Tuberculosis of the ribcage by dissemination of Koch bacilli.

INTRODUCTION: Tuberculosis (TB) is an infectious, transmissible and immune disease caused by the Mycobacterium tuberculosis-complex (MTBC). Although osteoarticular tuberculosis (OATB) has been widely described, the ribcage variety remains a rare form. CASE REPORT: A thirteen-month-old male and a twenty-month-old female, both with pain and increased volume of anterolateral left rib cage were described. Physical examination revealed the presence of a soft consistent mass at the level of the 9th and 5th costal arches in the male and female patients respectively. Upon clinical evaluation, tuberculosis was suspected, which was confirmed by X-ray and histopathological studies. After confirmation, the management, based on anti-tuberculosis therapy was started as follows: nine months of anti-tuberculosis therapy for the male patient and fourteen months for the female. The outcomes were favorable for both patients. However, further interventions, consisting of abscess drainage in the male patient and excisional biopsy in the female patient were necessary. With these therapeutic interventions, to date, the patients are without any evidence of active TB.

A 20-year retrospective study of osteoarticular tuberculosis in a pediatric third level referral center.

PURPOSE: The objective of the present study is to describe the clinical, diagnostic, radiological and therapeutic aspects of osteoarticular tuberculosis (OATB) in patients in a tertiary pediatric hospital, to know if the diagnosis of OATB in pediatrics is a challenge due to its insidious clinical presentation. METHODS: A retrospective, descriptive study of the cases of Tuberculosis (TB) in children was carried out. A total of 159 cases met the condition for the analysis. RESULTS: The most frequent TB modality was extrapulmonary in 85%. Out of this, only 29% was OATB. The mean age was 4.9 years (range 8 months-16 years). Eighty-six per cent of cases received Bacille Calmette-Guérin (BCG) vaccination at birth. Median time of symptoms prior to diagnosis was 8 months. Microbiological confirmation was achieved only in five cases, with a high sensitivity to the antimicrobial treatment. Mycobacterium bovis BCG strain Tokio 172 was confirmed in three cases. Mortality rate was 0% during the time of study CONCLUSION: Our study describes the epidemiological characteristics of OATB cases in Mexican children. This data revealed a high prevalence of bone and joint TB infection. Pediatric OATB should be considered in cases with lytic bone lesions, fever and local pain. In countries with BCG immunization program, M. bovis should not be forgotten as an etiological agent. The low detection rate with one technique approach highlights the urgent need for more sensitive test to diagnose OATB in children.

BCG: a vaccine with multiple faces.

BCG has been recommended because of its efficacy against disseminated and meningeal tuberculosis. The BCG vaccine has other mechanisms of action besides tuberculosis protection, with immunomodulatory properties that are now being discovered. Reports have shown a significant protective effect against leprosy. Randomized controlled trials suggest that BCG vaccine has beneficial heterologous (nonspecific) effects on mortality in some developing countries. BCG immunotherapy is considered the gold standard adjuvant treatment for non-muscle-invasive bladder cancer. BCG vaccine has also been tested as treatment for diabetes and multiple sclerosis. Erythema of the BCG site is recognized as a clinical clue in Kawasaki disease. BCG administration in the immunodeficient patient is associated with local BCG disease (BCGitis) or disseminated BCG disease (BCGosis) with fatal consequences. BCG administration has been associated with the development of autoimmunity. We present a brief review of the diverse facets of the vaccine, with the discovery of its new modes of action providing new perspectives on this old, multifaceted and controversial vaccine.

Case Report: Chest Wall Tuberculosis without Pulmonary Involvement in Three Pediatric Immunocompetent Patients.

Primary rib cage tuberculosis (TB) is an infrequent form of presentation and represents 1% of all cases of osteoarticular TB. We report three cases of children who were previously healthy and who began with swelling of the anterior surface of the rib as initial manifestation of TB. The most important clinical presentations in this series were swelling and pain, with lytic lesions and a soft tissue mass in image studies simulating oncologic pathologies. Because none of the cases had positive epidemiological contact, TB was initially not considered, so the delay in diagnosis from the onset of symptoms was 4, 1, and 2 months, respectively. The diagnosis was made through histomorphological analyses. Treatment was administered during 12, 10, and 9 months. Posttreatment studies did not show any evidence of extrapulmonary TB and until date, the patients remained without relapse or active disease. The findings in our cases illustrate that the diagnosis of chest wall TB should be suspected in all patients from endemic areas who present rib injury.

Linezolid-associated optic neuropathy in a pediatric patient with Mycobacterium nonchromogenicum: A case report.

