Impacto de la implantación de la reacción en cadena de la polimerasa a enterovirus en el manejo de la meningitis aséptica / Impact of introducing an enterovirus polymerase chain reaction in the management of aseptic meningitis

INTRODUCCIÓN: El diagnóstico de meningitis aséptica basado en la reacción en cadena de la polimerasa (PCR) frente a enterovirus en líquido cefalorraquídeo es un método rápido y sensible. OBJETIVO: Valorar la influencia de la implantación de la PCR a enterovirus en el uso de antibióticos y la estancia hospitalaria en meningitis aséptica. MATERIAL Y MÉTODOS: Estudio prospectivo de ni˜nos con meningitis aséptica durante un a˜no, utilizando como grupo control a pacientes previos a la implantación de la técnica. RESULTADOS: La realización de la PCR se asoció a un menor uso de antibióticos respecto al grupo control (16,2% vs. 41,4%; p = 0,029), a un menor tiempo de administración (0,54 vs. 2 días; p = 0,014) y a una disminución no significativa de la duración del ingreso (3,57 vs. 4,21 días; p = 0,376). CONCLUSIÓN: La implantación de la PCR a enterovirus disminuye la utilización de antibióticos y la estancia hospitalaria

INTRODUCTION: The diagnosis of aseptic meningitis, based on an enterovirus PCR (EV-PCR) in cerebrospinal fluid, is a rapid and sensitive test. OBJECTIVE: To assess the impact of introducing EV-PCR on the use of antibiotics and hospital length of stay in aseptic meningitis. MATERIAL AND METHODS: A prospective study that included children with aseptic meningitis during one year. The patients prior to the introduction of the test formed the control group. RESULTS: The performance of the PCR test was associated with less use of antibiotics compared to the control group (16.2% vs 41.4%, P = .029) and with fewer days of administration (.54 vs. 2 days, P=.014). A non-significant decrease in length of stay (3.57 vs. 4.21 days, P=.376) was also observed in the study group. CONCLUSION: The introduction of the EV-PCR test decreases the use of antibiotics and hospital length of stay

[Impact of introducing an enterovirus polymerase chain reaction in the management of aseptic meningitis]. / Impacto de la implantación de la reacción en cadena de la polimerasa a enterovirus en el manejo de la meningitis aséptica.

INTRODUCTION: The diagnosis of aseptic meningitis, based on an enterovirus PCR (EV-PCR) in cerebrospinal fluid, is a rapid and sensitive test. OBJECTIVE: To assess the impact of introducing EV-PCR on the use of antibiotics and hospital length of stay in aseptic meningitis. MATERIAL AND METHODS: A prospective study that included children with aseptic meningitis during one year. The patients prior to the introduction of the test formed the control group. RESULTS: The performance of the PCR test was associated with less use of antibiotics compared to the control group (16.2% vs 41.4%, P=.029) and with fewer days of administration (.54 vs. 2 days, P=.014). A non-significant decrease in length of stay (3.57 vs. 4.21 days, P=.376) was also observed in the study group. CONCLUSION: The introduction of the EV-PCR test decreases the use of antibiotics and hospital length of stay.

Tuberculosis en el niño / Tuberculosis in the child

La tuberculosis continúa siendo una de las principales causas de morbimortalidad en todo el mundo incluyendo a los niños. El diagnóstico microbiológico puede intentarse tras nebulización de suero hipertónico y aspirado nasofaríngeo aunque el rendimiento sigue siendo bajo. Cuando se consigue aislar el germen, siempre debe hacerse un estudio de sensibilidad a fármacos por la creciente incidencia de cepas con resistencia a uno o varios fármacos. Las técnicas basadas en la PCR aceleran la obtención de resultados a los principales fármacos. La resistencia a isoniacida y rifampicina (MDR) y en ocasiones a alguna fluoroquinolona, junto con alguna de los fármacos inyectables de segunda línea (XDR), complica extraordinariamente el tratamiento, obligando a utilizar drogas menos efectivas y con más efectos secundarios. En España se aconseja el tratamiento con cuatro fármacos en la fase inicial, siendo el etambutol el utilizado generalmente, en espera del estudio de sensibilidad del niño o de su fuente de contagio. En el diagnóstico de la infección tuberculosa las técnicas b asadas en la liberación de interferón gamma son especialmente útiles en niños vacunados con BGC. Como tratamiento de la infección tuberculosa latente puede utilizarse el régimen de isoniazida y rifampicina durante 3 meses, que mejora el cumplimiento (AU)

