Meningitis bacteriana por Streptococcus pyogenes: revisión de la literatura / Bacterial meningitis due to Streptococcus pyogenes: literature review

Introducción: el Streptococcus pyogenes (S. pyogenes) es una etiología poco habitual de meningitis bacteriana a pesar de ser un germen que frecuentemente produce infecciones en otras localizaciones en la edad pediátrica. Material y métodos: se revisaron los casos de bacteriemia por S. pyogenes y los factores de riesgo asociados en la base de datos del Servicio de Microbiología del Hospital Universitario La Paz desde junio de 2002 a junio de 2012. Resultados: únicamente se encontró un caso de bacteremia por S. pyogenes asociado a meningitis, que se describe en este artículo. Conclusiones: a pesar de su baja incidencia, se debe tener en cuenta el S. pyogenes en el diagnóstico diferencial de meningitis bacterianas, especialmente en pacientes con factores de riesgo asociados (AU)

Introduction: Streptococcus pyogenes (S. pyogenes) is a rare cause of meningitis despite being a common source of pediatric infections in other sites. Material and methods: A search was performed of the pediatric patients with S. pyogenes bacteremia in the microbiology database of the Hospital Infantil La Paz from June 2002 until June 2012. Results: A single case of S. pyogenes meningitis was found and is reported in this article. Conclusions: Despite its low incidence, S. pyogenes should be considered in the differential diagnosis of meningitis, particularly in patients with associated risk factors (AU)

[Pneumococcal conjugate vaccine failure in HIV-infected child. Clinical case]. / Fallo de la vacuna antineumocócica conjugada en un niño VIH positivo. A propósito de un caso.

Despite appropriate antimicrobial therapy and vaccination, invasive pneumococcal infections remain associated with significant mortality, especially in selected high-risk groups (asplenic, humoral immunity deficient patients, etc.). We present a 13-year-old caucasian boy with HIV infection (vertical transmission). He received treatment with highly-active antiretroviral therapy (amprenavir, lamivudine and zidovudine) and vaccination with 23-valent vaccine (6 years old) and 7-valent pneumococcal conjugate vaccine (10 years old). His CD4 count and his viral load at these times were 2,063/microl and 13461 cop/ml, when he was 6 years old and 1,315/microl and 32400 cop/ml when he was 10 years old, respectively. The latest CD4 count (1,000/microl) and his viral load (3800 cop/ml) confirmed satisfactory control of the disease. He was referred to our emergency department presenting with fever, head and stomach-ache and vomiting. In the following hours his condition continued to deteriorate and depressed level of consciousness and meningismus were observed. Streptococcus pneumoniae, serotype 18 C, was detected in blood and cerebrospinal fluid cultures. Despite appropriate treatment with antibiotics (cefotaxime and vancomycin) and anti-oedema medications, brain-death was confirmed 24 hours after his admittance.

[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.

[Why are HIV-infected infants still being born in Spain?]. / Por qué se infectan aún niños con el virus de la inmunodeficiencia humana en España?

INTRODUCTION: Despite the success of preventive measures against mother-to-child transmission (MTCT) of human immunodeficiency virus-1 and -2 (HIV-1 and -2) in developed countries, HIV-infected infants continue to be born. The aim of this study was to evaluate failures in the prevention of MTCT and the clinical characteristics of infected infants. METHODS: The Foundation for the Investigation and Prevention of AIDS in Spain (FIPSE) Cohort in Madrid prospectively follows up children at risk of MTCT HIV born in eight public hospitals in Madrid. From May 2000 to December 2005, 632 children born to HIV-infected mothers were evaluated. Data from pregnancy follow-up, antiretroviral therapy (ART), and symptoms at diagnosis in infected infants were analyzed. RESULTS: Nine infants were infected. The rate of vertical transmission was 1.42 (95% CI 0.7-2.68). Of the nine mothers, seven had not received ART during pregnancy (and five had not received ART at delivery). Of the mothers who received ART, one had only done so for the last month of pregnancy. Two infants were given three drugs as prevention of MTCT, one received bitherapy and six received monotherapy. The median age at diagnosis was 2.4 months (range 7 days-2 years). The mean plasma viral load at diagnosis was 276,000 copies/ml (range: 11,900-1,000,000). Five of the infants were symptomatic at diagnosis (P. jirovaci pneumonia in two, sepsis in one, recurrent bacterial infections in one, hepatosplenomegaly in one). Four of the nine infants had been admitted to hospital prior to HIV diagnosis. DISCUSSION: Missed opportunities for the prevention of MTCT were identified in eight of the nine HIV-infected infants (89%). Administration of AZT during labor in HIV-infected mothers and triple therapy for the prevention of MTCT in high risk infants is not universal. Hospital admission in young infants at risk might lead to suspicion of infection in infants born to HIV-infected mothers. Improved implementation of all the preventive measures for MTCT should be encouraged.

[Incidence and clinical characteristics of Kawasaki's disease]. / Incidencia y características clínicas de la enfermedad de Kawasaki.

