Etiology and classification of acute pancreatitis in children admitted to ICU using the Pediatric Sequential Organ Failure Assessment (pSOFA) score.

BACKGROUND: Pediatric acute pancreatitis (AP) is rare but increasing. Severe AP is associated with higher morbidity and mortality. However, there are no universally accepted prognostic criteria for AP. METHODS: This retrospective study included children with AP admitted to an intensive care unit (ICU) of our tertiary pediatric center between January 2009 and December 2018. The severity of organ dysfunction in AP was assessed according to the modified Atlanta criteria using the Pediatric Sequential Organ Failure Assessment (pSOFA) and Computed Tomography Severity Index (CTSI). RESULTS: Seventy acute episodes of AP were evaluated in 55 children with primary pancreatitis. In addition, secondary AP was diagnosed in 15 patients originally admitted to ICU for different indications. Mild AP [no organ dysfunction, normal computed tomography (CT) finding] was the most prevalent (64/85 episodes in 49 children), followed by moderate AP (15 children; pSOFA 2-9 points, CTSI 3-4 points on admission). Severe AP (pSOFA 4-17 points, CTSI 6-10 points) was diagnosed in 6 children with traumatic or secondary AP. The most frequent etiologies of primary AP episodes were idiopathic (39%) and biliary (31%). Children with idiopathic AP had frequent relapses and comorbidities. Hereditary AP was typically mild, but presented with high pancreatic enzyme levels and recurrence rates. Admission at ICU and an interval without enteral nutrition (EN) were relatively short in drug-induced AP and relatively long in secondary and traumatic AP. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 13 patients with biliary AP and in 4 patients with traumatic AP. No AP-related death was observed. CONCLUSION: pSOFA score accurately reflects the severity and prognosis of AP in children.

Severe linezolid-induced lactic acidosis in a child with acute lymphoblastic leukemia: A case report.

Linezolid is an antibiotic increasingly used for treatment of resistant Gram-positive infections, which blocks bacterial proteosythesis through direct inhibition of mitochondrial ribosomes. The most common adverse effects of linezolid include gastrointestinal symtoms, peripheral neuropathy, bone marrow depression and lactic acidosis. Here we present a rare case of a 9-year-old female, a survivor of acute lymphoblastic leukemia (ALL) and a hematopoietic stem cell transplant (HSCT), who developed life-threatening lactic acidosis with vomiting, impaired consciousness and Kussmaul breathing after 51 days of intravenous linezolid administration due to mycobacterial infection. She fully recovered after drug discontinuation and normalization of the plasma levels. We conclude that plasma lactate concentrations should be monitored closely during any linezolid treatment, particularly in patients with hepatic or renal dysfunction.

Acute onset of autoimmune hepatitis in children and adolescents.

BACKGROUND: Autoimmune hepatitis (AIH) is a rare progressive liver disease, which manifests as acute hepatitis in 40%-50% of pediatric cases. This refers predominantly to spontaneous exacerbations of previously unrecognized subclinical AIH with laboratory and histological signs of chronic hepatitis, or to acute exacerbations of known chronic disease. Only a few of these patients fulfill criteria for acute liver failure (ALF). METHODS: Forty children diagnosed with AIH in our center between 2000 and 2018 were included in this study. All of them fulfilled revised diagnostic criteria of the International Autoimmune Hepatitis Group (IAIHG) for probable or confirmed AIH, and other etiologies of liver diseases were excluded. Patients were divided into two groups: acute AIH (A-AIH) or chronic AIH (C-AIH). RESULTS: Acute onset of AIH occurred in 19/40 children (48%). Six of them fulfilled the criteria of ALF with coagulopathy and encephalopathy. Five of 6 children with ALF suffered from exacerbation of previously undiagnosed chronic AIH, among which 4 children were histologically confirmed as micronodular cirrhosis. The remaining one patient had fulminant AIH with centrilobular necrosis, but no histological signs of previous chronic liver damage. We observed significantly lower levels of albumin, higher levels of aminotransferases, bilirubin, INR, IgG, higher IAIHG score and more severe histological findings in A-AIH than in C-AIH. No differences in patient age and presence of autoantibodies were observed between A-AIH and C-AIH. All children, including those with ALF and cirrhosis, were treated with corticosteroids, and are alive and achieved AIH remission. Liver transplant was not indicated in any patient. CONCLUSION: Rapid and accurate diagnosis of A-AIH may be difficult. However, timely start of immunosuppressive therapy improves prognosis and decreases number of indicated liver transplantations in children with AIH.

