Neumonía y glomerulonefritis aguda en la infancia. ¿Una asociación infrecuente? / Pneumonia and acute glomerulonephritis in the childhood, an unusual association?

Introducción: En el desarrollo de la glomerulonefritis aguda están implicados diferentes patógenos; se ha descrito con poca frecuencia la asociación entre neumonía bacteriana y glomerulonefritis aguda. Pacientes y métodos: Estudio retrospectivo de los pacientes ingresados en nuestro hospital entre los años 2005 y 2015 con diagnóstico de glomerulonefritis aguda y neumonía; se excluyeron los que presentaron faringoamigdalitis estreptocócica, infección cutánea o neumonía en el mes previo. Resultados: Tres pacientes presentaron neumonía y glomerulonefritis. Las neumonías fueron lobares e indicativas de infección bacteriana. Las manifestaciones clínicas de glomerulonefritis fueron simultáneas al diagnóstico de neumonía. Los anticuerpos antiestreptolisina (ASLO) se encontraban aumentados en todos los pacientes, y el componente sérico C3 era bajo. Un paciente presentó una bacteriemia por Streptococcus pneumoniae serotipo 33, y otro un antígeno positivo de neumococo en orina. Todos los pacientes desarrollaron un síndrome nefrítico agudo. Se llevó a cabo un tratamiento conservador, con una evolución excelente en todos los casos. El complemento se normalizó en todos ellos. El tiempo medio de ingreso fue de 8 días. Conclusiones: Este estudio aporta nuevas evidencias sobre la asociación entre neumonía y glomerulonefritis aguda. Destaca que la glomerulonefritis es simultánea al cuadro infeccioso. Los ASLO pueden no ser específicos de infección por Streptococcus pyogenes, o bien estos pacientes habían presentado una glomerulonefritis aguda postestreptocócica poco sintomática que se agravó debido a la infección neumocócica (AU)

Introduction: Different pathogens are involved in the develop­ment of acute glomerulonephritis; the association between bacterial pneumonia and acute glomerulonephritis has been rarely reported. Patients and methods: Retrospective study of patients admitted to our hospital from 2005 to 2015 with an acute glomerulonephritis and pneumonia diagnosis, excluding those who had in the previous month either streptococcal pharyngeal infection, skin infection or pneumonia. Results: 3 patients had pneumonia and glomerulonephritis. Pneumonias were lobar and suggestive of bacterial infection. The clinical manifestations of glomerulonephritis and pneumonia were simultaneous. The ASO was high and C3 was low in all patients. A patient presented a bacteremia by Streptococcus pneumoniae and another one, positive urine pneumococcal antigen. All patients developed an acute nephritic syndrome. Its treatment was conservative; the evolution was excellent in all cases. C3 reached a normal value in all of them. The average hospitalization days were 8. Conclusions: Our study provides new evidences about the association between pneumonia and acute glomerulonephritis. It stands out that glomerulonephritis and the infectious process are simultaneous. ASO could not be specific for Streptococcus pyogenes infection, or perhaps these patients had an APSGN oligosymptomatic that was worsened by pneumococcal infection (AU)

Nefritis focal aguda: nuestra experiencia / Acute focal nephritis: our experience

La nefritis focal aguda se define como una lesión renal causada por infección focal aguda sin licuefacción. No es posible diferenciar mediante el cuadro clínico o de laboratorio una nefritis focal aguda de una pielonefritis aguda, siendo necesario el estudio de imagen. En las escasas publicaciones pediátricas al respecto, no existe uniformidad en las pautas de actuación diagnóstica y terapéutica. Presentamos una revisión de los casos de nefritis focal aguda diagnosticados y tratados en nuestro hospital en los últimos 8 años. En nuestra serie, todos los pacientes presentaron una evolución favorable en el momento agudo, con desaparición de la fiebre a los 2-4 días de tratamiento y normalización de la imagen ecográfica en un máximo de 9 días, a pesar de recibir diferentes pautas antibióticas. Sin embargo, al realizar gammagrafía de control a los 6-9 meses del episodio encontramos un porcentaje de hipocaptaciones focales superior al de la pielonefritis aguda sin complicaciones suspurativas

Acute focal nephritis is defined as a renal injury caused by acute focal infection without liquefaction. As it is not possible to differentiate clinically or by laboratory tests acute focal nephritis from acute pyelonephritis, imaging studies become necessary. Pediatric reports on this topic are scarce, and there are no current available guidelines on diagnosis and management. We report a series of acute focal nephritis cases diagosed and treated at our hospital in the last 8 years. All patients included in this study had a favorable outcome in the acute phase, with defervescence within 2-4 days of treatment. Ultrasound imaging normalized in a maximum of 9 days, despite the different antibiotic regimens employed. However, renal scan performed 6 to 9 months after the acute episode showed a higher percentage of focal hipocaption when compared to acute pyelonephritis without suppurative complications

Neuropsychological and genetic differences between age-associated memory impairment and mild cognitive impairment entities.