OBJECTIVE: The aim of this study was to analyze the incidence and clinical spectrum of Kawasaki's disease in children attended in our hospital. PATIENTS AND METHODS: Retrospective review of all children with Kawasaki's disease evaluated in the Department of Infectious Diseases of Hospital La Paz (Madrid, Spain) from January 1999 to June 2002. Information included clinical manifestations, age, sex, seasonal occurrence, treatment, development of cardiovascular abnormalities, and incidence rate. RESULTS: Forty-five patients with Kawasaki's disease were analyzed during the study period. Age ranged between 4 months and 13 years. Thirty-seven children were aged 5 years old or less and 15 children were younger than 2 years. The most common symptom was fever in 98 % of the patients. Five patients developed coronary aneurysms. Of these, four were aged less than 2 years and three were treated after the first week of onset of fever. The annual incidence rate in our health area was estimated at 15.1 cases per 100,000 children aged 5 years or less. CONCLUSIONS: The annual incidence rate for Kawasaki's disease in our area was similar to that in Europe and the United States. Coronary aneurysms were more common in children aged less than 2 years and in patients who received treatment after 1 week of the onset of fever.

[Anti-retroviral treatment of HIV infection in the child]. / Tratamiento antirretroviral de la infección por el VIH en el niño.

The treatment of HIV infection has changed recently in children and adults. The new guidelines are based on a better knowledge of viral pathogenesis, control of the infection and treatment effectiveness using the viral load, and the availability of new antiretroviral drugs. Cumulative clinical experience and the results of therapeutic trials suggest that treatment should begin early, before immune system disorders occur, in order to prevent viral dissemination and neurological involvement. Combined therapy with at least two drugs is recommended, although triple therapy with two inhibitors of inverse transcriptase and a protease inhibitor is advised as a way to delay the appearance and selection of resistant viral strains. Given the complexity of these treatment guidelines, the side effects of antiretroviral agents, and drug interactions with many medications, meticulous and detailed information for the family and child is necessary to ensure compliance and guarantee therapeutic effectiveness. The object should be to achieve an individualized and rational therapy that is adapted to the childís schedule and uses the drug formulation that the child best tolerates. The are reasons for optimism because new drugs are being developed and many of our patients will undoubtedly benefit from them. However, it should not be forgotten that many children with HIV infection in the third world cannot receive treatment for social and economic reasons.

[Long-term follow-up study of 35 children with ADS treated with zidovudine (AZT)]. / Estudio evolutivo de 35 niños afectos de síndrome de inmunodeficiencia adquirida (SIDA) en tratamiento con Zidovudina (AZT).

Thirty-five children diagnosed of AIDS were studied in order to evaluate toxicity and efficacy of oral Zidovudine treatment (AZT), as well as to analyze the clinical, biochemical, immunological and virological evolution of HIV infection throughout the treatment. Patients (19 males and 16 females) were studied from April 1988 to May 1990 with a mean follow-up time of 13.5 months (SD = 6.7 months). The mean age of the group was 4.68 years. The means of acquisition of this disease was 71.45 vertical and 28.6% via hemo-derivatives. Tolerance has been good with the main toxicity being hematological (28.5% anemia and/or neutropenia), 23% of which required blood supplements. The presence of neurological involvement and thrombopenia were observed in the incidence of greater toxicity. No influence on weight during AXT treatment was observed and hepatosplenomegalia and adenopathies were not modified. Bacterial and opportunistic infections were observed in 97.1% and 20% of patients, respectively. Neurological evolution was irregular and the improvement observed in some patients was mild and transitory. Three patients died during the follow-up from intercurrent infectious process. A progressive increase in MCV and a tendency towards leucopenia and lymphopenia (mainly in hemo-derivative infected patients) was observed. Neither significant immunological nor virological changes were observed during the treatment (except the tendency to diminish basal hypergammaglobulinemia). The results of this study were compared to other pediatric series treated with AZT.

[IgG2 deficiency associated with recurrent pneumonia and asthma (review of an IgG subclass)]. / Déficit de IgG2 asociado a neumonías de repetición y asma. (Revisión de subclases de IgG).

Very low levels of IgG2 were detected in a 7 1/2 years old girl affected by recurrent pneumonias and atopic related disease. A similar clinical picture was present in two siblings (of 9 and 4 years old), although their of IgG subclass deficiencies is made, with special emphasis on IgG2 and their relationship with recurrent sinopulmonary infections, atopy and other immunodeficiencies.

[Short term treatment of infantile pulmonary tuberculosis]. / Tratamiento de corta duración de la tuberculosis pulmonar infantil.

Due to the scarcity of published articles on short-course chemotherapeutic regimens for pediatric pulmonary tuberculosis, the following study has been carried out: Twenty-five children diagnosed of pulmonary tuberculosis were administered a short course therapeutic regimen consisting of three tuberculostatics for the first two month (isoniazid, rifampicin and pyrazinamide) and only two (isoniazid and rifampicin) for the following four months. The results were compared with those obtained from a control group of twenty-five children receiving the "classical" therapy: two drugs (isoniazid and rifampicin) for a nine month period. The statistical analysis did not demonstrate any significant difference related to evolution, duration and complications of the disease, between both groups. Therefore, this short course therapeutic regimen could be accepted for pediatric pulmonary tuberculosis.

[Boutonneuse fever in children]. / Fiebre botonosa en el niño.

Due to an increase in the number of cases of spotted fever, a prospective study was undertaken in 31 children affected by the disease, including clinical, laboratory and microbiological data from may to october of 1983. The most frequent symptoms found were: fever 100%, "tache noire" 87%, and a maculopapular rash 81%. The Weil-Felix reaction was positive in 65% of them and indirect immunofluorescence was positive in 81%, confirming the sensitivity and specificity of this serologic procedure. The 27 children who received specific treatment, 26 with tetracycline and one with chloramphenicol, differed considerably in a lesser duration of their symptoms, in comparison with the group of children without treatment.