[Invasive pneumococcal disease and hemolytic uremic syndrome]. / Enfermedad neumocócica invasiva y síndrome hemolítico urémico.

INTRODUCTION: Streptococcus pneumoniae is an infrequent casual agent of hemolytic uremic syndrome (HUS) with more severity than classic HUS. CASE REPORT: We present two patients with pneumococcal pneumonia and empyema who developed HUS. One patient the renal function returned to normal and the other needed a renal transplantation. CONCLUSION: Pneumococcal invasive disease may be a cause of severe HUS, so a high index of suspicion is mandatory to prompt appropriate diagnosis and management.

Enfermedad neumocócica invasiva y síndrome hemolítico urémico / Invasive pneumococcal disease and hemolytic uremic syndrome

Introducción: Streptococcus pneumoniae es un agente etiológico infrecuente del síndrome hemolítico urémico (SHU) con una mayor gravedad que el SHU clásico. Casos clínicos: Presentamos 2 pacientes con pleuroneumonía neumocócica que desarrollaron SHU. En un caso la evolución fue hacia la normalización de la función renal y en el otro, hacia la insuficiencia renal, que requirió trasplante renal. Conclusión: La enfermedad neumocócica invasiva puede ser causa de SHU grave. Un alto índice de sospecha es necesario para un diagnóstico precoz y un adecuado tratamiento (AU)

Introduction: Streptococcus pneumoniae is an infreqüent casual agent of hemolytic uremic syndrome (HUS) with more severity than classic HUS. Case report: We present two patients with pneumococcal pneumonia and empyema who developed HUS. One patient the renal function returned to normal and the other needed a renal transplantation. Conclusion: Pneumococcal invasive disease may be a cause of severe HUS, so a high index of suspicion is mandatory to prompt appropriate diagnosis and management (AU)

[Pneumococcal endocarditis in a previously healthy 17-month-old boy]. / Endocarditis neumocócica en niño de 17 meses previamente sano.

Invasive pneumococcal infection is a severe disease and its incidence may be increasing. Endocarditis due to Streptococcus pneumoniae is uncommon, particularly in children without risk factors. Etiologic diagnosis is difficult when cultures are negative. We report the case of a previously healthy, 17-month-old boy not vaccinated against pneumococcus who, during the course of pneumonia treated with beta-lactam antibiotics, developed cardiorespiratory deterioration and heart murmur. Mitral valve vegetation was identified by transthoracic echocardiography. Endocarditis was diagnosed and new antibiotics were given for 6 weeks (cefotaxime, gentamycin and vancomycin). Cultures were negative. Because of lack of improvement, prosthetic mitral replacement was indicated. S. pneumoniae was identified by polymerase chain reaction (PCR) in the pathological specimen. Outcome was favorable, and the patient remained symptom-free after 6 months of follow-up. The possibility of endocarditis as an invasive pneumococcal infection should be considered in children without risk factors. PCR is a useful technique to establish the etiology when cultures are negative.

Endocarditis neumocócica en niño de 17 meses previamente sano / Pneumococcal endocarditis in a previously healthy 17-month-old boy

La enfermedad invasora neumocócica es una entidad grave y cuya incidencia parece en aumento. La endocarditis por Streptococcus pneumoniae es infrecuente, particularmente en niños sin factores de riesgo. Su caracterización etiológica resulta difícil ante cultivos negativos. Se presenta un niño de 17 meses, previamente sano, no vacunado frente a neumococo. Durante una neumonía tratada con betalactámicos aparecen deterioro cardiorrespiratorio progresivo y soplo cardíaco. La ecocardiografía transtorácica muestra una vegetación mitral. Se diagnostica endocarditis y se adecua la antibioterapia (cefotaxima, gentamicina y vancomicina, mantenidas 6 semanas). Los cultivos resultan negativos. Ante la no mejoría se interviene, colocándose una prótesis. En la válvula resecada, mediante técnica de reacción en cadena de polimerasa (PCR), se identifica S. pneumoniae. La evolución es buena, permaneciendo asintomático a los 6 meses de seguimiento. Debe considerarse la posibilidad de endocarditis como forma invasora de infección neumocócica en niños sin factores de riesgo, y la utilidad de la PCR para establecer su etiología ante cultivos negativos

Invasive pneumococcal infection is a severe disease and its incidence may be increasing. Endocarditis due to Streptococcus pneumoniae is uncommon, particularly in children without risk factors. Etiologic diagnosis is difficult when cultures are negative. We report the case of a previously healthy, 17-month-old boy not vaccinated against pneumococcus who, during the course of pneumonia treated with beta-lactam antibiotics, developed cardiorespiratory deterioration and heart murmur. Mitral valve vegetation was identified by transthoracic echocardiography. Endocarditis was diagnosed and new antibiotics were given for 6 weeks (cefotaxime, gentamycin and vancomycin). Cultures were negative. Because of lack of improvement, prosthetic mitral replacement was indicated. S. pneumoniae was identified by polymerase chain reaction (PCR) in the pathological specimen. Outcome was favorable, and the patient remained symptom-free after 6 months of follow-up. The possibility of endocarditis as an invasive pneumococcal infection should be considered in children without risk factors. PCR is a useful technique to establish the etiology when cultures are negative

[Acute liver failure due to T cell lymphoma without hepatic infiltration]. / Insuficiencia hepática aguda por linfoma de células T sin infiltración hepática.

