Guía de la Sociedad Española de Infectología Pediátrica para el diagnóstico y tratamiento de la toxoplasmosis congénita / The Spanish Society of Pediatric Infectious Diseases Guidelines for the diagnosis and treatment of congenital toxoplasmosis

La toxoplasmosis congénita es la consecuencia de la transmisión fetal por vía transplacentaria de Toxoplasma gondii tras la primoinfección materna. El riesgo de infección fetal es bajo en infecciones en el primer trimestre y va aumentando con la edad gestacional, mientras que la gravedad de la infección disminuye con esta. El diagnóstico de infección materna se realiza mediante la demostración de seroconversión o ante la presencia de IgM positiva con anticuerpos IgG de baja avidez. Las gestantes con infección demostrada deben recibir espiramicina para intentar evitar su transmisión al feto. El diagnóstico de infección fetal se realiza mediante reacción en cadena de la polimerasa (PCR) en líquido amniótico obtenido a partir de la semana 18 de gestación. Si esta prueba resulta positiva, debe iniciarse tratamiento a la embarazada con pirimetamina, sulfadiazina y ácido folínico. La mayoría de los niños infectados nacen asintomáticos pero hasta el 80% desarrolla secuelas visuales o neurológicas durante su infancia y adolescencia. El diagnóstico neonatal es complicado porque los anticuerpos IgM e IgA y la PCR en sangre y líquido cefalorraquídeo pueden ser falsamente negativos. En estos casos, el diagnóstico puede realizarse mediante la constatación de un ascenso significativo de los anticuerpos IgG o la persistencia de los mismos después del año de vida. El tratamiento neonatal con pirimetamina y sulfadiazina disminuye la posibilidad de secuelas a largo plazo. La toxoplasmosis congénita es una enfermedad prevenible mediante el cribado pregestacional y la adopción de medidas de profilaxis primaria en las gestantes seronegativas (AU)

Congenital toxoplasmosis is the result of transplacental fetal infection by Toxoplasma gondii after the primary maternal infection. The severity of the disease depends on the gestational age at transmission. First trimester infections are more severe, but less frequent, than third trimester infections. Acute maternal infection is diagnosed by seroconversion or by the detection of IgM antibodies and a low IgG avidity test. In these cases, spiramycin should be initiated to prevent transmission to the fetus. For identification of fetal infection, polymerase chain reaction (PCR) testing of amniotic fluid after 18 weeks gestation should be performed. If fetal infection is confirmed, the mothers should be treated with pyrimethamine, sulfadiazine and folinic acid. Most infants infected in utero are born with no obvious signs of toxoplasmosis, but up to 80% developed learning and visual disabilities later in life. Neonatal diagnosis with IgM/IgA antibodies or blood/cerebrospinal fluid PCR may be difficult because false-negative results frequently occur. In these cases diagnosis is possible by demonstrating a rise in IgG titers during follow-up or by the detection of antibodies beyond one year of age. Early treatment with pyrimethamine and sulfadiazine may improve the ophthalmologic and neurological outcome. Congenital toxoplasmosis is a preventable disease. Pre-pregnancy screening and appropriate counseling regarding prevention measures in seronegative women may prevent fetal infection (AU)

[The Spanish Society of Pediatric Infectious Diseases Guidelines for the diagnosis and treatment of congenital toxoplasmosis]. / Guía de la Sociedad Española de Infectología Pediátrica para el diagnóstico y tratamiento de la toxoplasmosis congénita.

Congenital toxoplasmosis is the result of transplacental fetal infection by Toxoplasma gondii after the primary maternal infection. The severity of the disease depends on the gestational age at transmission. First trimester infections are more severe, but less frequent, than third trimester infections. Acute maternal infection is diagnosed by seroconversion or by the detection of IgM antibodies and a low IgG avidity test. In these cases, spiramycin should be initiated to prevent transmission to the fetus. For identification of fetal infection, polymerase chain reaction (PCR) testing of amniotic fluid after 18 weeks gestation should be performed. If fetal infection is confirmed, the mothers should be treated with pyrimethamine, sulfadiazine and folinic acid. Most infants infected in utero are born with no obvious signs of toxoplasmosis, but up to 80% developed learning and visual disabilities later in life. Neonatal diagnosis with IgM/IgA antibodies or blood/cerebrospinal fluid PCR may be difficult because false-negative results frequently occur. In these cases diagnosis is possible by demonstrating a rise in IgG titers during follow-up or by the detection of antibodies beyond one year of age. Early treatment with pyrimethamine and sulfadiazine may improve the ophthalmologic and neurological outcome. Congenital toxoplasmosis is a preventable disease. Pre-pregnancy screening and appropriate counseling regarding prevention measures in seronegative women may prevent fetal infection.