Tuberculosis continues to be one of the principal causes or morbidity-mortality in the world, including children. The microbiological diagnosis may be attempted after hypertonic serum nebulization and nasopharyngeal aspirate, although yield continues to be low. Once it has been possible to isolate the germ, a drug sensitivity study should also be performed due to the growing incidence of strains with resistance to one or several drugs. The polymerase chain reaction (PCR) based techniques accelerate the obtaining of results to the principal drugs. Resistance to isoniazid and rifampicin (MDR) and sometimes to some fluoroquinolone together with some of the second-line injectable drugs (XDR) extremely complicate the treatment, requiring the use of less effective drugs with more side effects. In Spain, treatment with four drugs in the initial phase is recommended, ethambutol generally being used, while waiting for the sensitivity study of the child or of their source of infection. In the diagnosis of the tuberculous infection, the interferon gamma release assays are especially useful in BCG vaccinated children. As treatment of latent tuberculous infection, the isoniazid and rifampicin combination during 3 months can be used, which improves compliance (AU)

[Should pulmonary computed tomography be performed in children with tuberculosis infection without apparent disease?]. / Debe realizarse una tomografía computarizada torácica a los niños con infección tuberculosa sin enfermedad aparente?

BACKGROUND: During early childhood, in particular, there is a continuum between tuberculosis infection and disease. When establishing the diagnosis in a child with suspected tuberculosis, the distinction between infection and disease frequently depends on the interpretation of the chest X-ray. Some studies have shown hilar and mediastinal lymphadenopathies on computed tomography (CT) in children with tuberculosis infection without apparent disease, i.e., asymptomatic children with a positive tuberculin skin test and normal chest X-ray. These observations raise the issue of whether pulmonary CT should be performed in children with tuberculosis infection without apparent disease and whether different types of therapy should be administered depending on the results. METHODS: We reviewed the physiopathology of tuberculosis infection and disease, diagnostic methods and treatment, and the literature on the use of pulmonary CT scan in pediatric tuberculosis. RESULTS: Modern CT scanners indicate hilar and mediastinal lymphadenopathies in many of the children with tuberculosis infection with no apparent disease on chest X-rays. However, neither the size nor the morphology of these adenopathies allows active tuberculosis to be diagnosed. The natural history of childhood tuberculosis indicates that most children show hilar lymphadenopathies after the primary infection, although progression to disease is rare and is characterized by the presence of clinical symptoms. The exceptions are children younger than 4 years old and those with immune alterations who more frequently show progression of infection to disease and who require close follow-up. In addition, the experience accumulated over many years in the treatment of tuberculosis infection with isoniazid has shown this drug to be effective in both short- and long-term prevention of active disease. Official guidelines and expert opinion do not recommend systematic pulmonary CT scan in these children or modification of treatment according to the results. CONCLUSIONS: Hilar and mediastinal lymph nodes are frequently found in the CT scans of children with tuberculosis infection without apparent disease but there is no evidence that these adenopathies indicate active disease or that these children require different treatment. Consequently, until demonstrated otherwise, pulmonary CT scanning and changes in chemoprophylaxis are not justified in children with tuberculosis infection.

¿Debe realizarse una tomografía computarizada torácica a los niños con infección tuberculosa sin enfermedad aparente? / Should pulmonary computed tomography be performed in children with tuberculosis infection without apparent disease?