NAS agar is more suitable than McKay agar for primary culture of Streptococcus milleri group (SMG) fastidious bacteria, S. intermedius in particular.

Streptococcus milleri group (SMG) is a group of three streptococcal species (S. anginosus, intermedius and constellatus) that act as opportunist pathogens, among others in cystic fibrosis. Due to their fastidious character, they are both difficult to cultivate and to differentiate from less pathogenic streptococcal species, therefore being most probably underdiagnosed. Semi-selective McKay agar and NAS agar were developed to facilitate SMG recovery from clinical samples; however, direct comparison of recovery rates has not been published yet. We tested the performance of both media on 123 patient samples and demonstrated general superiority of NAS agar for SMG recovery during primary cultivation convincingly. This observation was also confirmed by quantitative drop tests during subculture. Despite the undisputed overall superiority of NAS agar over McKay agar, a smaller fraction of strains grew better on McKay agar. Inter-strain differences were the most probable explanation. Therefore, when economic conditions are not limiting and maximum recovery rate is desirable, both plates are advised to be used in parallel for primary cultivation of clinical samples.

McRAPD unlike MALDI-TOF MS is a suitable candidate for routine discrimination of new Haemophilus influenzae strain acquisition in chronic obstructive pulmonary disease (COPD) and cystic fibrosis.

BACKGROUND AND AIMS: Haemophilus influenzae new strain acquisition has been demonstrated to increase the relative risk of acute exacerbation fourfold in contrast to colonisation or chronic infection by the same strain in chronic obstructive pulmonary disease (COPD). Unfortunately, molecular typing techniques are not suitable for routine use due to cost, labour-intensity and need for special expertise. We tested two techniques potentially useful for routine typing, namely the newly available MALDI-TOF MS and the modified McRAPD compared to MLST as the gold standard. METHODS: In 10 patients (10.8%) suffering from COPD or cystic fibrosis, H. influenzae isolates were recovered repeatedly at different timepoints from the same patient during the study period. This allowed for thirteen pairwise comparisons of typing results in isolates recovered consecutively from the same patient to test the ability of the techniques to uncover new strain acquisition. RESULTS: MLST detected 9 cases of new strain acquisition among the 13 pairwise comparisons. However, MALDI-TOF MS reported all 13 pairs as different and thus new. In contrast, McRAPD was able to differentiate all the new strain acquisitions from pre-existing ones, both by visual inspection of melting profiles and by Relative Significant Difference values. CONCLUSIONS: Unlike MALDI-TOF MS, McRAPD appears to be a suitable candidate for routine discrimination of new strain acquisitions because of its accuracy and, rapid, easy and economic performance.

[Prolonged culture in a humid chamber increases the yields of pathogenic bacteria from the respiratory tract samples of patients suffering from cystic fibrosis].

Current standards of care for cystic fibrosis (CF) patients lack unequivocal recommendations concerning the duration of primary culture of bacteriological samples. With the exception of Burkholderia cepacia (5 days), the minimum recommended duration of primary culture varies between 48 and 72 hours. Our aim was to evaluate the effect of an extended 10-day period of primary culture in a humid chamber in samples acquired from the respiratory tract of patients suffering from CF. Compared to standard culture, prolonged culture in a humid chamber yielded 1.85 times more isolates of pathogenic species in pharyngeal swabs (76 versus 41 isolates) and 1.4 times more isolates in sputum samples (116 versus 82), but only 1.14 times more isolates in nasal swabs (25 versus 22). Prolonged culture was most beneficial for Achromobacter spp. (6 versus 0), Stenotrophomonas maltophilia (16 versus 5) and Pseudomonas aeruginosa (69 versus 49), whereas there was little or no benefit at all for Staphylococcus aureus (87 versus 73) and Moraxella catarrhalis (10 versus 10). Therefore, prolonged culture in a humid chamber may definitely be recommended for pharyngeal swabs and sputum samples obtained from patients suffering from CF to achieve the maximum recovery rate of pathogenic bacteria, in particular non-fermenting Gram-negative rods.

