Multicentric analysis of childhood tuberculosis in Turkey.

Only a few series of pediatric tuberculosis (TB) have been reported in the last 20 years. The purpose of this study was to evaluate the clinical, radiological, microbiological, and treatment characteristics of childhood TB. A total of 539 children with childhood TB diagnosed over a 12-year period (1994-2005) in 16 different centers in Turkey participated in the study. The medical records of all childhood TB patients were investigated. A total of 539 children (274 males, 265 females) with childhood TB aged 10 days-17 years participated in the study. Age distribution was nearly equal among all age groups. We detected the index case in 39.8% of the patients. More than one index case was detected in 17.3% of the patients. A minimum 15-mm induration is accepted on tuberculin skin test (TST) following Bacillus Calmette-Guérin (BCG) vaccination. The TST was positive in 55.3% of the patients. Acid-fast bacillus smear was positive in 133, and polymerase chain reaction for Mycobacterium tuberculosis was positive in 45 patients. In 75 patients (13.9%), cultures yielded M. tuberculosis. One hundred fifty-one patients (28%) did not present for followup, and families of 5 patients (0.9%) discontinued the treatment. Pulmonary TB (n=285) and meningeal TB (n=85) were the most frequent diseases. In 29% of the patients, there was poor adherence to treatment or patients were lost to follow-up. We have demonstrated that household contact screening procedures play a major and important role, especially considering the high ratio of cases with contact index cases. We also recommend that the positive TST values should be reviewed according to the local cut-off data and should be specified in as many countries as possible. In view of the considerably high percentages of patients lost to follow-up and treatment discontinuation observed in our study, we suggest that application of directly observed treatment short-course (DOTS) is preferable.

Nosocomial infections due to Acinetobacter baumannii in a pediatric intensive care unit in Turkey.

The aim of this study is to document the clinical characteristics and outcomes of Acinetobacter baumannii infections in pediatric patients in a pediatric intensive care unit (PICU) in Turkey. The ages ranged from 1 month to 16 years with a mean age of 55.5 months, and the male-to-female ratio was 1:1.5. Ventilator-associated pneumonia (10 patients) was the leading diagnosis, followed by catheter-related blood stream infection (4 patients), and bacteremia and ventilator-associated pneumonia associated with meningitis (1 patient) due to A. baumannii. Mechanical ventilation (93.3%), central venous catheter (73.3%), urinary catheter (93.3%), and broad spectrum antibiotic usage (80%) were the frequently seen risk factors. Neuromuscular (40%) and malignant (26.7%) disorders were the most common underlying diseases. Nosocomial A. baumannii is commonly multidrug-resistant, prolongs the length of stay in the PICU and increases the mortality rates in pediatric critical care.

Changing patterns of rotavirus genotypes in Turkey.

To describe the circulation dynamics of human rotavirus genotypes and to understand the epidemiological changes of rotavirus infection in Turkey, one of the countries where the highest mortality rates are seen due to rotavirus in Europe. Stool samples of children under 5 years of age which gave positive results for rotavirus antigen were stored at -20°C and then genotyped using multiplex reverse transcription polymerase-chain reaction. Of the 494 stool samples, 137 (28.1%) were positive for rotavirus antigen and 100 (73%) samples which could be genotyped successfully were included in the study. 42 (42%) samples were from inpatients, and 58 (58%) were from outpatients. The median age of the children was 16 months (5 days-59 months). G9 and P[8] were the most frequent G and P genotypes, and were detected in 30 (30%) and 55 patients (55%), respectively. In 90 samples for which both G and P genotypes could be determined, 34 different combinations were found. G9P[8] was the most frequent genotype detected in 19 patients (19%), followed by G1P[8] and G4P[6] each in 7 (7%) patients. The incidence of mixed infection was found to be 26%. Novel strains like P2A[6] and P[5] and unusual reassortant strains were detected. Distribution of rotavirus genotypes exhibited distinctive changes in this study. When the ever-changing epidemiology of rotaviruses is taken into account, ongoing surveillance studies are important before the inclusion of rotavirus vaccines in national immunization program of Turkey.

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: experience from multiple tertiary paediatric centres in Turkey.

BACKGROUND: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey. METHODS: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals. RESULTS: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis. CONCLUSIONS: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

Acute neonatal suppurative parotitis: a case report and review of the literature.

