[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

Clinical predictors of high risk bleeding endoscopic lesions in children with haematemesis

Background: Haematemesis is an alarming symptom in children, even if the proportion of normal endoscopies ranges from 10 to 21% and the causes are often benign. The purpose of the study was to identify clinical predictors of endoscopic lesions with high risk of bleeding and to establish a score that predict the presence of these lesions

Methods:Retrospective study carried in Children's Hospital of Tunis between 1997 and 2006 involved children with haematemesis who underwent Upper gastrointestinal endoscopy. Several clinical parameters were analyzed. Univariate analysis and multivariate logistic regression were performed to identify predictive parameters of endoscopic lesions with high risk of bleeding. A score was developed from the parameters derived from the multivariate analysis. The sensitivity and specificity of the score were determined

Results: Among 2814 endoscopies, 814 were conducted for haematemesis and 489 were selected for the study. 140/489 had lesions with high risk of bleeding. Multivariate logistic regression analysis identified six factors independently associated with high risk bleeding lesions: endoscopy performed within 48 hours [OR=2.2; 95% CI 0.7-6.9], re-bleeding [OR=1.4; 95% CI 0.7-2.5], the importance of the bleeding, mild to severe [OR=1.8; 95% CI 1.1- 3], bright red haematemesis [OR=1; 95% CI 0.2-5.8], history of gastrointestinal and liver disease [OR=1.6; 95% CI 1.1-3] and intake of gastro toxic drugs [OR=1.3; 95% CI 0.8-2.3]. Then, we established a score. The sensitivity, specificity, positive predictive value and negative predictive value of this score were respectively 79.6%, 32.9%, 34.9% and 78% for a cut off value> 0.22

Conclusion: The clinical predictive parameters of high risk bleeding lesions identified have not yielded a score with significant sensitivity and specificity. A prospective study should be performed to improve the score

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

Endoscopic diagnosis in a Tunisian paediatric population with upper gastrointestinal bleeding [UGIB]

Esophagogastroduodenoscopy [EGD] is currently considered the first line diagnostic procedure chosen for Upper Gastrointestinal Bleeding [UGIB] since 1970. However, studies are still limited in our country. Finding out the most common causes of UGIB in children and whether the causes differed according to age in developing and developed countries. A retrospective review of the medical records of children referred to the Paediatric Gastroenterology Department of The Tunis Hospital of Children between January 1998 and December 2006 for upper gastrointestinal bleeding. The children were divided into three groups; G1: neonates; G2: infants; G 3: children and adolescents. The study involved 614 endoscopies. The aetiology was not ascertained in 20.68%of cases. G1 included 125 newborns: 24 with no identified causes, 97 mucosal lesions [isolated or associated]; two ulcers and two tumours. G2 and G3 included respectively 205 infants and 289 children. Toxic drug intake was recorded in 140 out of 489 patients. Endoscopy was normal in 101 cases. Peptic oesophagitis was recorded in 57/205 [27.8%] of G2 infants versus 52/284 [10%] of G3 children [p=0.015]. Gastritis was recorded in 164/284 [55.6%] of G2 infants versus 86/205 [41.9%] of G3 children [p

[Pediatric Crohn's disease in Tunisia]

Crohn's disease occur mainly in adults. However, pediatric onset forms are not rare and have many characteristics.To study clinical, diagnostic, therapeutic and evolutive characteristics of crohn's disease in tunisian children. Retrospective multicenter study conducted in 10 pediatric departments on a period of 10 years [2000-2008]. 43 children were included. The sex-ratio was 1.68. The mean age at the onset of the symptoms was 11 +/- 2.3 years [5-16 years]. The age of onset was inferior to 10 years in 25% of the children. The delay before management was superior to 1 year in 25% of cases. The initial symptoms were dominated by diarrhea [95%]. Perineal manifestations were present at diagnosis in 30% of children and extra-digestive manifestations in 53%. Ileocolonic localization was the most frequent [46%]. The initial disease flare was moderate in 83% of cases. The treatment was medical in 77% of cases, nutritional and medical in 18.5%. Maintenance therapy was instituted in 86% of cases and consisted essentiallay in azathioprin [62%]. The mean follow-up was 3 years and 4 months. 60% of the children had at least one acute flare. During evolution, 7% of children had anoperineal surgery and 11% an intestinal resection. Crohn's disease seems rare in Tunisia. The time of diagnosis is often delayed. The management is based on immunosuppressive therapy and nutritional support