The Streptococcus milleri group in chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: S. anginosus, constellatus and intermedius, also known as the Streptococcus milleri group (SMG) are three streptococcal species more frequently detected in cases of invasive disease, abscesses and empyema in particular. Recent research suggests they play a role in exacerbations of cystic fibrosis (CF). Owing to poor recovery on standard culture media and difficult differentiation from non-pathogenic streptococci, SMG may be underdiagnosed in routine settings. We aimed to establish the incidence of SMG in chronic obstructive pulmonary disease (COPD) patients compared to CF patients and to examine possible links of SMG to exacerbations that plays a key role in progression of COPD. METHODS: Altogether, 90 respiratory tract samples of patients suffering from CF or COPD were examined during the period from July 2012 to December 2013. Semi-selective McKay agar was used for primary cultivation of SMG and MALDI TOF MS was used for species identification that was confirmed by biochemical profiling and specific PCR. RESULTS: We confirmed the presence of SMG in CF (17.6% incidence in adult patients) and newly established its presence in COPD (10.3% incidence). In COPD, SMG was detected in 4 cases of acute exacerbations, where no other bacterial pathogen was detected. In 3/4 cases, increased CRP level indicated bacterial infection as a cause of the exacerbation and in all 3 cases, patients recovered during antibiotic treatment. CONCLUSIONS: Our data indicate SMG may act as opportunist pathogens able to cause exacerbations in COPD.

Performance of pyrosequencing versus MALDI-TOF MS in bacteria identification in chronic lung disease.

Rapid identification of the etiological agent in bacterial infection is necessary for correct diagnosis and appropriate therapy. In general, identification of pure cultures of bacteria using conventional phenotyping techniques requires 4-24 hours. Recently available new molecular technologies offer the potential of same day species identification once pure culture is available. Our aim was to evaluate the performance of rDNA V1 hypervariable region pyrosequencing, and the whole cell MALDI-TOF MS protein profiling in routine species identification. During the period from June 2012 to June 2014, 1.140 pure culture isolates were recovered from 402 samples from 126 patients suffering cystic fibrosis, chronic obstructive pulmonary disease or bronchiectasis. All the isolates were subjected to species identification by both techniques. Unfortunately, pyrosequencing was able to reach the species level in 43.2% of isolates only, whereas MALDI-TOF was clearly superior with 96.8% respectively. The overall sensitivity values also clearly underlined the superiority of MALDI-TOF MS with 96.8% compared to 85.1% achieved by pyrosequencing. Generally, MALDI-TOF MS turned out to be the best suitable technique in routine bacterial identification, whereas pyrosequencing could be recommended as the method of choice particularly in situations where MALDI-TOF MS fails to identify rare species.

[Relation of risk factors between metabolic syndrome and nonalcoholic fatty liver disease in children and adolescents]. / Vztah rizikových faktoru mezi metabolickým syndromem a nealkoholickým ztucnením jater u detí a dospívajících.

AIM: In recent years, nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome (MS) in children have increased in line with the increased prevalence of obesity. The aim of this retrospective study was to evaluate a relation between NAFDL and MS in children. METHODS: NAFLD was defined as an elevation of serum transaminase level and hyperechogenic feature of liver on ultrasonography. MS definition was based on the diagnostic criteria of the International Diabetes Federation. The biopsies were done in patients with elevated transaminase levels lasting more than one year. Liver biopsy features were graded according to the NAFLD activity scoring (NAS) and Paediatric NAFLD Histological Score (PNHS). RESULTS: NAFLD was diagnosed in 39 patients and MS was confirmed in 20 patients. The significant differences between patients with MS and without MS were found in the insulin resistance (IR) (P < 0,001), cholesterol levels (P < 0,04) and GGT levels (P < 0,05). Biopsies were done in 20 patients. MS was present in 10 children. No difference was found in the degree of steatosis and NAS in groups with and without MS. No differences were observed in the occurrence of MS diagnostic criteria between patients with and without nonalcoholic steatohepatitis which were evaluated by PNHS. CONCLUSION: Prediction factors for NAFLD are obesity, IR, dyslipidemia. NAFLD is frequently associated with MS. Liver biopsy is necessary for determination of NAFLD histological activity because no non-invasive examination defines the degree of liver pathology.

Montelukast decreases plasma endothelin-1 and serum eosinophil cationic protein levels in paediatric atopic asthma.