Documento de consenso sobre etiología, diagnóstico y tratamiento de la otitis media aguda / Consensus document on the aetiology, diagnosis and treatment of acute otitis media

Se presenta el documento de consenso sobre otitis media aguda (OMA) de la Sociedad de Española Infectología Pediátrica (SEIP), Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Sociedad Española de Urgencias Pediátricas (SEUP) y de la Asociación Española de Pediatría de Atención Primaria (AEPAP).Se analizan la etiología de la enfermedad y los posibles cambios de esta después de la introducción de la vacunas antineumocócicas 7-valente, 10-valente y 13-valente. Se hace una propuesta diagnóstica basada en la clasificación de la otitis media aguda en confirmada o probable. Se considera OMA confirmada si hay coincidencia de 3 criterios: comienzo agudo, signos de ocupación del oído medio (u otorrea) y signos o síntomas inflamatorios, como otalgia o intensa hiperemia timpánica y OMA probable cuando existan solo 2 criterios. Se propone como tratamiento antibiótico de elección la amoxicilina oral a 80mg/kg/día repartido cada 8 h. El tratamiento con amoxicilina-ácido clavulánico a dosis de 80mg/kg/día se indica si el niño es menor de 6 meses, en lactantes con clínica grave (fiebre>39°C o dolor muy intenso), cuando haya historia familiar de secuelas óticas por OMA o un fracaso terapéutico de la amoxicilina(AU)

This is the consensus document on acute otitis media (AOM) of the Sociedad Española de Infectología Pediatrica (SEIP), Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Sociedad Española de Urgencias Pediátricas (SEUP) and Asociación Española de Pediatría de Atención Primaria (AEPAP). It discusses the aetiology of the disease and its potential changes after the introduction of the pneumococcal 7-valent, 10-valent and 13-valent vaccines. A proposal is made based on diagnostic classification of otitis media as either confirmed or likely. AOM is considered confirmed if 3 criteria are fulfilled: acute onset, signs of occupation of the middle ear (or otorrhea) and inflammatory signs or symptoms, such as otalgia or severe tympanic hyperaemia. Oral amoxicillin is the antibiotic treatment of choice (80mg/kg/day divided every 8hours). Amoxicillin-clavulanate (80mg/kg/day) is indicated in the following cases: when the child is under 6 months, in infants with severe clinical manifestations (fever>39°C or severe pain), there is family history of AOM sequels, and after amoxiciline treatment failure(AU)

Documento de consenso sobre etiología, diagnóstico y tratamiento de la otitis media aguda / Consensus document on the aetiology, diagnosis and treatment of acute otitis media

Se presenta el documento de consenso sobre otitis media aguda (OMA) de la Sociedad Española de Infectología Pediátrica (SEIP), la Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), la Sociedad Española de Urgencias Pediátricas (SEUP) y la Asociación Española de Pediatría de Atención Primaria (AEPap). Se analizan la etiología de la enfermedad y los posibles cambios de esta después de la introducción de la vacunas antineumocócicas 7-valente, 10-valente y 13-valente. Se hace una propuesta diagnóstica basada en la clasificación de la OMA en confirmada o probable. Se considera OMA confirmada si hay coincidencia de tres criterios: comienzo agudo, signos de ocupación del oído medio (u otorrea) y signos o síntomas inflamatorios, como otalgia o intensa hiperemia timpánica, y OMA probable cuando existan solo dos criterios. Se propone como tratamiento antibiótico de elección la amoxicilina oral en dosis de 80 mg/kg/día repartidas cada ocho horas. El tratamiento con amoxicilina-ácido clavulánico en dosis de 80 mg/kg/día se indica si el niño es menor de seis meses, en lactantes con clínica grave (fiebre >39 ºC o dolor muy intenso), cuando haya historia familiar de secuelas óticas por OMA o un fracaso terapéutico de la amoxicilina(AU)

We present the consensus document on acute otitis media (AOM) written by the Spanish Society of Pediatric Infectology (SEIP), the Spanish Society of Outpatient and Primary Care Pediatrics (SEPEAP), the Spanish Society of Pediatric Emergency Care (SEUP) and the Spanish Association of Primary Care Pediatrics (AEPAP). The document analyses the etiology of the disease and the possible shifts in it following the introduction of the 7-valent, 10-valent, and 13-valent pneumococcal vaccines. The document proposes diagnosing AOM as confirmed or probable. The AOM diagnosis is considered confirmed if three criteria are met: acute onset, signs of fluid in the middle ear (or otorrhea), and symptoms of inflammation, such as otalgia or marked erythema in the middle ear, and considered probable when only two of these criteria are met. The proposed first choice for antibiotic treatment is 80 mg/kg/day of amoxicillin administered orally in doses at eight hour intervals. Treatment with amoxicillin-clavulanic acid in doses of 80 mg/kg/day are indicated in children younger than six months, in infants with a severe presentation (fever >39 °C or acute pain), when there is a family history of AOM sequelae, or in cases of amoxicillin treatment failure(AU)

[Consensus document on the aetiology, diagnosis and treatment of acute otitis media]. / Documento de consenso sobre etiología, diagnóstico y tratamiento de la otitis media aguda.