Nodular gastritis: an endoscopic indicator of helicobacter pylori infection in children

Helicobacter pylori [Hp] infection is a common and universally distributed bacterial infection. It is predominantly acquired in childhood. To assess the relationship between endoscopic nodular gastritis and Hp infection. A retrospective study was conducted in children who underwent upper gastrointestinal endoscopy for chronic abdominal pain. All children who had five gastric biopsies for histologic analysis, urease test and Hp culture were included in the study. The Sensitivity and sensibility of nodular gastritis were determined and different parameters were studied according the presence or not of nodular gastritis[age, gender, Hp status, gastritis score and lymphoid follicles]. 49 children, mean age 6.9 +/- 3 years [range 1-12 years] were eligible for the analysis. Hp Infection was diagnosed in 35 out of the 49 children [71.5%]. Nodular gastritis was recorded in 16 out of 49 children and in 14 infected children and 2 out of 14 non infected children [p=0.07], 40% sensitivity, 85.7% specificity, 87.5% positive predictive value, and 36,4% negative predictive value. The parameters associated significantly to the presence of nodular gastritis were older age: [p=0.04], Hp infection: [p=0.01], chronic gastritis: [p=0.05], active gastritis: [p=0.02], follicular gastritis: [p=0.005], higher gastritis score: [p=0.005]. Completely normal gastric mucosal histology was never found in infected children with antral nodularity. Among all infected children, the gastritis score was significantly higher when there was a nodular gastritis and follicular gastritis was significantly associated to nodular gastritis. The endoscopic pattern of antral nodularity identifies children with Hp infection, and active chronic follicular gastritis

[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

[Interventional endoscopy in the gastrointestinal tract in children]

Interventional endoscopic procedures involving the gastrointestinal [GI] tract in children are very common. Over the last several years the number of procedures in this area has steadily increased. To study indications and results of GI interventional endoscopies performed in a Pediatric GI unit. Retrospective study over a period of 10 years [1999- 2008]. Data were collected from endoscopic files. All procedures were performed endoscopically under general anesthesia. 185 interventional endoscopic procedures were done during this period in 96 patients [58 boys] median age: 4.9 +/- 4.7 years [1 month-13 years]. Indications were as follows: esophageal stenosis [n= 46; 47.9%], rectal polyp resection [n=21; 19.8%], esophageal varices ligation [n=19; 19.7%], foreign body extractions [n= 8; 8.3%] and percutaneous endoscopic gastrostomy [n= 2; 2.1%]. One hundred and thirteen esophageal dilations [61.1% of procedures] were performed in 46 patients: caustic stenosis [n=22; 22.9%], peptic stenosis [n=13; 13.5%] and anastomotic stenosis [n= 11; 11.4%]. The main indication of interventional GI endoscopy in this series was oesophageal stenosis followed by rectal polyp resection, esophageal varices ligation and foreign body extractions

[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

[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

[ 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

[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

kyste hydatique du poumon chez l'enfant a propos de 54 cas

The purpose of this retrospective study is to clarify the clinical, radiological and evolutionary aspects of the hydatid cyst of the lung. Over a period of 9 years [January, 1983 - December, 2001], we brought together in the pediatric service B of Children's hospital of Tunis, 54 cases of hydatid cyst of the lung. The average age is of 7 years 3 months [extremes 2 and 14 years], and the sex- ratio of 1, 16. 61% of the children are of rural origin. Bronchpulmonary infection is the most frequent circumstance of discovery [72% of cases], hemoptysis is revealing in 37% of cases. Discovery is fortuitous in 7% of cases. The radiography of the chest is of a big diagnostic contribution. The radiological aspects obtained are: a homogeneous opaqueness [61%], a diverse opaqueness [26%], an image of lung abscess [22%], an aspect of floating membrane [4%], a pleural effusion [9%], and an opaqueness with growing gas [4%]. Chest echography was contributory in 77% of cases. 74% of the children were operated without complications. The others were lost