OBJECTIVE: To neuropsychologically and genetically compare age-associated memory impairment (AAMI) and mild cognitive impairment (MCI) entities and to determine what proportion of AAMI diagnosed individuals could also receive a MCI diagnosis. To compare the distribution of a previously known genetic risk factor for Alzheimer's disease (apolipoprotein E common polymorphism) associated with these two conditions with a sample of the normal aging. DESIGN: Neuropsychological and genetic assessments in AAMI and MCI individuals. Genetic assessment in AAMI, MCI, and control subjects. SETTING: General health centers and geriatric homes from northeastern Spain (Catalunya). PARTICIPANTS: One hundred and four subjects presenting subjective memory complaints were selected and the AAMI and MCI criteria were applied. One hundred and twenty-four healthy Spanish subjects age 50 and older were defined as controls. MEASUREMENTS: Memory, language, and frontal lobe functions were assessed using standard neuropsychological tests. The apolipoprotein E (apo E) polymorphism was obtained by using polymerase chain reaction (PCR) and HhaI restriction endonuclease. RESULTS: Sixty-seven percent of previously diagnosed AAMI individuals could also be identified as MCI subjects. These MCI cases differed from those only-AAMI individuals both in neuropsychological and genetic analyses, performing worse not only on memory but also on language and frontal lobe tests and presenting high and low prevalences of the apo E epsilon 3/epsilon 4 and epsilon 3/epsilon 3 genotypes, respectively. The general AAMI sample of 93 individuals also differed from controls in the apo E genotype and allele distributions but these differences were no longer present after subtracting the MCI cases (63 subjects). These findings reflect that the differences between the memory impaired sample and the control sample regarding the apo E polymorphism were mainly attributable to MCI individuals and not to those who received only a diagnosis of AAMI alone. CONCLUSIONS: Our findings suggest that among AAMI subjects, those who also fulfill the MCI criteria present a neuropsychological and genetic profile closer to that previously related to Alzheimer's disease than those individuals only eligible for a diagnosis of AAMI. However, our findings also suggest that using only the AAMI criteria still appears to select a population that differs genetically from the normal older population.

The discrepancy between daily practice and the policy of a decision-analytic model: the management of fever of unknown origin.

The optimal treatment of children with fever of unknown origin is controversial, in spite of two decision analyses that advise treatment with antibiotics for all such children. The aim of this study was to analyze the differences between pediatricians' diagnostic and therapeutic decisions and the outcomes of the decision-analytic models. Thirty-six pediatricians were asked to evaluate 30 patient cases and to give their diagnostic and therapeutic judgments. In addition, the pediatricians were asked questions about the epidemiology of fever of unknown origin. Analyses showed that the differences in policy between pediatricians and the models could not be explained by the reasons mentioned in the literature, i.e., 1) differences in epidemiologic data used, 2) differences in the weighting of clinical information, and 3) differences in the evaluation of outcomes. The differences in policy might be due to a difference between the objective of the models and pediatricians' aim. In a curative setting, pediatricians are not trying to prevent meningitis (or another serious disease) by treating possible occult bacteremia, but rather aim to detect meningitis in an early stage. A decision analysis determining the most cost-effective strategy for early detection of meningitis might therefore be more easily accepted by pediatricians.

High levels of interleukin 10 and tumor necrosis factor alpha in cerebrospinal fluid during the onset of bacterial meningitis.

Since interleukin-10 (IL-10) controls the production of tumor necrosis factor alpha (TNF-alpha) and this latter cytokine has a deleterious effect on neuronal cells, we determined the levels of both cytokines in cerebrospinal fluid (CSF) from children with bacterial meningitis. High levels of IL-10 (1,164 pg/mL) and TNF-alpha (3,158 pg/mL) were detected in CSF from 10 children with meningitis, but these cytokines were not detectable in CSF from 12 controls. In vitro neutralization of IL-10 demonstrated that endogenously formed IL-10 is important for limiting the production of TNF-alpha by leukocytes. We assume that IL-10 in CSF will decrease the inflammatory reaction associated with meningitis and will result in the development of fewer sequelae because of its inhibitory effect on the production of TNF-alpha.

