[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

randomized, controlled trial of nebulized 5% hypertonic saline and mixed 5% hypertonic saline with epinephrine in bronchiolitis

Bronchiolitis is a public health problem in the word and in Tunisia. Nebulized hypertonic saline seems to have some benefits in bronchiolitis. The aim of this study is to evaluate the efficacy of nebulized 5% hypertonic saline alone or mixed with epinephrine in bronchiolitis as measured by improvement in clinical score, oxygen saturation or reduction in duration of hospitalization. This prospective, double blind, placebo controlled, randomized clinical trial was performed at Children's Hospital of Tunis from February 2012 to Mars 2012. A total of 94 patients less than 12 months of age with diagnosis of moderately severe bronchiolitis were enrolled and assigned to receive 5% nebulized hypertonic saline, mixed 5% hypertonic saline with standard epinephrine 0,1% or normal saline [placebo] at admission and every 4 hours during hospitalization. There were no significant difference between nebulized 5% hypertonic saline, mixed 5% hypertonic saline with epinephrine or normal saline at baseline, T30 min, T60 min, and T120 min after start study in Wang severity score, oxygen saturation in room air, rate respiratory and heart rate. There was no difference in duration of hospitalization. Nebulized 5% hypertonic saline or mixed 5% hypertonic saline with epinephrine are safety but does not appear effective in treating moderately ill infants with the first acute bronchiolitis

Utility of lumbar puncture for febrile seizures among infants under one year old.

Febrile seizure is a frequent cause of hospitalization. Its management remains problematic According to the American Academy of Pediatrics, lumbar puncture, which is not devoid of risk, is strongly recommended in infants under 1 year. To define the utility of lumbar puncture in the management of febrile seizures in infants under 12 months and to identify risk factors of meningitis and to respond to this question: " lumbar puncure should be done in which infant with febrile seizure?" This retrospective study was conducted in the department of pediatrics B in the Children Hospital of Tunis on eight-year period [2000-2008]. In all statistical tests, significance level was set at 0.05. One hundred and six cases were collected during the period of study. Seizures related to bacterial meningitis were seen in 11 cases [10%]. We have separated two groups: GI infants presented bacterial meningitis, and G2 infants with febrile seizure. The comparison between the two groups G1 and G2 showed the following predictors factors of meningitis: age 5mm [p<0.001], recurrence of seizure in the same day[p=0,006], neurological abnormalities p<0.001], CRP>20 mg/1[p=0.03], hyponatremia

Marfan syndrome in a Triplo-X girl: a new association?

Triple X is a sex chromosomal abnormality that involves the presence of three sex chromosomes resulting in 47, XXX karyotype. Most patients suffering from this syndrome are usually mentally normal or subnormal with no gross malformation. To report an unusual association between Triple X and Marfan disease in a girl. A case of a triple X girl with craniofacial dysmorphy and skeletal anomalies, who did feat Marfan criteria by age, is presented. To the best of our knowledge this association has never been reported. Some clinical features are common between Triplo X and Marfan disease so a careful follow-up is needed and investigations should be performed in these patients because Marfan syndrome may be incomplete in early age

[Mediastinal tuberculosis mass in a three-month-old boy]

Mediastinal mass of tuberculous origin is exceedingly rare in infant. To report an exceedingly rare case of mediastinal mall of tuberculous origin. We report a three-month-old boy who presented a one month history of wheezing a persistent pneumopathy. Radiological investigations showed a large posterior mediastinal mass which infiltrates lungs. Thoracoscopic biopsy showed caseous necrosis with granuloma suggestive of tuberculosis. The outcome was favourable with antituberculous chemotherapy. Mediatinal mass of tuberculous origin should be considered in differential diagnosis of mediastinal masses in children; be suggested in mediastinal mass in children

[Congenital cutaneous candidiasis associated with respiratory distress in a full-term newborn]

Congenital candidiasis is rare occurring in most cases in premature and low birth weight new born. It can produce a spectrum of disease ranging from a diffuse skin eruption to a severe spectrum of disease with or without skin involvement. Amphotericin B is the first-line agent for the treatment of systemic disease. To describe a congenital candidiasis in a full-term new born. At birth, the newborn had a generalized, erythematous, papulovesicular eruption. He was treated by topic antifungal therapy. However, on the third day, he developed a systemic disease with respiratory distress and fever. Ear, skin swab and gastric aspirate grew to Candida albicans. The new born was given fluconazole for 10 days with favourable outcome. Early topic therapy did not prevent systemic spread of congenital cutaneous candidiasis in our case. Treatment with fluconazole, as the first- line agent, seems effective and safety

