Management of acute respiratory distress syndrome in a child with adenovirus pneumonia: case report and literature review / Manejo da síndrome do desconforto respiratório agudo em criança com pneumonia por adenovírus: relato de caso e revisão da literatura

ABSTRACT Objective: To report the case of a child who developed acute respiratory distress syndrome (ARDS) from a pulmonary infection by adenovirus. Case description: A female patient aged 2 years and 6 months, weighting 10,295 grams developed fever, productive cough and vomiting, later on progressing to ARDS despite initial therapy in accordance with the institutional protocol for ARDS treatment. The child evolved to refractory hypoxemia and hypercapnia, requiring high parameters of mechanical pulmonary ventilation and use of vasoactive agents. In the treatment escalation, the patient received steroids, inhaled nitric oxide (iNO), was submitted to the prone position, started oscillatory high-frequency ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) was indicated due to severe refractory hypoxemia. During this time, the patient's clinical response was favorable to HFOV, improving oxygenation index and hypercapnia, allowing the reduction of vasoactive medications and mechanical ventilation parameters, and then the indication of ECMO was suspended. The patient was discharged after 26 days of hospital stay without respiratory or neurological sequelae. Comments: Adenovirus infections occur mainly in infants and children under 5 years of age and represent 2 to 5% of respiratory diseases among pediatric patients. Although most children with adenovirus develop a mild upper respiratory tract disease, more severe cases can occur. ARDS is a serious pulmonary inflammatory process with alveolar damage and hypoxemic respiratory failure; Adenovirus pneumonia in children may manifest as severe pulmonary morbidity and respiratory failure that may require prolonged mechanical ventilation. Exclusive pulmonary recruitment and HFOV are advantageous therapeutic options.

RESUMO Objetivo: Descrever paciente que evoluiu com síndrome do desconforto respiratório agudo (SDRA) a partir de infecção pulmonar por adenovírus. Descrição do caso: Paciente de dois anos e seis meses, sexo feminino, peso de 10295 g, que apresentou com quadro de febre, tosse produtiva e vômitos, evoluindo para SDRA. Apesar da terapêutica inicial em conformidade com o protocolo institucional de tratamento da SDRA, a criança evoluiu para hipoxemia e hipercapnia refratárias, necessitando de elevados parâmetros de ventilação pulmonar mecânica e utilização de agentes vasoativos. No escalonamento da terapêutica, a paciente recebeu terapias adjuvantes, foi iniciada ventilação oscilatória de alta frequência (VOAF) e indicada oxigenação por membrana extracorpórea (OMEC) pela hipoxemia grave refratária. Nesse ínterim, a paciente apresentou resposta clínica favorável à VOAF, melhorando do quadro ventilatório e possibilitando a redução das medicações vasoativas e dos parâmetros de ventilação mecânica. A paciente recebeu alta hospitalar após 26 dias de internação, sem sequelas respiratórias ou neurológicas. Comentários: As infecções por adenovírus ocorrem principalmente em lactentes e crianças com menos de cinco anos de idade e representam de 2 a 5% das doenças respiratórias entre os pacientes pediátricos. Embora a maioria das crianças com infecção por adenovírus desenvolva doença leve do trato respiratório superior, casos mais graves podem ocorrer com comprometimento do trato respiratório inferior. A pneumonia por adenovírus em crianças pode se manifestar com morbidade pulmonar grave e insuficiência respiratória com risco de vida, o que resulta na necessidade de suporte mecânico prolongado. O recrutamento pulmonar exclusivo pela VOAF pode ser uma opção terapêutica útil.

Adenovirus: de la neumonía a la bronquiolitis obliterante / Adenovirus: from pneumonia to obliteran bronchiolitis

Post-infectious bronchiolitis obliterans (BOPI) is a chronic obstructive disease, resulting from an acute injury and an abnormal repair process, with diffuse pulmonary fibrosis and peribronchiolar fibrosis, which cause chronic respiratory failure with prolonged oxygen dependence. The most common cause of this disease is severe bronchiolitis / pneumonia due to adenovirus (ADV), mainly in group B, before 2 years of age. In its pathogenesis are factors of the host and the characteristics of the virus that has mechanisms to prevent immunity and cause a chronic infection with great inflammatory response. This involves numerous cells (mainly lymphocytes) and cytokines that are produced by a chronic infection by ADV, which maintains a prolonged inflammatory process, determining different degrees of lung damage. In this article we will discuss the mechanisms by which this damage occurs.

La bronquiolitis obliterante postinfecciosa (BOPI) es una enfermedad obstructiva crónica, resultante de una injuria aguda y un proceso de reparación anómalo, con fibrosis pulmonar y peribronquiolar difusa, que causan insuficiencia respiratoria crónica con dependencia de oxigeno prolongada. La causa más frecuente de esta enfermedad es una bronquiolitis/neumonía grave por adenovirus (ADV), principalmente del grupo B, antes de los 2 años de vida. En su patogenia intervienen factores del huésped y las características del virus que tiene mecanismos para evitar la inmunidad y provocar una infección crónica con gran respuesta inflamatoria. En esta participan numerosas células (principalmente linfocitos) y citoquinas que se producen por una infección crónica por ADV, lo que mantiene un proceso inflamatorio prolongado, determinando distintos grados de daño pulmonar. En este artículo abordaremos los mecanismos por los cuales se produce este daño.