This is the consensus document on acute otitis media (AOM) of the Sociedad Española de Infectología Pediatrica (SEIP), Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Sociedad Española de Urgencias Pediátricas (SEUP) and Asociación Española de Pediatría de Atención Primaria (AEPAP). It discusses the aetiology of the disease and its potential changes after the introduction of the pneumococcal 7-valent, 10-valent and 13-valent vaccines. A proposal is made based on diagnostic classification of otitis media as either confirmed or likely. AOM is considered confirmed if 3 criteria are fulfilled: acute onset, signs of occupation of the middle ear (or otorrhea) and inflammatory signs or symptoms, such as otalgia or severe tympanic hyperaemia. Oral amoxicillin is the antibiotic treatment of choice (80mg/kg/day divided every 8hours). Amoxicillin-clavulanate (80mg/kg/day) is indicated in the following cases: when the child is under 6 months, in infants with severe clinical manifestations (fever>39°C or severe pain), there is family history of AOM sequels, and after amoxiciline treatment failure.

Síndrome de escaldadura estafilocócia en un neonato / Staphylococcal scalded síndrome in a newborn

Se presenta un caso de escaldadura estafilocócica en un neonato de 12 días. El diagnóstico es principalmente clínico, basado en las lesiones cutáneas características (signo de Nikolski). La inmadurez fisiológica del neonato hace necesarios un diagnóstico y tratamiento precoces (AU)

A case of staphylococcal scalded syndrome in a 12 day old newborn is presented. The diagnosis is principally clinical, based on the characteristic skin lesions (Nikolski sign). The physiological immaturity of the newborn makes an early diagnosis and treatment necessary (AU)

[Late onset group B Streptococcus infection: 7 year experience in a tertiary hospital (2000-2006)]. / Infección tardía por estreptococo del grupo B: experiencia en un hospital de tercer nivel (2000-2006).

INTRODUCTION: Group B Streptococcus (GBS) is a major cause of neonatal infection. Two forms of the disease have been described according to the age of presentation: early, beginning in the first 6 days of life, and late, occurring from day 7 up to 3 months of age. OBJECTIVES: To analyze the epidemiology of the late onset form of GBS disease in a tertiary hospital after implementing preventive strategies aimed to reduce the rate of vertical transmission. METHODS: We retrospectively reviewed the medical records of children diagnosed with late GBS infection between January 2000 and December 2006. Diagnostic criteria included a positive blood culture and/or a positive cerebrospinal fluid (CSF) culture for GBS in any patient aged between 7 and 89 days. RESULTS: 24 patients were identified, most of them presenting after January 2005. Median age was 36.2 days (range 9 to 81). GBS isolates in blood were found in 20 patients, 1 in CSF and 3 in both. Most frequently children presented with fever (70.8 %) and irritability (54.1 %). Five patients (20.8 %) had a cellulitis-adenitis syndrome. Cefotaxime and ampicillin were the most often used antibiotic combination. No ampicillin resistances were found. CONCLUSIONS: The number of children with late GBS disease has increased in our center. Accordingly, the recent recommendations for the prevention of perinatal GBS vertical transmission were not effective for reducing late GBS infection. This may be due to horizontal infections from maternal sources, community or cross infections. It is important to maintain clinical suspicion of late GBS infection and start early antibiotic treatment.

[Increase in the incidence of bacterial pneumonia between 2001 and 2004]. / Incremento de la incidencia de neumonía bacteriana entre 2001 y 2004.

AIM: To study patients with typical community-acquired pneumonia (CAP) admitted to our hospital between 2001 and 2004 in order to analyze the incidence of this disease in our health area during this period. METHODS: A retrospective study was performed of patients with CAP admitted to our hospital from 2001 to 2004. Only those patients who fulfilled the criteria for typical pneumonia of possible bacterial origin based on clinical and radiological features and laboratory data were included. The annual incidence rates of CAP were analyzed using demographic data from our health area and from all children admitted to the infectious diseases unit of our hospital during this period. RESULTS: During the study period, 569 children were diagnosed with typical CAP: 116 in 2001, 133 in 2002, 154 in 2003 and 166 in 2004. The incidence rate was 1.3 cases/1,000 children under 14 years old/year in 2001, 1.51 in 2002, 1.69 in 2003 and 1.72 in 2004. These findings represent an increment of 25% in the incidence per 1,000/children/year and an increment of 53% in the incidence per 100 children admitted to our unit. Blood cultures were performed before antibiotic therapy was administered in 487 patients and were positive in 22 (4.5%). Streptococcus pneumoniae was isolated in 21 patients and Streptococcus pyogenes in one. Chest radiographs revealed lobar consolidation in 95% of the patients and 15 % developed pleural effusion. CONCLUSIONS: Cases of CAP of probable pneumococcal etiology increased in our health area during the study period. The number of complicated cases also increased.