Neonatal suppurative parotitis (NSP) is an uncommon disease. Information about the etiopathogenesis and management of the disease is very limited. Here, we describe a newborn who developed NSP due to Pseudomonas aeruginosa and who was treated successfully with antibiotics.

Aseptic meningitis in a child due to 2009 pandemic influenza A (H1N1) infection.

Neurologic manifestations of seasonal influenza 2009 pandemic influenza A (H1N1) are now known to include encephalitis, acute disseminated encephalomyelitis, Guillain-Barré syndrome, transverse myelitis, and acute necrotizing encephalopathy. We report a case of 2009 pandemic influenza A (H1N1) meningitis in a previously healthy six-year-old girl who presented with fever, headache, abdominal pain, and vomiting. The infection was confirmed via nasopharyngeal and throat swabs. She was treated with oseltamivir successfully. To our knowledge, she is the first child diagnosed as pandemic influenza A (H1N1) meningitis.

Hemophagocytic lymphohistiocytosis associated with 2009 pandemic influenza A (H1N1) virus infection.

Hemophagocytic lymphohistiocytosis (HLH) has not been described earlier in the context of 2009 pandemic influenza A (H1N1) virus infection, although certain populations are thought to be at risk for complicated pandemic influenza A disease. Here, we report the second case of HLH after infection with the influenza A H1N1 virus treated with peroral oseltamivir successfully.

Ampicillin/sulbactam for children hospitalized with community-acquired pneumonia.

Childhood community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, but studies on the treatment of children hospitalized with CAP are limited. Although ampicillin/sulbactam is frequently used to treat the pediatric population there are very limited data about the effect of the parenteral form for childhood CAP. Hence, a retrospective study was conducted to assess clinical response to empirical parenteral ampicillin/sulbactam among children hospitalized with CAP. A total of 501 children with presumed bacterial etiology and treated with intravenous ampicillin/sulbactam were included in the study. Treatment was defined as failure if the initial ampicillin/sulbactam therapy was changed because of no clinical improvement 72 h or more after its use or clinical worsening at any time. Thirty-one (6.2%) children needed treatment change whereas 470 (93.8%) were treated successfully with ampicillin/sulbactam. In multivariate analysis, male gender [OR (95%CI): 3.32 (1.37-8.04), p = 0.008], CRP levels [OR (95%CI) 1.04 (1.01-1.08), p = 0.024], and existence of pleural effusion [OR (95%CI) 5.74 (2.17-15.15), p = 0.0001] were found to be significantly associated with treatment failure for the whole study group. For the subgroup of children between 3 and 60 months of age; respiratory rate [OR (95%CI) 1.06 (1.02-1.10), p = 0.0006] was also found to be an additional risk factor. In conclusion, this is the largest study showing that empiric parenteral ampicillin/sulbactam is effective, safe, and well tolerated for treatment of children hospitalized with CAP. However, pleural effusion was found to be the main factor associated with treatment failure.

Invasive Candida infections in children: the clinical characteristics and species distribution and antifungal susceptibility of Candida spp.

The aims of the study were to examine the distribution of Candida spp. isolated from sterile body sites, the antifungal susceptibility of the isolates to amphotericin B, fluconazole, voriconazole, and caspofungin, and factors affecting mortality with invasive Candida infections in children. Thirty-five children with invasive candidiasis between January 2004 and January 2008 were evaluated retrospectively. The antifungal susceptibility of isolated Candida species was studied by Etest. Of the invasive Candida infections, 65.7% were due to C. albicans. The second most common isolated species was C. parapsilosis (11.4%). The rates of resistance to fluconazole, amphotericin B and voriconazole were 8.5%, 2.8% and 5.7%, respectively. Caspofungin was the most effective antifungal agent. 22.8% of the patients died in the first 30 days. In univariate analyses, increased mortality was associated with stay in the intensive care unit, the presence of central venous catheter (CVC), failure to remove CVC, and mechanical ventilation.

Baboon syndrome induced by oral antitussive-decongestant agent in a child.

We present the case of a three-year-old boy who developed a special exanthem after oral intake of an antitussive-decongestant agent. The clinical findings were compatible with baboon syndrome. To our knowledge, this is one of the rare reported cases of baboon syndrome associated with use of an antitussive-decongestant including pseudoephedrine HCI, dextromethorphan HBr and chlorpheniramine maleate.