Antecedentes En la infancia, la infección y la enfermedad tuberculosa forman parte de una acción continua. Cuando se hace la evaluación diagnóstica de un niño con sospecha de tuberculosis, la distinción entre infección o enfermedad recae con frecuencia en la interpretación de la radiografía de tórax. Algunos estudios han puesto de manifiesto mediante tomografía computarizada (TC) la presencia de adenopatías hiliares y mediastínicas en niños con infección tuberculosa sin aparente enfermedad, es decir, asintomáticos, con tuberculina positiva y con radiografía de tórax normal. Estos hallazgos abren el debate de si es necesario realizar TC torácica a niños con infección tuberculosa sin enfermedad aparente y si hay que administrar un tratamiento distinto según su resultado. Métodos Se analiza la fisiopatología de la infección y la enfermedad tuberculosa, su diagnóstico y tratamiento y la bibliografía existente sobre la utilización de la TC en la tuberculosis infantil. Resultados Las modernas TC helicoidales visualizan ganglios linfáticos hiliares y mediastínicos en muchos de los niños con infección tuberculosa sin aparente enfermedad. Sin embargo, ni por el tamaño ni por la morfología de estas adenopatías se puede afirmar que se correspondan con enfermedad activa. La historia natural de la tuberculosis indica que la mayoría de los niños presentan adenopatías hiliares tras la infección inicial y que la evolución a enfermedad es infrecuente y se caracteriza por la presencia de síntomas clínicos. La excepción la presentan los niños menores de 4 años y los niños con alteraciones de la inmunidad, en los que la infección progresa con mayor frecuencia a enfermedad y en los que habrá que hacer un estrecho seguimiento. Además, la experiencia acumulada durante muchos años en el tratamiento de la infección tuberculosa con isoniacida ha demostrado su eficacia a corto y a largo plazo en la prevención de la enfermedad activa. Los consensos oficiales y la opinión de expertos no recomiendan la realización de TC en estos niños ni adecuar el tratamiento a sus resultados. Conclusiones Con frecuencia se encuentran ganglios en zonas hiliares y mediastínicas al realizar una TC en niños con infección tuberculosa sin enfermedad aparente. Sin embargo, no existen evidencias de que estos hallazgos se correspondan con enfermedad activa ni de que haya que tratarlos como tal. Mientras no se demuestre lo contrario, a los niños con infección tuberculosa no es necesario realizarles una TC torácica y se les debe administrar el tratamiento actualmente recomendado

Background During early childhood, in particular, there is a continuum between tuberculosis infection and disease. When establishing the diagnosis in a child with suspected tuberculosis, the distinction between infection and disease frequently depends on the interpretation of the chest X-ray. Some studies have shown hilar and mediastinal lymphadenopathies on computed tomography (CT) in children with tuberculosis infection without apparent disease, i.e., asymptomatic children with a positive tuberculin skin test and normal chest X-ray. These observations raise the issue of whether pulmonary CT should be performed in children with tuberculosis infection without apparent disease and whether different types of therapy should be administered depending on the results. Methods We reviewed the physiopathology of tuberculosis infection and disease, diagnostic methods and treatment, and the literature on the use of pulmonary CT scan in pediatric tuberculosis. Results Modern CT scanners indicate hilar and mediastinal lymphadenopathies in many of the children with tuberculosis infection with no apparent disease on chest X-rays. However, neither the size nor the morphology of these adenopathies allows active tuberculosis to be diagnosed. The natural history of childhood tuberculosis indicates that most children show hilar lymphadenopathies after the primary infection, although progression to disease is rare and is characterized by the presence of clinical symptoms. The exceptions are children younger than 4 years old and those with immune alterations who more frequently show progression of infection to disease and who require close follow-up. In addition, the experience accumulated over many years in the treatment of tuberculosis infection with isoniazid has shown this drug to be effective in both short- and long-term prevention of active disease. Official guidelines and expert opinion do not recommend systematic pulmonary CT scan in these children or modification of treatment according to the results. Conclusions Hilar and mediastinal lymph nodes are frequently found in the CT scans of children with tuberculosis infection without apparent disease but there is no evidence that these adenopathies indicate active disease or that these children require different treatment. Consequently, until demonstrated otherwise, pulmonary CT scanning and changes in chemoprophylaxis are not justified in children with tuberculosis infection

[Respiratory function assessment in cooperative patients. Part I. Spiromery and bronchodilator reversibility testing]. / Estudio de la función pulmonar en el paciente colaborador. Parte I.

Assessment of respiratory function is the principal tool in the study of patients with lung diseases, allowing physiopathological alterations to be detected, and the severity of the process, its clinical course, and treatment response to be identified. Nowadays, assessment of respiratory function is among the investigations used by Spanish pediatricians. The Techniques Group of the Spanish Society of Pediatric Pneumology undertook the design of a protocol for the study of pulmonary function in children that would incorporate the most recent published consensus documents on basic pulmonary function assessment (spirometry and bronchodilator reversibility testing) and on airway hyperreactivity evaluation using nonspecific provocation tests. The aim of this protocol is to provide a guide to good clinical practice until new changes, based on scientific evidence, are produced.