Unusual case of thiamine responsive megaloblastic anemia

Thiamine responsive megaloblastic anemia syndrome is a rare autosomal recessive disorder defined by the occurrence of megaloblastic anemia, diabetes mellitus, and neurosensoriel deafness, responding in varying degrees to thiamine treatment. Report an unusual case of this rare disorder. We report the case of a four-year-old boy who presented unusual features of thiamine- responsive megaloblastic anemia. In addition to the typical triad of the syndrome, he presented leuconeutropenia, hepatosplenomegalia, cardiac abnormalities including absent P waves, mitral and tricuspid insufficiency, retinitis pigmentosa, nystagmus, developmental delay and a brain Magnetic resonance imaging ischemic lesion. Lactate levels in serum and the lactate/ pyruvate ratio were increased. The mitochondrial mutation m.3243A > G located in MTTL1 gene encoding for transfer RNA leucine [tRNALeu[UUR]] was not found. Treatment with thiamine resulted in normalisation of the haemoglobin level, white cell count, and glucose and lactate levels. On three years follow up, the patient did not need insulinotherapy. These data sign the crucial role that thiamine plays for many cells and tissues and its importance in the activity of the respiratory chain

[ randomized, controlled trial of nebulized terbutaline in the first acute bronchiolitis in infant less than 12 months old]

Despite the common clinical practice, the available evidence on the efficacy of bronchodilators therapy for bronchiolitis is conflicting. The aim of this study is to evaluate the efficacy of nebulized terbutaline in bronchiolitis as measured by improvement in clinical score, oxygen saturation or reduction in duration of hospitalization. This prospective, double blind, placebo controlled, randomized clinical trial was performed at Children's Hospital of Tunis from December 2004 to April 2006. A total of 35 patients less than 12 months of age with diagnosis of moderately severe bronchiolitis were enrolled and assigned to receive nebulized terbutaline or normal saline placebo at admission [TO], at 30 minutes after admission [T30] and every four hours during a study period. Outcome measurements included: Respiratory Distress Assessment Instrument [RDAI] score, respiratory rate, oxygen saturation, heart rate and the duration of hospitalization. There were no significant difference between terbutaline and placebo at baseline, T30 min, T60 min, and T120 min after start study in RDAI score, oxygen saturation in room air, rate respiratory and heart rate. There was no difference in duration of hospitalization. Nebulized terbutaline therapy does not appear effective in treating moderately ill infants with the first acute bronchiolitis

[Community acquired pneumonia in children]

Community acquired pneumonia is responsible for a high morbidity in children. The etiological diagnosis is not always easy and treatment remains probabilistic. To analysis clinical patterns and the outcome of community acquired pneumonia and to find arguments in favour of its origin. A prospective analysis of the files of 39 children [20 boys, 19 girls] hospitalized between [1 December 2004-30 June 2005] for community acquired pneumonia was performed. Included children whad between 6 months ad 15 years-old. The mean age was of 3 years and three months. Germ was identified in 41%of cases: Mycoplasma pneumoniae was the most important germ found in9 cases, pneumococcus was found in 4 cases and hemophilus in four cases. Coinfection pneumococcus and mycoplasma were found in two cases. None virus was identified. We have separated two groups: bacterial pneumonia and pneomoniae without definite etiology. Fat cough was associated to bacterial pneumonia mycoplasma pneomoniae was significantly associated with high fever and dry cough. We haven't found any others associations between clinical, biological or radiological patterns and the two groups of pneumonia. C-reactive protein more than 66 mg/I has sensitivity of 77%, specificity of 73.3%, positive predictive value of 46.7 99 of and negative predictive value of 91.7%. The outcome was favourable in all cases. Theses results showed the necessity to improve our microbiological methods to identify infectious agents of pneumonia. Mycoplasma pneumonia seems to be a frequent germ in preschool children

Infantile onest of cockayne syndrome without photosensitivity in a Tunisian Girl

Cockayne syndrome is a rare autosomal recessive disorder with dwarfism, mental retardation, and otherwise clinically heterogeneous features. Classically, the onset of Cockayne syndrome starts in the second year of life. The failure of RNA synthesis to recover to normal rates after UV-C irradiation provides a useful diagnostic test and the clinical feature that correlates most strongly with defective RNA synthesis is photosensitivity. To report an unusual case of Cockayne Syndrome. A case of a five-year-old girl with Cockayne with an onset in early infancy the girl and without photosensitivity is presented. The diagnosis was confirmed by the failure of RNA synthesis to recover to normal rate after UV-C irradiation. The patient died at the age of 6 of pneumonia. Although rare, Cockayne syndrome may be presented without photosensitivity and had an early onset

[Pyelonephritis xanthogranulomatous in childhood: case report and litterature review]

Xanthogranulomatous pyelonephritis [XGP] is a specific form of chronic inflammatory kidney disease rarely seen in children. The Symptoms are often vague and non-specific the aim of this paper is to return the particularities of imaging features in xanthogranulomatous pyelonephritis. insisting on differential diagnosis with renal tumors, especially in case of no renal stone or tract obstruction evidence, We report a case of xanthogranulomatous pyelonephritis in a 2-year-old boy involving the lower renal pole which demonstrates the diagnostic difficulties encountered in this disease Xanthogranulomatous pyelonephritis is a rare condition in children and should be included in the differential diagnosis of a child presenting a renal mass