Clinical and epidemiological characteristics of children with Kawasaki disease in Turkey.

BACKGROUND: Kawasaki disease (KD) is the leading cause of acquired heart disease in childhood in the developed countries. The objective of this study is to describe the clinical and epidemiological characteristics of children with KD in Turkey. METHODS: The medical records of 24 patients treated for KD between January 1994 and June 2009 at Ankara University Medical School, Turkey were reviewed. RESULTS: The male-to-female ratio was 1.4 : 1. The median age at diagnosis was 2 years (range: 6.5 months to 11 years). Conjunctivitis and changes in the lips and oral cavity were seen in 21/24 (87.5%), cervical lymphadenopathy 17/24 (70.8%), polymorphous rash 16/24 (66.7%) and peripheral changes in 12/24 (50%). Coronary artery abnormality (CAA) was observed in 8/24 (33.3%) cases. CAA was seen in both the complete and incomplete groups with similar frequency (31.3% vs. 37.5%, respectively). CONCLUSIONS: KD must be kept in mind in the differential diagnosis of infants with prolonged fever.

Bacteraemia and candidaemia: a considerable and underestimated complication of severe rotavirus gastroenteritis.

Despite the high incidence of rotavirus gastroenteritis, secondary bacteraemia later in the course of the disease has rarely been reported. To date, the exact incidence of this complication has not been determined. A prospective study was conducted between January 2007 and December 2008 to determine the incidence of bacteraemia by organisms of the normal intestinal flora during severe rotavirus gastroenteritis. Rotavirus gastroenteritis was diagnosed by antigen detection in stool. A previously described 20-point numerical score system was used to determine the severity of disease. There were 289 cases (30%) of rotavirus gastroenteritis during the study period, 106 (36.7%) of which were accepted to be severe rotavirus gastroenteritis and hospitalized. On admission stool and blood cultures tested negative. In cases of persistent or recurrent fever, additional blood cultures were obtained. Among cases with severe rotavirus gastroenteritis, 4 (3.8%) had positive blood cultures (Klebsiella pneumoniae in 1 patient, Escherichia coli in 1 patient, Pseudomonas aeruginosa and Candida albicans in 1 patient, and Candida albicans in 1 patient). All patients were successfully treated with fluid replacement and antimicrobial therapy. Bacteraemia and candidaemia appear to be a considerable and underestimated complication of severe rotavirus gastroenteritis.

Soluble endothelial protein C receptor level in children with sepsis.

Endothelial protein C receptor (EPCR) is primarily localized on the endothelial cells of large blood vessels. EPCR enhances activation of protein C by 5- to 20-fold. EPCR appears to be physiologically significant in the control of blood coagulation and inflammation and in the host response to gram-negative sepsis. In this study, the authors evaluated serum-soluble EPCR level in septic children in a pediatric intensive care unit (PICU) in a university hospital. The study was performed between March 2006 and September 2007 and consisted of 39 patients with sepsis and 40 healthy children. Septic patients were enrolled consecutively. Serum-soluble EPCR level was determined by enzyme-linked immunosorbent assay. The ages of the children with sepsis and those in the control groups ranged between 59 +/- 68 and 68 +/- 52 months, respectively. The serum sEPCR levels of septic children and those in control groups were 87 (38-260) and 72 (42-180) ng/mL (p > .05), respectively. The mortality rate was 25.6% in our patients. Escherichia coli and Klebsiella pneumonia were the most common pathogens. Among these children 16 had sepsis, 23 had septic shock, 15 had multiple organ dysfuntion syndrome, and 12 had disseminated intravascular coagulation. sEPCR levels of survivors were 96 (44-260) and those of nonsurvivors' were 82.5 (38-325) ng/mL (p > .05). Serum soluble endothelial protein C receptor level is not elevated in children with sepsis, and it is not a prognostic parameter in septic children.

Neonatal suppurative submandibular sialadenitis.

Neonatal sialadenitis of the submandibular gland is a very rare clinical entity. Information about the etiopathogenesis and management of the disease is very limited. Prematurity, prolonged gavage feeding and dehydration are the frequent causes. This report presents a rare case of isolated suppurative submandibular sialadenitis in a full-term newborn without any risk factors. Possible etiology, diagnosis and management of this uncommon disease are discussed.