Estudio de la función pulmonar en el paciente colaborador. Parte I / Respiratory function assessment in cooperative patients. Part I. Spiromery and bronchodilator reversibility testing

La exploración de la función pulmonar es una herramienta fundamental en el estudio de los pacientes con problemas neumológicos. Permite detectar alteraciones fisiopatológicas, valorar la gravedad de un proceso, su evolución y la respuesta al tratamiento. En la actualidad forma parte de las exploraciones utilizadas por los pediatras españoles. El grupo de Técnicas de la Sociedad Española de Neumología Pediátrica (SENP) se propuso elaborar un protocolo de estudio de la función pulmonar en el paciente pediátrico que incorpore los últimos estándares acordados, fundamentalmente, sobre la práctica de estudios de la función pulmonar básica (espirometría y prueba broncodilatadora) y sobre el estudio de la hiperreactividad de la vía aérea mediante pruebas de provocación inespecífica. Con él se pretende obtener una guía de buena práctica clínica como referencia hasta que se produzcan cambios basados en nuevas evidencias científicas

Assessment of respiratory function is the principal tool in the study of patients with lung diseases, allowing physiopathological alterations to be detected, and the severity of the process, its clinical course, and treatment response to be identified. Nowadays, assessment of respiratory function is among the investigations used by Spanish pediatricians. The Techniques Group of the Spanish Society of Pediatric Pneumology undertook the design of a protocol for the study of pulmonary function in children that would incorporate the most recent published consensus documents on basic pulmonary function assessment (spirometry and bronchodilator reversibility testing) and on airway hyperreactivity evaluation using nonspecific provocation tests. The aim of this protocol is to provide a guide to good clinical practice until new changes, based on scientific evidence, are produced

Tuberculosis in children-is PCR the diagnostic solution?

Polymerase chain reaction (PCR) has been recently incorporated as a diagnostic tool for the diagnosis of tuberculosis. The benefit of rapid results and greater sensitivity compared with traditional microbiological methods makes PCR a suitable technique in childhood tuberculosis, especially when diagnosis is difficult or when urgent diagnosis is needed. However, the possibility of false-positive results must be considered, especially if the clinical and epidemiologic context of the child make the diagnosis of tuberculosis improbable. The commercial 'Amplicor PCR test' lacks good sensitivity and specificity and it would be necessary to develop other commercial easy-to-use PCR kits that provides better yield.

Comparison of amplicor, in-house polymerase chain reaction, and conventional culture for the diagnosis of tuberculosis in children.

A total of 251 clinical specimens (235 gastric aspirates and 16 bronchoalveolar lavages) from 88 children were prospectively tested in a blinded manner for the presence of Mycobacterium tuberculosis complex, by use of the Amplicor M. tuberculosis test and by means of in-house polymerase chain reaction (PCR). The results were compared with those obtained by conventional culture and by direct microscopy. All of the children underwent extended follow-up to verify or exclude the clinical diagnosis of tuberculosis. The results of the different tests, when compared to the final clinical diagnosis, were a sensitivity of 60% and a specificity of 96.8% for in-house PCR, 44% and 93.7% respectively for the Amplicor test, 44% and 100% for mycobacterial culture and 12% and 100% for microscopy. Amplicor tests presented false-positive findings in children without tuberculous infection. We conclude that both in-house PCR and the Amplicor test are rapid methods that can be helpful for difficult or urgent diagnosis of tuberculosis in children. However, efforts should be aimed toward improvement of the sensitivity and specificity of an easy-to-use PCR kit.

Diagnosis of tuberculosis in children using a polymerase chain reaction.

We investigated the value of the polymerase chain reaction (PCR) in the diagnosis of active tuberculosis in children and evaluated the relationship between PCR results in children with tuberculous infections and mediastinal adenopathies detected by computerized tomography (CT-Scan). This was a controlled, blinded, prospective study comparing nested PCR, mycobacterial cultures and the clinical diagnosis based on 350 clinical specimens from 117 children referred for evaluation of suspected pulmonary tuberculosis. All children with tuberculous infection but without active disease underwent a chest CT-scan to detect the presence of mediastinal adenopathies not evident on chest x-ray. The sensitivity of PCR was 56.8% in children with clinically active disease (culture: 37.8%; smears: 13.5%). A major advantage of PCR over cultures was noted when there was no parenchymal involvement on chest radiograph and when the patient was undergoing anti-tuberculous treatment. There were nine specimens with false-negative PCR results due to the presence of amplification reaction inhibitors. PCR was positive in five children with tuberculous infection without active disease and these children presented mediastinal adenopathies on the CT-scan that were not evident on chest radiography. There were no false-positive PCR results in the control groups of children. We conclude that nested PCR is a rapid and sensitive method for the early diagnosis of tuberculosis in children. It is especially useful when the diagnosis of active tuberculosis is difficult. In our study children with tuberculous infection without apparent disease who have positive PCR results have mediastinal adenopathies on CT-scan.