GES) program includes prioritized CCT for CL carriers between 35 and 49 years of age. Aim: To assess the access and opportunity of CCT in a screening program of CL in Family Medicine Centers, according to the age of the patients. Material and Methods: A systematic ultrasound screening program of CL was developed in Family Medicine Centers ANCORA-UC between March 2009 and March 2013 during which 1.450 individuals were assessed, (80% women) and 281 were identified as having CL (19.4%). After a minimum follow up interval of six months, patients with CL were contacted and surveyed by phone. They were categorized as being beneficiaries of the GES program (those aged between 35 to 49 years) or not (those aged < 35 o > 49 years). Results: Two hundred thirteen patients were contacted (76%), 81 beneficiaries of the program and 132 non-beneficiaries. The attending physician indicated CCT to 191 patients (89.6%). During a mean follow-up time of 641 days/person, 100 patients had CCT, 11% of which were emergency interventions due to complications. A greater proportion of program beneficiaries than non-beneficiaries had an elective CCT (74 and 21% respectively). The waiting interval for elective CCT was longer in non-beneficiaries compared with beneficiaries (340 ± 247 and 229 ± 201 days respectively). Only 46% of the elective CCT in GES patients were done within deadlines determined by the program (≤ 150 days). Conclusions: The age of patients at the moment of CL diagnosis conditions the access and opportunity to CCT. Beneficiaries of the explicit health care guaranties program have higher rates of cholecystectomy with less waiting time.