Stenotrophomonas maltophilia bacteraemia in Turkish children.

BACKGROUND: Stenotrophomonas maltophilia is an important cause of life-threatening nosocomial infection. AIM: To evaluate the clinical features, antibiotic treatment and prognosis of S. maltophilia bacteraemia. METHODS: Patients with blood cultures positive for S. maltophilia at the Children's Hospital, Ankara University Medical School between 1995 and 2005 were evaluated retrospectively. The results were compared with those of a case-control group of patients with Pseudomonas aeruginosa bacteraemia (n=33). Antibiotic susceptibilities of S. maltophilia strains were determined by disc diffusion. Susceptibility to ciprofloxacin was also determined by broth dilution. RESULTS: Thirty-six (2.2%) blood cultures were positive for S. maltophilia. Neutropenia was more common in the P. aeruginosa group (p=0.001). Breakthrough bacteraemia developed more commonly during carbapenem treatment in the S. maltophilia group (p=0.02). Ciprofloxacin and trimethoprim-sulfamethoxazole in combination with/without an aminoglycoside were the antibiotics most commonly selected to treat S. maltophilia bacteraemia. Mortality was more common in the P. aeruginosa (13/33) than in the S. maltophilia (2/33) group (p=0.001). According to susceptibility, determination by the disk diffusion method, beta-lactam antibiotics, aminoglycosides and chloramphenicol had little or no effect, whereas trimethoprim-sulfamethoxazole, doxycycline and fluoroquinolones were more active against S. maltophilia strains. However, ciprofloxacin susceptibility results were quite different when determined by disk diffusion (97% isolates susceptible) and broth dilution (49% isolates susceptible). CONCLUSIONS: Although S. maltophilia bacteraemia is rare in children, antibiotic resistance to these strains is an important problem. Tetracyclines, trimethoprim-sulfamethoxazole and fluoroquinolones are the most active agents against S. maltophilia strains.

Hemophagocytic lymphohistiocytosis associated with visceral leishmaniasis.

Visceral leishmaniasis (VL), is a systemic disease caused by the dissemination of protozoan parasite Leishmania throughout the reticuloendothelial system. It may mimic or lead to several types of hematological disorders including hemophagocytosis. Infection associated hemophagocytic syndrome implicating Leishmania is very rare and often difficult to diagnose. Here, we describe a child with hemophagocytic lymphohistiocytosis (HLH) associated with VL.

The coexistence of thymic carcinoma and multiple granulomas in a Turkish child.

Thymic carcinoma, which is a thymic epithelial neoplasm with obvious cytologic atypia, is a rare neoplasm. The authors report on a 10-year-old boy who presented with respiratory distress due to bulky anterior mediastinal mass. Histological and immunohistochemical studies confirmed a lymphoepithelioma-like pattern thymic carcinoma. In addition, evaluation of the specimen showed foci of caseation and multiple granulomas with extensive central necrosis within the thymic tissue. The child received chemotherapy, followed by surgery and radiotherapy. To rule out difficulties of tuberculosis he also received antituberculosis therapy. Two years after cessation of treatment, he is still in remission for thymic carcinoma.

Difficult intubation of a child through laryngeal mask airway with two tracheal tubes.

UNLABELLED: Difficult tracheal intubation occurs infrequently. It is estimated that difficult laryngoscopy occurs in 1-2% of patients. Tracheal intubation of especially small infants can be challenging. When faced with a difficult airway, intubation through a laryngeal mask airway is one method of obtaining a secure airway. Here, we report a 23-mo-old girl with chronic lung disease and severe pneumonia, who was admitted to our paediatric intensive care unit. Since the patient could not be intubated by the standard method, because her larynx was up and forward, she was intubated successfully with a laryngeal mask airway through which two consecutive tracheal tubes were inserted. CONCLUSION: Laryngeal mask airway has an important role as a back-up device in case direct visualization of the larynx is not possible.

Caspofungin treatment in two infants with persistent fungaemia due to Candida lipolytica.

Candida lipolytica has infrequently been identified as a cause of infection and is associated mostly with vascular catheter-related fungaemia. Patients reported in the literature have been successfully treated with catheter removal or amphotericin B treatment. We report 2 infants with C. lipolytica fungaemia unresponsive to catheter removal and amphotericin B therapy and treated successfully with the addition of caspofungin to amphotericin B.