Release of tumor necrosis factor: an innate host characteristic that may contribute to the outcome of meningococcal disease.

Tumor necrosis factor (TNF) plays a pivotal role in meningococcal disease. The TNF response to endotoxin, however, differs between individuals and can be determined in whole blood samples ex vivo. The release of TNF in whole blood samples from 50 survivors of meningococcal disease 6-58 months after hospital discharge was studied. The TNF response was higher in patients who had experienced a moderately severe disease course compared with patients with a mild course. The TNF response was low again in the survivors of fulminant disease, who on original hospital admission presented with risk factors exposing them to a high chance of mortality (50% overall). On admission, the patients who did not survive had initial TNF levels three times higher than those in survivors with a clinical disease presentation of similar severity. Overall interpretation of these findings is that the innate TNF response may contribute to the outcome of meningococcal disease.

C-reactive protein in the management of children with fever after allogeneic bone marrow transplantation.

The value of C-reactive protein (CRP) determinations in the analysis of fever after allogeneic bone marrow transplantation (BMT) was studied prospectively by serial measurements of serum CRP levels during 30 BMT episodes in 28 children and adolescents. The treatments and procedures accompanying BMT did not elicit a significant CRP response. Forty-three febrile episodes were registered and analyzed, without previous knowledge of the results of CRP determinations. The incidence of bacterial infection and acute graft-versus-host disease (GvHD) was low, 8/30 and 5/30, respectively. Raised CRP levels occurred only once in association with GvHD. A CRP level higher than 50 mg/l was not sensitive as an indicator of bacterial infection (4/8). A CRP level below 50 mg/l in the presence of fever, however, excluded bacterial infection with a specificity of 86% and a negative predictive value of 88%. When timed properly and interpreted together with clinical and microbiological findings, CRP measurements can be a valuable aid in the management of fever after BMT, especially as a negative predictor.

[Congenital cytomegalovirus infection]. / Congenitale cytomegalovirus-infectie.

Until recently, prevention and treatment of congenital cytomegalovirus infection was not possible. However, several studies on the epidemiology of congenital CMV infection and the development of vaccines, diagnostic tests and antiviral drugs such as ganciclovir may improve the perspectives for patients with congenital CMV disease. In this article we will discuss several of those developments that may offer new approaches for prevention and treatment of congenital CMV disease.

Changes in synaptosomal pH and rates of oxygen radical formation induced by chlordecone.

The resting pH of 7.14 +/- 0.02 within rat cortical synaptosomes is elevated in vitro by the insecticide chlordecone, in a dose-dependent manner. Chlordecone also reduces the rate of oxygen radical formation within synaptosomes. Both of these changes can also be demonstrated following in vivo treatment of rats with chlordecone (75 mg/kg body wt). Although chlordecone increases the permeability of the plasma membrane, the increase in pH observed is unlikely to be caused by this, since in vivo administration of chlordecone does not appreciably alter membrane order as evaluated by both a lipophilic probe, and a probe with an ionic segment. Another xenobiotic agent, methyl mercuric chloride, and a free radical generating system, an ascorbic acid-ferrous sulfate mixture, did not modulate synaptosomal pH, although membrane permeability was increased. Other evidence of the ability of synaptosomes to maintain homeostasis was the failure of mitochondrial inhibitors to significantly reduce pH. The drop in synaptosomal pH effected by amiloride, an inhibitor of Na+/H+ exchange, and the transient rise in pH caused by ammonium chloride further suggested that synaptosomes may be a good model in the study of the regulation of intracellular pH. The elevation of cytosolic pH, and depression of oxygen radical formation by chlordecone, may result from both the attenuation of respiratory metabolism and an impaired capacity of the plasma membrane to maintain ionic gradients.

Sonographic demonstration of portal venous gas in necrotizing enterocolitis.

Portal vein gas embolism was demonstrated by ultrasound in a preterm infant with necrotizing enterocolitis. This sign could not be detected radiographically. It is speculated that portal venous gas occurs more frequently than hitherto inferred from radiological studies. This observation points to the value of ultrasonography in providing early objective evidence in support of the diagnosis of NEC. The favourable outcome for the patient proves that portal venous gas embolism is not necessarily associated with a fulminant course of enterocolitis.

Toluene-induced alterations in rat synaptosomal membrane composition and function.