BACKGROUND: Toxic optic neuropathies are alterations of the optic nerve and can be caused by environmental, pharmacological, or nutritional agents. CASE: It is about a 7-year-old male patient, a native of the State of Mexico, Mexico who was diagnosed with cervical mycobacterial lymphadenitis that required management with linezolid. OBSERVATIONS: After 7 months of treatment, visual acuity of the left eye decreased and was accompanied by headache. Neuroinfection and other central nervous system affections were discarded. An adverse effect related to treatment with linezolid was suspected, and linezolid was suspended. The symptoms subsided after discontinuation; however, the patient continued to show decreased visual acuity of the left eye, assessed by his ability to count 2 fingers. The right eye remained unaffected. CONCLUSIONS: Neurotoxicity can be decreased by reducing the total dose of linezolid or by administrating it in an intermittent form. To avoid progression and loss of vision, we suggest frequent periodic ophthalmological evaluation in patients treated with linezolid.

Pulmonary tuberculous: Symptoms, diagnosis and treatment. 19-year experience in a third level pediatric hospital.

BACKGROUND: Pulmonary tuberculosis (PTB) is an infectious disease that involves the lungs and can be lethal in many cases. Tuberculosis (TB) in children represents 5 to 20% of the total TB cases. However, there are few updated information on pediatric TB, reason why the objective of the present study is to know the real situation of PTB in the population of children in terms of its diagnosis and treatment in a third level pediatric hospital. METHODS: A retrospective study based on a revision of clinical files of patients less than 18 years old diagnosed with PTB from January 1994 to January 2013 at Instituto Nacional de Pediatria, Mexico City was carried out. A probable diagnosis was based on 3 or more of the following: two or more weeks of cough, fever, tuberculin purified protein derivative (PPD) +, previous TB exposure, suggestive chest X-ray, and favorable response to treatment. Definitive diagnosis was based on positive acid-fast bacilli (AFB) or culture. RESULTS: In the 19-year period of revision, 87 children were diagnosed with PTB; 57 (65.5%) had bacteriologic confirmation with ZN staining or culture positive (in fact, 22 were ZN and culture positive), and 30 (34.5%) had a probable diagnosis; 14(16.1%) were diagnosed with concomitant disease, while 69/81 were immunized. Median evolution time was 21 days (5-150). Fever was found in 94.3%, cough in 77%, and weight loss in 55.2%. History of contact with TB was established in 41.9%. Chest X-ray showed consolidation in 48.3% and mediastinal lymph node in 47.1%. PPD was positive in 59.2%, while positive AFB was found in 51.7% cases. Culture was positive in 24/79 patients (30.4%), PCR in 20/27 (74.1%). 39 (44.8%) patients were treated with rifampin, isoniazid, and pyrazinamide while 6 (6.9%) received the former drugs plus streptomycin and 42 (48.3%) the former plus ethambutol. There were three deaths. CONCLUSIONS: PTB in pediatric population represents a diagnostic challenge for the fact that clinical manifestations are unspecific and the diagnosis is not confirmed in all cases; that is why clinical suspicion, X-ray findings and PPD are indispensable for opportune start of treatment.

Clinical and laboratory characteristics of infectious mononucleosis by Epstein-Barr virus in Mexican children.

BACKGROUND: Infectious mononucleosis (IM) or Mononucleosis syndrome is caused by an acute infection of Epstein-Barr virus. In Latin American countries, there are little information pertaining to the clinical manifestations and complications of this disease. For this reason, the purpose of this work was to describe the clinical and laboratory characteristics of infection by Epstein-Barr virus in Mexican children with infectious mononucleosis. METHODS: A descriptive study was carried out by reviewing the clinical files of patients less than 18 years old with clinical and serological diagnosis of IM by Epstein-Barr virus from November, 1970 to July, 2011 in a third level pediatric hospital in Mexico City. RESULTS: One hundred and sixty three cases of IM were found. The most frequent clinical signs were lymphadenopathy (89.5%), fever (79.7%), general body pain (69.3%), pharyngitis (55.2%), hepatomegaly (47.2%). The laboratory findings were lymphocytosis (41.7%), atypic lymphocytes (24.5%), and increased transaminases (30.9%), there were no rupture of the spleen and no deaths among the 163 cases. CONCLUSIONS: Our results revealed that IM appeared in earlier ages compared with that reported in industrialized countries, where adolescents are the most affected group. Also, the order and frequency of the clinical manifestations were different in our country than in industrialized ones.

Double blind study of placebo and ribavirin as prophylaxis in cases of contact with varicella in children.

The aim of this study was to determine whether or not ribavirin provides protection against varicella in those who come in contact with the virus. In a double blind placebo study, ribavirin (20 mg/kg/day, p.o.) or placebo was administered to children who had contact with varicella. Treatment was administered to 61 children (Group 1) within the first 3 days of contact, 45 of them were immunocompetent and 16 were immunodepressed. Treatment was given to 54 children on the 7th day after contact (Group 2); 48 of them were immunocompetent and 6 immunodepressed. In group 1, 11 (50%) of the immunocompetent treated with ribavirin developed chicken pox while 11 (50%) were asymptomatic. For seroconversion, there was no significant difference (p=0.586). In group 2, we did not find varicella in immunocompetent patients receiving ribavirin (0/24), for placebo there were 2 (2/24) cases of varicella. Varicella was not observed in immunodepressed patients in Group 2. A difference was not observed with the administration of ribavirin at day 3 or 7 versus placebo to prevent development of varicella. This study may have implications for the public health efforts in the prophylaxis of chicken pox.

