Lung mechanics in pediatric acute respiratory distress syndrome associated to acute COVID-19 and MIS-C: implications for therapies and outcomes. / Mecánica pulmonar en el síndrome de distrés respiratorio agudo pediátrico asociado a COVID-19 aguda y MIS-C.

OBJECTIVE: To describe lung mechanics in Pediatric Acute Respiratory Distress Syndrome (PARDS) associated with acute COVID-19 and MIS-C with respiratory failure. METHODS: A concurrent multicenter observational study was performed, analyzing clinical variables and pulmonary mechanics of PARDS associated with COVID-19 in 4 Pediatric intensive care units (PICU) in Peru. The subgroup analysis included PARDS associated with multisystem inflammatory syndrome in children (MIS-C), MIS-PARDS, and PARDS with COVID-19 primary respiratory infection, C-PARDS. In addition, receiver operating characteristic (ROC) curve analysis for mortality and lung mechanics was performed. RESULTS: 30 patients were included. The age was 7.5 (4-11) years, 60% were male, and mortality was 23%. 47% corresponded to MIS-PARDS and 53% to C-PARDS groups. C-PARDS had positive RT-PCR in 67% and MIS-PARDS none (p < 0.001). C-PARDS group had more profound hypoxemia (P/F ratio < 100, 86% vs. 38%, p < 0.01) and higher driving-pressure [14(10-22) vs 10(10-12) cmH2O], and lower compliance of the respiratory system (CRS) [0.5 (0.3-0.6) vs 0.7(0.6-0.8) ml/ kg/cmH2O] compared with MIS-PARDS (all p < 0.05). The ROC analysis for mortality showed that driving pressure had the best performance [AUC 0.91(95%CI0.81-1.00), with the best cut-off point of 15 cmH2O (100% sensitivity and 87% specificity). Mortality in C-PARDS was 38% and 7% in MIS-PARDS (p = 0.09). MV-free days were 12(0-23) in C-PARDS and 23(21-25) in MIS-PARDS (p = 0.02). CONCLUSION: Patients with C-PARDS have lung mechanics characteristics similar to classic moderate to severe PARDS. This was not observed in patients with MIS-C. As seen in other studies, a driving pressure ≥ 15 cmH2O was the best discriminator for mortality. These findings may help guide ventilatory management strategies for these two different presentations.

Hyperferritinemic sepsis secondary to invasive Toxoplasma gondii in a child with untreated HIV.

Background: Untreated human immunodeficiency virus (HIV)-immunosuppressed pediatric patients show high morbidity and mortality from opportunistic infections. Limited cases of hyperferritinemic sepsis have been described in patients with toxoplasmosis. Case report: We describe the case of a 13-year-old female patient with a history of untreated HIV who presented with hyperferritinemic sepsis secondary to Toxoplasma gondii infection and Pneumocystis jirovecci pneumonia. She received ventilatory support, inotropic drugs, treatment for opportunistic germs, and high-dose corticosteroids, but with unfavorable evolution. Conclusions: The global approach to sepsis with elevated ferritin guides to using of therapies aimed at neutralizing the severe inflammatory response. A timely diagnosis would allow prompt treatment and minimize complications.

Introducción: Los pacientes pediátricos inmunodeprimidos por el virus de la inmunodeficiencia humana (VIH) sin tratamiento presentan una elevada morbilidad y mortalidad por infecciones oportunistas. Se han descrito limitados casos de sepsis hiperferritinémica en pacientes con toxoplasmosis. Caso clínico: Se describe el caso de una paciente de 13 años con antecedente de VIH sin tratamiento que presentó sepsis hiperferritinémica secundaria a una infección por Toxoplasma gondii y neumonía por Pneumocystis jirovecci. Recibió soporte ventilatorio, uso de inotrópicos, tratamiento para gérmenes oportunistas y corticoides en altas dosis, pero su evolución fue desfavorable. Conclusiones: El abordaje global de la sepsis con ferritina elevada orienta a utilizar terapias dirigidas a neutralizar la respuesta inflamatoria severa, por lo que un diagnóstico oportuno permitiría iniciar el tratamiento prontamente y minimizar las complicaciones.

Hyperferritinemic sepsis secondary to invasive Toxoplasma gondii in a child with untreated HIV / Sepsis hiperferritinémica secundaria a Toxoplasma gondii invasiva en un paciente pediátrico con virus de inmunodeficiencia humana sin tratamiento

Abstract Background: Untreated human immunodeficiency virus (HIV)-immunosuppressed pediatric patients show high morbidity and mortality from opportunistic infections. Limited cases of hyperferritinemic sepsis have been described in patients with toxoplasmosis. Case report: We describe the case of a 13-year-old female patient with a history of untreated HIV who presented with hyperferritinemic sepsis secondary to Toxoplasma gondii infection and Pneumocystis jirovecci pneumonia. She received ventilatory support, inotropic drugs, treatment for opportunistic germs, and high-dose corticosteroids, but with unfavorable evolution. Conclusions: The global approach to sepsis with elevated ferritin guides to using of therapies aimed at neutralizing the severe inflammatory response. A timely diagnosis would allow prompt treatment and minimize complications.