Hepatomegaly and alterations in hepatic function are common to all patients with sickle-cell disease. In these patients, hepatic sickling is a manifestation of severe intrahepatic vaso-oclusive crises, even at levels of 25 % HbS and hematocrits of more than 45-50 %, which in 10 % of cases can lead to acute hepatic failure (AHF). AHF can be due to a variety of causes, including hematologic malignancies, but T cell lymphoma, which is usually secondary to diffuse hepatic infiltration and ischemia, is an exceptional cause, although other mechanisms can be involved. Cytokines released by lymphomas have recently been implicated as a cause of AHF.We describe a black girl with sickle cell disease, who developed AHF due to T cell lymphoma without lymphomatous infiltration of the liver. The only mechanism found to explain the clinical findings was release of cytokines by lymphoma. In patients with AHF of unknown etiology we propose early liver biopsy, because prognosis depends on the presence or absence of hepatic tumour infiltration. If AHF develops in a patient with diagnosed malignant disease, cytokine release may be the cause of AHF. Consequently, early diagnosis of the underlying disease and provision of liver support, as well as direct removal of inflammatory mediators from the circulation by exchange transfusion or other methods, should be the main priorities.

Insuficiencia hepática aguda por linfoma de células T sin infiltración hepática / Acute liver failure due to T cell lymphoma without hepatic infiltration

En pacientes con anemia de células falciformes, la hepatomegalia y alteración de la función hepática son comunes. En ellos, las crisis vasooclusivas intrahepáticas graves, pueden ocurrir con niveles de hemoglobina del 25 per cent y hematocrito superior a 45-50 per cent. Un 10 per cent pueden llegar a fallo hepático agudo (FHA). El FHA tiene diversas causas, entre ellas los procesos hematológicos malignos, excepcionalmente el linfoma de células T, que por lo general produce infiltración hepática e isquemia, aunque éste no es el único mecanismo lesional. Recientemente se ha considerado a las citocinas liberadas por linfomas como causa de FHA. Se presenta el caso de una niña de raza negra, con enfermedad de células falciformes, que presentó FHA secundario a un linfoma de células T que no infiltró al hígado, y donde el único mecanismo que se encontró para explicar el cuadro clínico fue el mediado por las citocinas. Cuando los estudios de imagen no confirman la infiltración hepática por células malignas, debe valorarse realizar una biopsia hepática, pues el pronóstico del FHA variará en función de si hay o no infiltración tumoral. Si la causa del FHA es compatible con una enfermedad neoplásica, las citocinas pueden ser las responsables del FHA. Por ello, establecer medidas de soporte de la función hepática e iniciar tratamiento precoz de la enfermedad de base, además de remover directamente estos mediadores inflamatorios de la circulación mediante exanguinotransfusión u otro procedimiento debe constituir la principal preocupación (AU)

[Transposition of the great arteries and pulmonary hypertension: inhaled nitric oxide as a therapy and early surgical correction]. / Transposición de grandes arterias e hipertensión pulmonar: tratamiento con óxido nítrico inhalado y corrección anatómica precoz.

OBJECTIVE: The objective of this study is to present our preliminary experience with pulmonary hypertension inhaled nitric oxide therapy with two newborns presenting with transposition of the great arteries, as well as the usefulness of the Doppler in pulmonary hypertension diagnosis. PATIENTS AND METHODS: Revision of the variations of the hypoxic parameters according to the therapy and revision of the diagnostic procedures in both cases was carried out. RESULTS: Nitric oxide therapy was followed by an evident improvement of the hypoxia and the patient's hemodynamic stabilization, which allowed surgical correction in optimal conditions. The ductal flow pattern allowed recognition of the presence of pulmonary hypertension. CONCLUSIONS: Inhaled nitric oxide must be taken into account as a very useful option in the treatment of this kind of patient and the Doppler examination allows the evaluation of the presence of pulmonary hypertensions.

[Cardiac tamponade in children as a complication of central venous catheterization. Report of four cases]. / Taponamiento cardiaco en niños como complicación de la cateterización venosa céntral. Presentación de cuatro casos.

Very few cases of children with cardiac tamponade from central venous catheterization have been reported. Four cases are described. In 3 patients the diagnosis was suspected, a pericardiocentesis was performed and they survived. The other patient died and, at autopsy, diagnosis was made. The available literature on cardiac tamponade from central venous catheters in children is reviewed, preventive measures are considered in detail and the need for a high index of suspicion is highlighted.

[Treatment of status asthmaticus. Experience of intravenous beta-adrenergic bronchodilator therapy in 71 cases]. / Tratamiento del estado asmático. Experiencia del tratamiento broncodilatador beta-adrenérgico EV sobre 71 casos.

A retrospective study of the patients admitted during the last 8 years with status asthmaticus is reported. We compare the requirement of mechanical ventilation with the beta-agonist therapy received and the type of asthma. About 71 patients admitted, 67% were IgE dependent asthmatic (EDA) children and 31% no-IgE dependent asthmatic (nEDA) ones. They needed intermittent positive pressure ventilation (IPPV) in 20 instances; no difference was found between both types of asthma. We studied the ventilatory parameters used. The 33% of EDA children was treated using a continuous IV infusion of hexoprenalina, requiring IPPV in 5 (31%) of them. The rest received a continuous IV of isoproterenol, and only the 16% required IPPV. We found isoproterenol to be more effective than hexoprenalina in the treatment of status asthmaticus. Similar results were obtained with the nEDA group. The Downes score was showed to be a good predictor-index scoring system in many cases.