[Staphylococcal scalded skin syndrome]. / Síndrome de escaldadura estafilocócica.

INTRODUCTION: Staphylococcal scalded skin syndrome is a rare disease caused by Staphylococcus aureus that produces exfoliative toxins. There are few epidemiological data in our environment. PATIENTS AND METHODS: We present an observational cohort study. We review the cases of staphylococcal scalded skin syndrome monitored at La Paz Children Hospital during the last ten years (January 1997 to December 2006). RESULTS: We obtained 26 patients, 7 in the first 5 years and 19 more in the following years. The mean age at diagnosis was 19 months. Four cases (15%) occurred during the neonatal period. Sixty-seven percent of the cases were diagnosed during spring and summer. Main clinical signs were: erythroderma with blisters and posterior desquamation (100%), perioral fissures (54%), fever (46%), conjunctivitis (42%) and palpebral edema (31%). No significant increases in leukocytes (mean: 11,341/.l) or C-reactive protein (mean: 9 mg/l) were found on blood analysis. Diagnosis was made by clinical findings. S. aureus was isolated in nasal or conjunctival samples on 59% of cases. All strains were sensitive to cloxacillin, clindamycin and vancomycin. The patients were treated with cloxacillin with good progress. CONCLUSIONS: Staphylococcal scalded skin syndrome seems to be more common in the last few years. It must be suspected in children with acute erythroderma and perioral or conjunctival lesions. Treatment with cloxacillin leads to healing without sequelae.

Infección tardía por estreptococo del grupo B: experiencia en un hospital de tercer nivel (2000-2006) / Late onset group B Streptococcus infection: 7 year experience in a tertiary hospital (2000-2006)

Introducción: El estreptococo del grupo B (SGB) es una causa importante de infección neonatal. Se han descrito dos formas de enfermedad en función de la edad de presentación: precoz, en los primeros 6 días de vida, y tardía, entre el séptimo día y a los 3 meses de edad. Objetivos: Analizar la epidemiología de la enfermedad tardía por SGB en un hospital de tercer nivel después de la implementación de las medidas de prevención de la transmisión vertical de la infección. Métodos: Se revisaron de forma retrospectiva las historias clínicas de los niños diagnosticados de enfermedad tardía por SGB desde enero del año 2000 hasta diciembre de 2006. Se consideraron como criterios diagnósticos un hemocultivo y/o un cultivo de líquido cefalorraquídeo (LCR) positivo para SGB en cualquier paciente entre 7 y 89 días de vida. Resultados: 24 pacientes fueron identificados, la mayor parte de ellos a partir de enero de 2005. La edad media fue de 36,2 días (rango: 9-81). En 20 pacientes el SGB se aisló en el hemocultivo; en 1 paciente, en el LCR y en 3 de ellos, en ambos. Los signos clínicos más frecuentes fueron fiebre (70,8 %) e irritabilidad (54,1 %). El síndrome de celulitis-adenitis se observó en 5 pacientes (20,8 %). El tratamiento antibiótico empírico más empleado fue la asociación de cefotaxima y ampicilina. No se observaron resistencias a la ampicilina. Los 4 casos de meningitis (16,6 %) desarrollaron secuelas neurológicas importantes. Conclusiones: El número de niños con infección tardía por SGB está aumentado en los últimos años. A pesar de la eficacia de las recomendaciones para la prevención de la transmisión vertical de la infección perinatal por SGB en la infección precoz, estas recomendaciones no han sido muy efectivas para reducir la infección tardía por SGB, posiblemente debido a infecciones horizontales desde la madre, la comunidad o fuentes nosocomiales. Es importante mantener la sospecha clínica de infección tardía por SGB e iniciar tratamiento antibiótico precoz (AU)

Introduction: Group B Streptococcus (GBS) is a major cause of neonatal infection. Two forms of the disease have been described according to the age of presentation: early, beginning in the first 6 days of life, and late, occurring from day 7 up to 3 months of age. Objectives: To analyze the epidemiology of the late onset form of GBS disease in a tertiary hospital after implementing preventive strategies aimed to reduce the rate of vertical transmission. Methods: We retrospectively reviewed the medical records of children diagnosed with late GBS infection between January 2000 and December 2006. Diagnostic criteria included a positive blood culture and/or a positive cerebrospinal fluid (CSF) culture for GBS in any patient aged between 7 and 89 days. Results: 24 patients were identified, most of them presenting after January 2005. Median age was 36.2 days (range 9 to 81). GBS isolates in blood were found in 20 patients, 1 in CSF and 3 in both. Most frequently children presented with fever (70.8 %) and irritability (54.1 %). Five patients (20.8 %) had a cellulitis-adenitis syndrome. Cefotaxime and ampicillin were the most often used antibiotic combination. No ampicillin resistances were found. Conclusions: The number of children with late GBS disease has increased in our center. Accordingly, the recent recommendations for the prevention of perinatal GBS vertical transmission were not effective for reducing late GBS infection. This may be due to horizontal infections from maternal sources, community or cross infections. It is important to maintain clinical suspicion of late GBS infection and start early antibiotic treatment (AU)