Resumen Introducción: Los pacientes pediátricos inmunodeprimidos por el virus de la inmunodeficiencia humana (VIH) sin tratamiento presentan una elevada morbilidad y mortalidad por infecciones oportunistas. Se han descrito limitados casos de sepsis hiperferritinémica en pacientes con toxoplasmosis. Caso clínico: Se describe el caso de una paciente de 13 años con antecedente de VIH sin tratamiento que presentó sepsis hiperferritinémica secundaria a una infección por Toxoplasma gondii y neumonía por Pneumocystis jirovecci. Recibió soporte ventilatorio, uso de inotrópicos, tratamiento para gérmenes oportunistas y corticoides en altas dosis, pero su evolución fue desfavorable. Conclusiones: El abordaje global de la sepsis con ferritina elevada orienta a utilizar terapias dirigidas a neutralizar la respuesta inflamatoria severa, por lo que un diagnóstico oportuno permitiría iniciar el tratamiento prontamente y minimizar las complicaciones.

Posterior reversible encephalopathy syndrome in a child with severe multisystem inflammatory syndrome due to COVID-19. / Síndrome da encefalopatia posterior reversível em uma criança com síndrome inflamatória multissistêmica grave devido à COVID-19.

Posterior reversible encephalopathy syndrome is a rare clinical and radiological syndrome characterized by vasogenic edema of the white matter of the occipital and parietal lobes, which are usually symmetrical, resulting from a secondary manifestation of acute dysfunction of the posterior cerebrovascular system. We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required assisted mechanical ventilation. The child developed multisystem inflammatory syndrome, and he was monitored in the pediatric intensive care unit and was provided mechanical ventilation and vasoactive agents for hemodynamic support. Additionally, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required close follow-up and were verified using brain magnetic resonance imaging for timely intervention. Currently, there are few reports of children with posterior reversible encephalopathy syndrome associated with multisystem inflammatory syndrome.

A síndrome da encefalopatia posterior reversível é uma rara síndrome clínica e radiológica caracterizada por edema vasogênico da matéria branca dos lobos occipital e parietal, que geralmente são simétricos, resultante de uma manifestação secundária de disfunção aguda do sistema cerebrovascular posterior. Descrevemos um caso de síndrome de encefalopatia posterior reversível secundária à infecção por SARS-CoV-2 em um menino de 9 anos de idade que desenvolveu insuficiência respiratória hipoxêmica aguda e necessitou de ventilação mecânica assistida. A criança desenvolveu síndrome inflamatória multissistêmica e foi monitorada na unidade de terapia intensiva pediátrica, tendo-lhe sido fornecidos ventilação mecânica e agentes vasoativos para suporte hemodinâmico. Além disso, desenvolveu manifestações clínicas pulmonares e extrapulmonares juntamente de manifestações neuropsiquiátricas que necessitavam de seguimento cuidadoso, tendo sido verificadas por ressonância magnética cerebral para intervenção oportuna. Atualmente, há poucos relatos de crianças com síndrome da encefalopatia posterior reversível associada à síndrome inflamatória multissistêmica.

Complications and neurologic deterioration after bilateral decompressive craniectomy in Gunshot penetrating brain injury in children

Background: Penetrating skull injuries in pediatrics (TPC) occupy a special place due to their rarity. The aim is to provide an overview of the current evidence on decompressive craniectomy in children, to describe the indications and to detail the complications. Reporte case: We present the case of a 12- year-old boy who suffered a TPC by a projectile that perforated his head, causing multiple brain injuries, and underwent early bilateral decompressive craniectomy, presenting the complications and neurological disabilities typical of the injury and surgery, with a reserved evolution and prognosis. Conclusions: Pediatric penetrating skull injuries should be of individualized management, type of injury and disease, experience of the treatment team, and the decision should always be consensual in front of the benefits and risks in the short and long term.

Introducción: Los traumatismos craneales penetrantes en pediatría (TPC) ocupan un lugar especial debido a su rareza. El objetivo es ofrecer una visión general de la evidencia actual sobre la craniectomía descompresiva en niños, describir las indicaciones y detallar las complicaciones. Reporte de caso: Presentamos el caso de un niño de 12 años que sufrió un TPC por un proyectil que le perforó la cabeza, causándole múltiples lesiones cerebrales, y fue sometido a craniectomía descompresiva bilateral temprana, presentando las complicaciones y discapacidades neurológicas propias de la lesión y la cirugía, con una evolución y pronóstico reservados. Conclusiones: Los traumatismos craneales penetrantes pediátricos deben ser de manejo individualizado, tipo de lesión y enfermedad, experiencia del equipo tratante, y la decisión debe ser siempre consensuada frente a los beneficios y riesgos a corto y largo plazo.