Toluene is a widely used organic solvent that can produce acute central nervous system (CNS) effects. Since toluene reaches relatively high concentrations in the CNS and is extremely lipophilic, we investigated its effects on rat brain membrane composition and function. Toluene (1 g/kg, lh) did not alter total brain microsomal phospholipid (PL) or cholesterol (CL) content. However, synaptosomal PL was decreased (24%), while synaptosomal CL was unaltered. The PL/CL ratio, an indirect index of membrane fluidity, did not change, suggesting that toluene did not affect membrane fluidity. Fluorescence polarization studies employing 1,6-diphenyl-1,3,5-hexatriene (DPH) showed that toluene did not alter synaptosomal membrane fluidity after administration in vivo (1 g/kg) or in vitro (0.5 to 5.0 mM). Dose-response and time-course studies showed that toluene maximally decreased synaptosomal PL after 1 g/kg, 1 h. The dose-response and time-course studies also showed that the toluene-induced decreases in PL were a result of specific decreases in phosphatidylethanolamine (PE). Since PE was decreased, we assessed whether toluene altered synaptosomal membrane function by investigating phospholipid methylation, a reaction which uses PE as its initial substrate. Toluene decreased the incorporation of methyl groups into lipid when [3H]-methionine was used as the methyl donor, but did not affect methylation when [3H]-adenosylmethionine was the methyl donor. These data suggest that toluene-induced specific decreases in synaptosomal PE and inhibition of phospholipid methylation may alter normal synaptic function and play a critical role in the mechanism(s) of action of toluene's CNS effects.

Multicentre dose range study of a yeast-derived hepatitis B vaccine.

Healthy young adult volunteers, 778 in number, without HBV markers were randomly distributed into groups and administered different lots of a yeast-derived hepatitis B vaccine (YDV) at different dose levels or a commercial plasma-derived vaccine (PDV), according to a 0, 1, 2, 12-month vaccination schedule. The YDV proved to be safe and well tolerated, even when partly purified lots were given. Reactions were mild and transient, comparable to those observed after PDV. One month after three YDV doses, 0-7% of subjects overall had failed to seroconvert; all those evaluated one month after the booster dose had seroconverted. No significant difference was found between the two vaccine types as far as seroconversion rates were concerned. Geometric mean anti-HBs levels following three vaccine doses were higher in seroconverters of the PDV groups. However, a booster dose of YDV resulted in high anti-HBs levels in all groups varying from 11,474 to 51,404 IU l-1 (purified YDV lot), 4915 to 18,832 IU l-1 (partly purified YDV lots) and 11,008 to 15,805 IU l-1 (PDV lots). Of seroconverters to the purified lots of YDV 93% attained 1000 IU l-1 after the booster dose, thus ensuring protection for a number of years. Dose-response studies provided a basis for the selection of 20 micrograms of highly purified YDV as the standard dose.

Acute tubulo-interstitial nephritis and uveitis syndrome (TINU syndrome).

Acute renal failure due to tubulo-interstitial nephritis developed in a 15-year-old girl. The disease was accompanied by uveitis and an inflammatory syndrome, consisting of a markedly increased erythrocyte sedimentation rate and high serum gamma globulin levels. The nephropathy as well as the inflammatory syndrome subsided spontaneously. A topical antiphlogistic treatment healed the ocular disease, which has not relapsed so far. The association of acute tubulo-interstitial nephritis and acute uveitis observed in several patients has led to the identification of a specific syndrome with a very particular symptomatology and course, the so-called TINU syndrome, the interest of which resides in the predictability of the complete reversibility of the nephropathy either spontaneously or after steroid treatment, contrasting with the marked tendency towards relapse of the uveitis. The demonstration of circulating immune complexes in the serum during the acute phase of the illness, as in our patient, further points to the involvement of immune processes in the syndrome, but the origin and pathogenesis remain as yet unknown.

[Echographically controlled ventricle punctures]. / Echografisch geleide ventrikelpuncties.

Ventricular taps are performed either for diagnostic or for therapeutic purposes. They are not free of risks. A new technique is presented, in which the placement of the needle is echographically monitored. Fifteen punctures were done in five children. All punctures were successful at first attempt, and were uneventful.

[Influence of intra-uterine growth retardation on plasma and adrenal corticosterone levels during development in rats]. / Influence du retard de croissance intra-utérine sur le taux de corticostérone plasmatique et surrénalien chez le rat au cours du développement

The evolution of plasma and adrenals corticosterone was followed in normal rats, sham rats, IUGR rats and their controls, during the foetal and post-natal development. Adrenals weight was significantly reduced in IUGR rats. Corticosterone plasma levels were lower in IUGR rats up to 24 hours after birth.