Incremento de la incidencia de neumonía bacteriana entre 2001 y 2004 / Increase in the incidence of bacterial pneumonia between 2001 and 2004

Objetivo: Estudiar los pacientes ingresados en nuestro hospital por neumonía típica adquirida en la comunidad (NAC) en los últimos 4 años y analizar la incidencia en este período. Métodos: Se seleccionaron retrospectivamente todas las NAC ingresadas en nuestro hospital entre los años 2001 y 2004. Se analizaron exclusivamente aquellas que cumplían criterios clínico-analítico-radiológicos de neumonía típica de posible origen bacteriano. Se analiza la incidencia de NAC según los datos de población de nuestra área sanitaria y del número de ingresos totales en la unidad de enfermedades infecciosas. Resultados: Se diagnosticaron un total de 569 NAC que cumplían criterios de bacteriana: 116 casos en 2001, 133 casos en 2002, 154 casos en 2003 y 166 casos en 2004. La incidencia fue de 1,38 casos/1.000 niños < 14 años de edad/año en 2001, 1,51 en 2002, 1,69 en 2003 y 1,72 en 2004. Esto supone un incremento de la incidencia del 25 % por 1.000 niños/año en nuestra área sanitaria y un incremento de la incidencia del 53 % por 100 ingresos en la unidad. Se realizó hemocultivo antes de la antibioterapia en 487 casos, de los cuales fueron positivos 22 (4,5 %), 21 para Streptococcus pneumoniae y 1 para Streptococcus pyogenes. El 95 % de los pacientes presentaba en la radiografía de tórax una imagen de consolidación. El 15 % de los pacientes tuvo derrame pleural. Conclusiones: En los últimos años hemos observado un aumento del número de casos de neumonía de posible origen neumocócico en España, al mismo tiempo que también se ha producido un incremento de los casos complicados (AU)

Aim: To study patients with typical community-acquired pneumonia (CAP) admitted to our hospital between 2001 and 2004 in order to analyze the incidence of this disease in our health area during this period. Methods: A retrospective study was performed of patients with CAP admitted to our hospital from 2001 to 2004. Only those patients who fulfilled the criteria for typical pneumonia of possible bacterial origin based on clinical and radiological features and laboratory data were included. The annual incidence rates of CAP were analyzed using demographic data from our health area and from all children admitted to the infectious diseases unit of our hospital during this period. Results: During the study period, 569 children were diagnosed with typical CAP: 116 in 2001, 133 in 2002, 154 in 2003 and 166 in 2004. The incidence rate was 1.3 cases/1,000 children under 14 years old/year in 2001, 1.51 in 2002, 1.69 in 2003 and 1.72 in 2004. These findings represent an increment of 25 % in the incidence per 1,000/children/year and an increment of 53 % in the incidence per 100 children admitted to our unit. Blood cultures were performed before antibiotic therapy was administered in 487 patients and were positive in 22 (4.5 %). Streptococcus pneumoniae was isolated in 21 patients and Streptococcus pyogenes in one. Chest radiographs revealed lobar consolidation in 95 % of the patients and 15 % developed pleural effusion. Conclusions: Cases of CAP of probable pneumococcal etiology increased in our health area during the study period. The number of complicated cases also increased (AU)