Extra pulmonary tuberculosis in children: a study of 41 cases

Extrapulmonary tuberculosis accounts for up o one third of all cases of tuberculosis and children show a higher predisposition to the development of extra-pulmonary tuberculosis. To review the clinical features of the extrapulmonary tuberculosis in children. Forty one children with extrapulmonary tuberculosis followed in the Children Hospital of Tunis between January 1995 and December 2007 were reviewed. Extrapulmonary tuberculosis constitutes 57.9%of all cases of tuberculosis. Male to female ratio was 0.7 and the mean age was 75 years. The most commonly involved sites were the peripheral lymphadenitis [14 cases] followed by abdominal [11 cases], central nervous system [7 cases], osteoarticular [5 cases] and multifocal [4 cases]. A positive family history of active tuberculosis was detected in 22.5%of the cases. Diagnosis delay was 4.7 months. Sequelae observed during the follow up were: neurosensory in 5 cases, and vertebral deformation in 1 case. Extrapulmonary tuberculosis represents an important fraction of tuberculosis in our study. The most common form is lymph nodes localization followed by abdominal and central system nervous forms. Neurosensory sequelae were frequent in central system nervous tuberculosis

[Infectious diarrhoea in children under five years]

To determine the prevalence of rotavirus in acute diarrhea among children under 5 years and to describe the epidemiology, clinical trials of rotavirus diarrhea and compare them with those of other gastroenteritis. A Prospective study during 1 year [1 January 2007-31 December 2007] was conducted in the department of Pediatrics B of the Children's Hospital of Tunis. 117 children aged under than 5 years and admitted for acute community gastroenteritis were included in the study. A search of rotavirus in the stool, collected within 48 hours of admission, was performed by a rapid detection of viral antigens: proteins specific RV group A [VP6 protein of the capsid] using enzyme immunoassay technique: sandwich ELISA [IDEIA Rotavirus Dako] Rotavirus diarrhea accounted for 25%of acute gastroenteritis. The average age of rotavirus gastroenteritis was ii months +/- 1 .78. We have noted a male predominance with a sex ratio of 1.2. The seasonal distribution of rotavirus gastroenteritis showed three peaks of incidence [January, May and July]. The respiratory signs were more frequently found in rotavirus gastroenteritis group. Rotavirus gastroenteritis had a higher severity score compared with other gastroenteritis [8.44 vs 6.75 P=0.01]. The duration of hospitalization was longer in rotavirus group with a difference close to significance p=0.07. The seasonal distribution of rotavirus gastroenteritis has three peaks of incidence. The gastroenteritis Rotavirus affects very young infants and has more severe symptoms than other gastroenteritis and is significantly associated with respiratory signs

Pneumocoocal infection and haemolytic uremic syndrome

Hemolytic uremic syndrome, one of the common causes of acute renal failure in children, is characterized by the triad of microangiopathy, haemolytic anemia, thrombocytopenia and acute renal failure. The diarrhoea-associated Hemolytic uremic syndrome is usually termed as a typical Hemolytic uremic syndrome. Streptococcus pneumoniae is an uncommon etiological pathogen for inducing Hemolytic uremic syndrome, and Streptococcus pneumoniae associated Hemolytic uremic syndrome is also termed as atypical hemolytic uremic syndrome. To report two pediatric cases of invasive S pneumoniae complicated with hemolytic uremic syndrome HUS. The first patient presented with pneumococcal pneumonia and empyema and the second patient presented with pneumococcal pneumonia and meningitis. The two patients were under one year of age and required peritoneal dialysis with improvement of renal function in one; the other died. Pneumococcal invasive disease may be a cause of severe 1-IUS, so a high index of suspicion is mandatory to prompt appropriate diagnosis and management

[Fanconi anemia complicated by neutropenic enterocolitis]

Neutropenic enterocolitis [NEC] also known as typhlitis is an acute, life-threatening inflammation of the small and large bowel often seen in patients with leukaemia undergoing cytotoxic chemotherapy; occasionally this syndrome could present in other immunocompromised patients. To report an unusual case of fanconi anemia complicated by neutropenic enterocolitis. We report a case of a 13-year-old boy affected by Fanconi anemia with severe neutropenia and who presented Neutropenic enterocolitis. Abdominal ultrasonography showed thickening of cecum and ascending colon of 1.18cm. The outcome was favourable with medical management. Neutropenic enterocolitis in Fanconi anemia is a rare and a severe illness; however the outcome is improved with early management

[Neonatal meningitis by Neisseria meningitidis B]

Neisseria meningitidis is one of the major causes of meningitis in children and adolescents, but it is uncommonly found in neonatal meningitis. To report a rare case of meningitis by Neisseria meningitides B. We report the case of neonatal meningitis in a 20 day-old girl without shock or purpura. The symptoms were fever and seizures. The culture of cerebrospinal fluid showed to be positive for Neisseria meningitidis B. culture blood was negative. Antibiotic therapy was started at admission and maintained for 3 weeks. The outcome was favourable without neurological sequelae. Early diagnosis and treatment are mandatory for life saving