Síndrome da encefalopatia posterior reversível em uma criança com síndrome inflamatória multissistêmica grave devido à COVID-19 / Posterior reversible encephalopathy syndrome in a child with severe multisystem inflammatory syndrome due to COVID-19

RESUMO A síndrome da encefalopatia posterior reversível é uma rara síndrome clínica e radiológica caracterizada por edema vasogênico da matéria branca dos lobos occipital e parietal, que geralmente são simétricos, resultante de uma manifestação secundária de disfunção aguda do sistema cerebrovascular posterior. Descrevemos um caso de síndrome de encefalopatia posterior reversível secundária à infecção por SARS-CoV-2 em um menino de 9 anos de idade que desenvolveu insuficiência respiratória hipoxêmica aguda e necessitou de ventilação mecânica assistida. A criança desenvolveu síndrome inflamatória multissistêmica e foi monitorada na unidade de terapia intensiva pediátrica, tendo-lhe sido fornecidos ventilação mecânica e agentes vasoativos para suporte hemodinâmico. Além disso, desenvolveu manifestações clínicas pulmonares e extrapulmonares juntamente de manifestações neuropsiquiátricas que necessitavam de seguimento cuidadoso, tendo sido verificadas por ressonância magnética cerebral para intervenção oportuna. Atualmente, há poucos relatos de crianças com síndrome da encefalopatia posterior reversível associada à síndrome inflamatória multissistêmica.

ABSTRACT Posterior reversible encephalopathy syndrome is a rare clinical and radiological syndrome characterized by vasogenic edema of the white matter of the occipital and parietal lobes, which are usually symmetrical, resulting from a secondary manifestation of acute dysfunction of the posterior cerebrovascular system. We describe a case of posterior reversible encephalopathy syndrome secondary to SARS-CoV-2 infection in a 9-year-old boy who developed acute hypoxemic respiratory failure and required assisted mechanical ventilation. The child developed multisystem inflammatory syndrome, and he was monitored in the pediatric intensive care unit and was provided mechanical ventilation and vasoactive agents for hemodynamic support. Additionally, he developed pulmonary and extrapulmonary clinical manifestations along with neuropsychiatric manifestations that required close follow-up and were verified using brain magnetic resonance imaging for timely intervention. Currently, there are few reports of children with posterior reversible encephalopathy syndrome associated with multisystem inflammatory syndrome.

Utility of multimodal monitoring in children with cerebral free-living amoebae in intensive care. Account of a fatal clinical case / Utilidad del monitoreo multimodal en niños con amebiasis cerebral en terapia intensiva. Relato de un caso clínico

Acanthamoeba spp. and Balamuthia mandrillaris are causative agents of granulomatous amebic encephalitis (GAE), while Naegleria fowleri causes primary amebic meningoencephalitis (PAM). PAM is an acute infection lasting a few days, whereas GAE is a chronic or subacute infection that can last up to several months. In the present case we report a 10-year-old girl with amebic encephalitis symptomatology, evolution, medical-surgical intervention, specific therapy, and patient outcome. Cerebral involvement continues to have high mortality in pediatric patients, despite guided therapy through multimodal monitoring in pediatric intensive care, however noninvasive methods during cerebral evaluation play an important role in optimizing cerebral hemodynamics at the patient's bedside. We conclude that this case demonstrates the usefulness of multimodal monitoring, where we used intraparenchymal ICP sensor, conventional Transcranial Doppler, NIRS, color coded transcranial doppler, optic nerve sheath measurement, DVNO/DTO ratio, pupillometry, and EEG that helped to make appropriate decisions during the clinical evolution of our patient, which would help us to make an early diagnosis and avoid delays in interventions.

Acanthamoeba spp. y Balamuthia mandrillaris son agentes causantes de encefalitis amebiana granulomatosa (GAE), mientras que Naegleria fowleri causa meningoencefalitis amebiana primaria (PAM). La PAM es una infección aguda que dura unos pocos días, mientras que la GAE es una infección crónica o subaguda que puede durar hasta varios meses. En el presente caso reportamos a una niña de 10 años con sintomatología encefalitis amebiana, evolución, intervención médico-quirúrgicas, terapia específica y desenlace de la paciente. La afectación cerebral sigue teniendo alta mortalidad en los pacientes pediátricos, a pesar de la terapéutica guiada a través del monitoreo multimodal en cuidados intensivos pediátricos, sin embargo, los métodos no invasivos durante la evaluación cerebral, tiene un papel importante para optimizar la hemodinamia cerebral a la cama del paciente. Concluimos que este caso demuestra la utilidad del monitoreo multimodal, en donde utilizamos sensor PIC intraparenquimal, Doppler transcraneal convencional, Dúplex transcraneal codificado en color, NIRS, medición DVNO, ratio DVNO/DTO, pupilometría, y EEG que ayudó a tomar decisiones adecuadas durante la evolución clínica de nuestro paciente, que nos ayudaría hacer un diagnóstico precoz y evitar demoras en las intervenciones.