Síndrome de escaldadura estafilocócica / Staphylococcal scalded skin syndrome

Introducción: El síndrome de escaldadura estafilocócica es una enfermedad causada por Staphylococcus aureus productor de toxinas exfoliativas. Es poco frecuente y apenas hay datos de su epidemiología en nuestro país. Pacientes y métodos: Se llevó a cabo un estudio observacional de cohortes en el que se revisaron los casos de escaldadura estafilocócica controlados en el Hospital Materno-Infantil La Paz en los últimos 10 años (enero 1997-diciembre 2006). Resultados: Se obtuvo un total de 26 pacientes, 7 en los primeros 5 años y 19 en los siguientes, con una media de edad en el momento del diagnóstico de 29 meses; 4 casos (15 %) fueron de diagnóstico neonatal. El 67 % de los casos ocurrieron en primavera y verano. Las manifestaciones clínicas más frecuentes fueron: eritrodermia con aparición de ampollas y descamación posterior (100 %), fisuración y costras periorales (54 %), fiebre (46 %), conjuntivitis (42 %) y edema palpebral (31 %). En la analítica no se detectó un aumento significativo de leucocitos (media: 11.341/μl) ni de proteína C reactiva (media: 9 mg/l). El diagnóstico fue principalmente clínico, con aislamiento de S. aureus en frotis nasal o conjuntival en el 59 % de los casos. Todas las cepas fueron sensibles a cloxacilina, clindamicina y vancomicina. El tratamiento se realizó con cloxacilina intravenosa con evolución favorable. Conclusiones: El síndrome de escaldadura estafilocócica parece ser más frecuente en los últimos años y debe sospecharse en un niño con eritrodermia aguda y afectación conjuntival o peribucal. El tratamiento con cloxacilina consigue la curación sin secuelas (AU)

Introduction: Staphylococcal scalded skin syndrome is a rare disease caused by Staphylococcus aureus that produces exfoliative toxins. There are few epidemiological data in our environment. Patients and methods: We present an observational cohort study. We review the cases of staphylococcal scalded skin syndrome monitored at La Paz Children Hospital during the last ten years (January 1997 to December 2006). Results: We obtained 26 patients, 7 in the first 5 years and 19 more in the following years. The mean age at diagnosis was 19 months. Four cases (15 %) occurred during the neonatal period. Sixty-seven percent of the cases were diagnosed during spring and summer. Main clinical signs were: erythroderma with blisters and posterior desquamation (100 %), perioral fissures (54 %), fever (46 %), conjunctivitis (42 %) and palpebral edema (31 %). No significant increases in leukocytes (mean: 11,341/μl) or C-reactive proein (mean: 9 mg/l) were found on blood analysis. Diagnosis was made by clinical findings. S. aureus was isolated in nasal or conjunctival samples on 59 % of cases. All strains were sensitive to cloxacillin, clindamycin and vancomycin. The patients were treated with cloxacillin with good progress. Conclusions: Staphylococcal scalded skin syndrome seems to be more common in the last few years. It must be suspected in children with acute erythroderma and perioral or conjunctival lesions. Treatment with cloxacillin leads to healing without sequelae (AU)

Úlcera lingual crónica de diagnóstico difícil (enfermedad de Riga-Fede) / Difficult-to-diagnose chronic lingual ulcer (Riga-Fede disease)

No disponible

[Multidrug-resistant tuberculosis in the pediatric age group]. / Tuberculosis mutirresistente en la edad pediátrica.

AIMS: To study the clinical and epidemiological features in eight pediatric patients with multidrug-resistant tuberculosis (MDR-TB) diagnosed from 1994 to 2005 in three hospitals in Madrid (Spain). METHODS: A retrospective study was performed in patients aged less than 15 years old with positive culture for multidrug-resistant Mycobacterium tuberculosis and patients with negative cultures diagnosed after contact with MDR-TB. RESULTS: Pulmonary tuberculosis was diagnosed in seven patients and arthritis in one. Fifty percent of the patients were immigrants and an adult source case was found in four (50%). M. tuberculosis was isolated in gastric juice in four patients and in synovial biopsy in one. In three patients cultures were negative but these patients had previously been in contact with MDR-TB. Two strains were resistant to isoniazid and rifampicin, four were resistant to isoniazid, rifampicin and streptomycin, one was resistant to isoniazid, rifampicin, streptomycin and pyrazinamide, and one was resistant to 11 drugs. Six patients initially received conventional treatment without improvement. Patients received therapy for 15 months (range: 12 to 18) with 3 to 5 drugs according to the sensitivity study. The following adverse effects were observed: creatine phosphokinase increase (one patient), tendinitis (one patient), alteration of visual evoked responses (one patient) and transitory psychosis (one patient). One patient required pulmonary lobectomy. All patients responded satisfactorily to medical treatment. CONCLUSIONS: MDR-TB should be suspected in patients not responding to TB treatment, especially those from countries with high resistance rates. In patients with negative cultures, treatment should rely on the results of a sensitivity study in the adult source case. MDR-TB requires the use of second-line anti-TB drugs for prolonged periods with possible toxic effects.