Enfermedad de Kawasaki e infección por adenovirus en un lactante / Kawasaki disease and adenovirus infection in an infant

La enfermedad de Kawasaki es una vasculitis febril aguda propia de la infancia con afectación de vasos de pequeño y mediano calibre. Predomina en niños de entre 1 a 5 años, siendo excepcional en lactantes. El diagnóstico se basa en criterios clínicos, sin embargo debido a su frecuente presentación atípica genera dificultades diagnósticas que pueden determinar retardo en la instauración del tratamiento lo que repercute negativamente en el pronóstico. Se presenta el caso clínico de un lactante de 3 meses, previamente sano, que en el curso de una infección respiratoria por adenovirus desarrolla enfermedad de Kawasaki. La infección viral previa y/o concomitante, descrita en la literatura como un posible factor desencadenante en individuos genéticamente predispuestos, planteó mayores dificultades al equipo tratante. El objetivo de esta comunicación es alertar sobre la presentación de esta enfermedad en asociación con infecciones virales en edades precoces, para contribuir al diagnóstico y tratamiento oportunos.

Kawasaki disease (KD) is an acute febrile vasculitis of early childhood which affects small and medium blood vessels. It prevails in children between 1 to 5 years old, being it unusual in children younger than one year old. Diagnosis is based on clinical criteria, although, due to its frequently atypical presentation, it is difficult to diagnose, what may result in a delayed initiation of treatment and the subsequent negative impact on prognosis. The study presents the clinical case of a 3 month old child with a healthy medical record, who developed Kawasaki disease during a respiratory infection caused by adenovirus. A previous viral infection and/or concomitant, posed greater difficulties to the treating team because according to literature. Viral infections are described as possible triggering factors in individuals who are genetically predisposed. The objective of this comunication is to warn on how this medical condition can be associated to viral infections at early ages as well as to contribute to early diagnosis and treatment.

Infeccions as the etiology for obesity / Infecções na etiologia da obesidade

The role of infection on obesity development has been questioned since the early 1980's. Several studies on animals have shown that fisiopathologic mechanisms through which infections can produce obesity do exist. At least eight types of obesity-inducing viruses have been identified in animals, especially poultry and mice. Studies on humans are far less convincing; however, two adenoviruses, Ad-36 and SMAM-1, have shown adipogenic properties. In vitro studies with 3T3-L1 cells stated the activation of the enzymatic pathway that leads to fatty tissue accumulation; in vivo studies have also detected higher levels of antibodies against such viruses on obese subjects. Although most known infections nowadays cause obesity through central nervous system lesions, the Ad-36 adenovirus infection affects fatty tissue directly, raising doubts regarding central role component in this case.

Desde o início dos anos 1980, o papel das infecções tem sido debatido quanto à etiologia da obesidade. Diversos estudos em modelos animais têm demonstrado que mecanismos fisiopatológicos ativados pelas infecções podem induzir também à obesidade. Pelo menos oito tipos de obesidade induzidas por viroses foram caracterizadas em animais, especialmente em camundongos e galinhas. Estudos em humanos existem, mas são menos convincentes. No entanto, duas adenoviroses (Ad-36 e SMAN-1) apresentam características adipogênicas. Estudos in vitro com a linhagem celular 3T3-L1 demonstraram que ativações enzimáticas levam ao acúmulo de gordura celular. Estudos in vivo detectaram níveis elevados de anticorpos contra certas viroses especialmente em indivíduos obesos. A maioria das infecções potenciais causadoras de obesidade atua produzindo ativações ou lesões no sistema nervoso central. Por outro lado, a infecção por Ad-36 adenovírus afeta diretamente o tecido adiposo, expandindo dessa forma a etiologia viral da obesidade para mecanismos hipotalâmicos e periféricos.

Necrotizing adenoviral pneumonia: manifestation of nosocomial infection in pediatric intensive care unit.

A 5-year-old child admitted in the pediatric intensive care unit developed fever and crepitations in the chest on 6(th) day of admission. She succumbed to her illness depite administration of adequate supportive and ventilatory care and anti-microbial therapy. At autopsy, she was diagnosed to have chronic ligneous type of tuberculous meningitis and necrotizing adnoviral pneumonia. There are hardly any reports of nosocomial adenoviral pneumonia from Indian centers. The case serves to remind intensivists to consider this diagnosis so that appropriate therapeutic adjustments and measures to prevent the spread of infection to other critically ill subjects are initiated.

The expression of coxsackie B virus adenovirus receptor (CAR) in viral myocarditis and dilated cardiomyopathy patients / 法医学杂志

OBJECTIVE@#To explore etiology and pathogenesis of viral myocarditis (VMC) and dilated cardiomyopathy (DCM).@*METHODS@#The expression of Coxsackie B virus and adenovirus receptors (CAR) were detected with modified immunohistochemical (IHC) technique in myocardium of left ventricle, right ventricle, interventricular septum, and septal papillary muscle from 28 patients with viral myocarditis, 31 patients with dilated cardiomyopathy and 17 control patients (including normal, hypertension heart disease, myocardial infarction and coronary atherosclerotic heart disease).@*RESULTS@#The brown staining on the cell membrane of myocardium represents positive result. 100% (28 of 28) of VMC patients (IHC surface integral: 4.3975 +/- 0.0365) and 84% (26 of 31) of DCM patients (4.2064 +/- 0.052 6) had prevalent CAR expression compared to 0% (0 of 19) control patients (0.073 1 +/- 0.0362). There were statistically significant differences between VMC/DCM and control patients (P < 0.05).@*CONCLUSION@#The prevalence of CAR expression was significantly higher in VMC and DCM patients (100% and 84% vs. 0% in control). In contrast, there was no difference found between VMC and DCM patients. These results suggest that both VMC and DCM involve viral etiology and could share a similar pathogenesis.