Infecciones nosocomiales en un hospital de tercer nivel de atención pediátrica: revisión de 11 años de vigilancia epidemiológica, 1988-1998 / Nosocomial infections at third level hospital pediatric care: review of 11 year of epidemiological suerveillance, 1988-1998

El problema de adquisición de una infección nosocomial continúa siendo el principal foco de atención en cualquier hospital de cualquier lugar del mundo, independientemente de que atienda grupos de pacientes adultos o pediátricos. Actualmente está cobrando importancia el problema de infecciones nosocomiales en las unidades de terapia intensiva (UCI), siendo el paciente pediátrico neonato, el más afectado.El presente artículo tiene como objetivo presentar la vigilancia epidemiológica de los casos y eventos de infección nosocomial que se presentaron en un periodo de once años, en los diferentes servicios del Instituto Nacional de Pediatría, con énfasis en el grupo neonatal. Este estudio comprende de 1988 hasta 1998.

Cefalotina amikacina vs. cefalotina isepamicina en el tratamiento inicial del paciente neutropénico febril / Cephalotine-amikacin vs. cephalotine isepamicine in the initial treatment of neutropenic patient febrile

Para evaluar la eficacia y seguridad de isepamicina y cefalotina vs. amikacina cefalotina en el tratamiento del paciente neutropénico febril, se realizó un estudio prospectivo longitudinal, aleatorizado, en donde se incluyeron 60 episodios de neutropenia y fiebre, en 58 pacientes menores de 18 años con diagnóstico de base hemato-oncológico, hospitalizados en el Instituto Nacional de Pediatría durante el periodo de abril de 1996 a febrero de 1997. Treinta y seis fueron asignados al grupo 1 (cefalotina + amikacina) y 24 en el grupo 2 (cefalotina isepamicina). No se encontraron diferencias estadísticamente significativas en relación con la edad, género, padecimiento hematooncológico de base y cuenta de neutrófilos absolutos al ingreso. Treinta y nueve pacientes (65 por ciento) tenían diagnóstico de leucemia aguda o linfoma, mientras que 21 niños (35 por ciento) tenían diagnóstico de tumor sólido. Se documentó clínicamente foco infeccioso aparente en 37 episodios (61 por ciento) y hubo documentación bacterilógica sólo en 2/60 (3.3 por ciento), el resto presentó fiebre de origen oscuro. La curación clínica fue similar en ambos grupos: 29/36 pacientes en el grupo 1 (80 por ciento) y 19/24 en el grupo 2 (79 por ciento) (Z=0.1311 y P 0.8966). Se modificó el tratamiento antimicrobiano en 7 pacientes del grupo 1 y cinco del grupo 2 por persistencia de la fiebre; dos pacientes fallecieron, uno en cada grupo, sin evidencia microbiológica de infección. En un solo paciente del grupo 1 se documentó en audiometría hipoacusia leve. Con esto podemos concluir que el tratamiento con isepamicina y cefalotina es una alternativa eficaz y segura en el tratamiento empírico inicial del paciente neutropénico febril

Resistencia a los fármacos antituberculosos en América Latina / Antituberculosis drug resistance in Latin American

La resistencia de M. tuberculosis a los fármacos es un problema de salud a nivel mundial. Se han implementado programas de control cuyos objetivo incluyen la detección de casos y un tratamiento acortado y estandarizado. Se revisan los factores de riesgo de presentar fármaco-resistencia al tratamiento contra la tuberculosis y los mecanismos de resistencia, así como la vigilancia epidemiológica, que junto con recomendaciones específicas es fundamental para el éxito de los programas

Mucormicosis rinocerebral en un niño con leucemia. Informe de un caso / Rhynocerebral mucormycosis in a child with leukemia. A case report

La mucormicosis es una infección aguda causada por hongos del orden de los mucorales que colonizan los tractos respiratorio e intestinal de personas sanas y causan enfermedad en personas inmunodeficientes, es más común en aquellos que cursan con diabetes mellitus y con menor frecuencia en personas con leucemia o linfomas. Una de las formas más frecuentes de mucormicosis es la rinocerebral, en la cual los pacientes presentan lesiones que inician a partir de la cavidad oral y avanzan destruyendo el paladar y estructuras faciales, septum nasal, senos y posteriormente el cerebro. El tratamiento consiste en debridación quirúrgica radical y manejo farmacológico con anfotericina B. Se comunica el caso de un niño de ocho años con leucemia mieloblástica variedad L1 que posterior a un ciclo de quimioterapia presenta mucormicosis rinocerebral corroborada por aislamiento del microorganismo (mucor sp.) y es tratada con anfotericina B con buena respuesta al tratamiento; a los cuatro meses presentan recaída por lo que se realiza debridación quirúrgica y se continúa terapia antimicótica, con la que evoluciona adecuadamente