Tuberculosis mutirresistente en la edad pediátrica / Multidrug-resistant tuberculosis in the pediatric age group

Objetivos Estudiar las características clínicas y epidemiológicas de 8 pacientes pediátricos con tuberculosis multirresistente (TB-MDR) diagnosticados en 3 hospitales de Madrid entre 1994 y 2005. Métodos Estudio retrospectivo que incluye pacientes menores de 15 años con aislamiento de Mycobacterium tuberculosis multirresistente y sin aislamiento que empezaron tras contacto con TB-MDR. Resultados Se diagnosticaron 7 tuberculosis pulmonares y una artritis. El 50 % eran inmigrantes y en el 50 % se confirmó contacto con adulto enfermo. Se aisló M. tuberculosis en jugo gástrico (4) y biopsia sinovial (1). En 3 pacientes no se consiguió aislamiento, pero se confirmó contacto con TB-MDR. Dos cepas presentaron resistencia a isoniazida (H) y rifampicina (R), cuatro a H, R y estreptomicina (S), una a H, R, S y pirazinamida (Z) y una a 11 fármacos. Seis pacientes recibieron tratamiento convencional inicial sin presentar mejoría. Una vez conocida la sensibilidad de la cepa, se administró tratamiento durante una media de 15 meses (rango: 12-18 meses) con 3-5 fármacos efectivos. Los efectos secundarios observados fueron: aumento de creatinfosfocinasa (1), tendinitis (1), alteración de potenciales visuales (1) y psicosis transitoria (1). Un paciente requirió lobectomía. Todos los pacientes evolucionaron satisfactoriamente. Conclusiones La TB-MDR debe sospecharse en casos con mala evolución, especialmente si proceden de zonas con altas tasas de resistencia. En niños enfermos con cultivos negativos y expuestos a TB-MDR, el tratamiento se realizará según el estudio de resistencias del caso índice. La resistencia limita las opciones terapéuticas y conlleva la utilización de fármacos con posibles efectos tóxicos

Aims To study the clinical and epidemiological features in eight pediatric patients with multidrug-resistant tuberculosis (MDR-TB) diagnosed from 1994 to 2005 in three hospitals in Madrid (Spain). Methods A retrospective study was performed in patients aged less than 15 years old with positive culture for multidrugresistant Mycobacterium tuberculosis and patients with negative cultures diagnosed after contact with MDR-TB. Results Pulmonary tuberculosis was diagnosed in seven patients and arthritis in one. Fifty percent of the patients were immigrants and an adult source case was found in four (50 %). M. tuberculosis was isolated in gastric juice in four patients and in synovial biopsy in one. In three patients cultures were negative but these patients had previously been in contact with MDR-TB. Two strains were resistant to isoniazid and rifampicin, four were resistant to isoniazid, rifampicin and streptomycin, one was resistant to isoniazid, rifampicin, streptomycin and pyrazinamide, and one was resistant to 11 drugs. Six patients initially received conventional treatment without improvement. Patients received therapy for 15 months (range: 12 to 18) with 3 to 5 drugs according to the sensitivity study. The following adverse effects were observed: creatine phosphokinase increase (one patient), tendinitis (one patient), alteration of visual evoked responses (one patient) and transitory psychosis (one patient). One patient required pulmonary lobectomy. All patients responded satisfactorily to medical treatment. Conclusions MDR-TB should be suspected in patients not responding to TB treatment, especially those from countries with high resistance rates. In patients with negative cultures, treatment should rely on the results of a sensitivity study in the adult source case. MDR-TB requires the use of second- line anti-TB drugs for prolonged periods with possible toxic effects

[Acute neonatal parotitis due to Streptococcus agalactiae]. / Parotiditis aguda neonatal por Streptococcus agalactiae.

We report two cases of group B streptococcal acute neonatal parotitis. Both patients showed late-onset infections in association with acute parotid swelling, without cellulitis or purulent drainage from Stensen's duct. Neither of the infants had meningitis, and Streptococcus agalactiae was isolated from blood cultures. Differential diagnosis with cellulitis-adenitis syndrome was based on clinical manifestations with supporting radiographic findings, which revealed parotid swelling with increased vascularization. Both infants were treated with a 2-week-course of intravenous cefotaxime, with complete recovery. Although the most common cause of acute neonatal bacterial parotitis is Staphylococcus aureus, Streptococcus agalactiae should be included in the differential diagnosis, especially in infants with late-onset sepsis.

Parotiditis aguda neonatal por Streptococcus agalactiae / Acute neonatal parotitis due to Streptococcus agalactiae

Presentamos 2 casos de parotiditis aguda neonatal por Streptococcus agalactiae. Ambos presentaron una tumefacción aguda en la región parotídea en el contexto de un cuadro séptico tardío, sin celulitis acompañante, ni supuración por el conducto de Stenon. Ninguno de los casos tuvo meningitis acompañante, aislándose S. agalactiae en el hemocultivo. El diagnóstico diferencial con el síndrome celulitis-adenitis se realizó por la clínica y las pruebas de imagen, que pusieron de manifiesto aumento del tamaño de la glándula parotídea y de su vascularización. Los 2 niños se trataron con cefotaxima durante 2 semanas con evolución favorable. Aunque el agente etiológico más frecuente de la parotiditis aguda bacteriana es Staphylococcus aureus, debemos incluir a S. agalactiae en el diagnóstico diferencial, especialmente en el contexto de una sepsis neonatal tardía

We report two cases of group B streptococcal acute neonatal parotitis. Both patients showed late-onset infections in association with acute parotid swelling, without cellulitis or purulent drainage from Stensen's duct. Neither of the infants had meningitis, and Streptococcus agalactiae was isolated from blood cultures. Differential diagnosis with cellulitis-adenitis syndrome was based on clinical manifestations with supporting radiographic findings, which revealed parotid swelling with increased vascularization. Both infants were treated with a 2-week-course of intravenous cefotaxime, with complete recovery. Although the most common cause of acute neonatal bacterial parotitis is Staphylococcus aureus, Streptococcus agalactiae should be included in the differential diagnosis, especially in infants with late-onset sepsis

Síndrome de escaldadura estafilocócica de presentación neonatal / Neonatal staphylococcal scalded skin syndrome

Introducción: La incidencia del síndrome de escaldadura estafilocócica en neonatos parece haber aumentado en los últimos años. Métodos: Revisamos los casos de síndrome de escaldadura estafilocócica de presentación neonatal, controlados en nuestro servicio en los últimos 10 años (1997-2006). Resultados: Durante este periodo, se diagnosticaron 26 casos de síndrome de escaldadura estafilocócica, 4 de ellos (15%) en el primer mes de vida. Todos presentaron eritrodermia, ampollas, costras perinasales, fisuración perioral y conjuntivitis purulenta. En ningún caso apareció fiebre ni elevación de reactantes de fase aguda. En todos los pacientes se aisló Staphylococcus aureus sensible a meticilina en el frotis nasal y conjuntival. Se realizó un tratamiento con cloxacilina intravenosa durante una media de 7 días, y los pacientes presentaron descamación en láminas sin lesiones residuales. Conclusiones: El síndrome de escaldadura estafilocócica se presenta en el periodo neonatal hasta en el 15% de los casos. El tratamiento temprano con cloxacilina intravenosa permite una evolución favorable, e iguala el buen pronóstico característico del resto de edades

Introduction: The incidence of staphylococcal scalded skin syndrome among newborn infants seems to be increasing in recent years. Methods: We review the cases of neonatal staphylococcal scalded skin syndrome followed at our hospital over the last 10 years (1997-2006). Results: Twenty-six cases of this syndrome were diagnosed, four of them (15%) during the first month of life. All of them presented erythroderma, bullae, perioral and nasal fissures and purulent conjunctivitis. None had fever, leukocytosis or an increase in C-reactive protein. Methicillin-sensitive Staphylococcus aureus was isolated in nasal or conjunctival samples. The patients were treated with intravenous cloxacillin for a mean period of 7 days and they presented desquamation without scarring. Conclusions: Staphylococcal scalded skin syndrome appears during the neonatal period in up to 15% of cases. Early treatment with intravenous cloxacillin results in a favorable outcome

[Nontuberculous mycobacterial lymphadenitis]. / Adenitis por micobacterias no tuberculosas.

OBJECTIVE: To study the clinical features, epidemiology and outcome of nontuberculous mycobacterial lymphadenitis (NTML). METHODS: A retrospective study was performed on 54 patients under 14 years old diagnosed with atypical mycobacterial lymphadenitis between 1987 and 2004. Inclusion criteria were: (i) positive polymerase chain reaction (PCR) test or culture; (ii) positive sensitin skin test 6 mm above Mantoux; (iii) histopathologic features compatible with mycobacterial infection and/or positive direct smear for acid-fast bacilli, Mantoux reaction less than 15 mm, a normal chest radiograph, absence of exposure to an adult with tuberculosis, negative Mantoux test reactions in family members, and exclusion of other causes of granulomatous adenitis. RESULTS: Fifty-four patients were included in the study. The number of NTML cases increased notably from 1996, coinciding with a decrease in cases of tuberculous adenitis. The mean age was 35 months (range: 14 months-6 years). Submandibular nodes were involved in 22 of 63 cases of adenitis (34.9%) and cervical nodes were involved in 21 (33.3%). In 8/42 patients (19%) the tuberculin skin test was larger than 10 mm. Cultures were positive in 52.9% of the cases (18/34) and PCR in 53.3% (8/15). The most frequently isolated mycobacteria was Mycobacterium avium (61%). Therapy failed in 8/21 patients receiving antibiotics (38%), in 10/13 patients with drainage alone (77%) and in none of the patients who underwent surgery (8/8). CONCLUSIONS: Nontuberculous mycobacterial adenitis has become more frequent in our hospital since 1996. Cultures do not always allow isolation of mycobacteria and the Mantoux test frequently yields false positive results, thus hampering diagnosis. The most effective treatment was surgical excision. Nevertheless, when the surgical approach is difficult or there is postoperative recurrence, pharmacological treatment can be useful.