BACKGROUND AND OBJECTIVE: Endothelin-1 (ET-1) is produced by vascular endothelial cells and epithelial cells, T-lymphocytes and phagocytes. Increased ET-1 levels have been demonstrated in the bronchial epithelium of asthma patients. In vitro, ET-1 stimulates mucus secretion, activates proinflammatory cells - macrophages and mast cells - and serves as a mitogenic stimulus for fibroblasts and smooth muscle. In addition, ET-1 activates phospholipase 2. Compared with healthy individuals, asthma patients have increased ET-1 levels during an attack and following stabilisation. Our study was designed to examine plasma ET-1 (P-ET) levels in paediatric atopic patients newly diagnosed with persistent mild bronchial asthma and 1 month after initiation of montelukast therapy. METHODS: Patients' histories were examined, and their blood eosinophil leucocyte count and levels of total serum immunoglobulin E (S-IgE), serum eosinophil cationic protein (S-ECP) and P-ET were determined. Thirty-six patients with persistent mild bronchial asthma were treated with the leukotriene receptor antagonist montelukast, administered once a day for 4 weeks. Second P-ET and S-ECP level determinations were made 4 weeks later with all the children included in the study. P-ET levels were also determined in a group of 27 healthy children who had no atopy in their medical histories and were taking no drugs (including montelukast), and who served as controls. RESULTS: The mean +/- SD pretreatment P-ET level in the 36 study children was 11.542 +/- 6.408 pg/L, and this decreased to 5.636 +/- 4.419 pg/L after 1 month's therapy with montelukast (statistically significant difference; p < 0.0001). Both of these values were significantly higher (p < 0.0001 and p < 0.031, respectively) than the mean level in the control group of 27 children (3.543 +/- 2.497 pg/L). The mean pretreatment S-ECP level was 35.78 +/- 19.58 microg/L, and this decreased to 19.54 +/- 13.86 microg/L after 1 month's therapy (p < 0.001). CONCLUSIONS: This study demonstrated a decrease in P-ET levels in children with mild asthma receiving montelukast. This indicates a reduction in the severity of the inflammatory response and, hence, provides evidence for the anti-inflammatory effect of montelukast. Monitoring both ET-1 and ECP levels at regular follow-up may be useful in assessing these two facets of activity of chronic inflammation in bronchial asthma.

Percentage of eosinophils with surface CD44 and levels of eosinophil cationic protein in the peripheral blood in children with bronchial asthma and their changes after montelukast therapy.

Bronchial asthma (BA) is chronic inflammation of the respiratory tract with a role played by a variety of cells, particularly mast cells, eosinophils (Eo), and T lymphocytes. The serum levels of Eo cationic protein (S-ECP) reflect the severity of bronchial inflammation and the level of bronchial hyperreactivity in asthma patients. One of the most important adhesion molecules is CD44. We examined S-ECP, the percentage of Eo with surface CD44 expression (EoCD44), and Eo count in the peripheral blood of newly diagnosed pediatric atopic patients with intermittent and persistent mild BA according to the Global Iniative for Asthma 2002, in a proportion of patients 3 months after initiation of montelukast therapy. Ninety-seven children with BA had their medical history taken, and S-ECP, with the percentage of EoCD44 determined by direct fluorescence from whole blood using flow cytometry with a Coulter EPICS XL cytometer, and Eo count, total serum immunoglobulin E levels (S-IgE) were determined. Therapy with montelukast (5 mg daily) was started in 23 children. Three months after the first collection, a second S-ECP level and EoCD44 count determinations were made. An inverse correlation between S-ECP and EoCD44 (-0.602; p < 0.0001) was found in the 97 children with BA. In the 23 children receiving montelukast we documented inverse correlation of fluctuation on S-ECP and EoCD44 after 3 months. These results were not significant. An inverse correlation between S-ECP and percent of EoCD44 was established in the 97 children with asthma before therapy initiation. The lower percentage of EoCD44 in peripheral blood in asthmatic children is due to Eo inflammation activity and attests to massive Eo invasion into the airways. Determination of the percentage proportion of EoCD44 is another potential indirect marker of the multiple features of Eo inflammation.

Bronchial asthma and Chlamydia pneumoniae antibodies in children aged 4-8 years in Olomouc district.

BACKGROUND: Although several studies have demonstrated an association between infection with Chlamydia pneumoniae and asthma, these were mainly limited to exacerbation of symptoms in adults with known asthma OBJECTIVE: We investigated the role of C. pneumoniae infection in 149 atopic children with chronic cough and asthma, comparing them with 241 control non-atopic subjects presenting at Olomouc hospital between 1999 and 2003 with non-specific symptoms (temperature above normal (subfebrile), abdominal pain, arthralgia, and other symptoms. METHODS: The levels of C. pneumoniae-specific antibodies were measured using Chlamydien-rELISA kits (Medac, Hamburg, Germany). RESULTS: In a group of 83 atopic children with chronic cough, IgM and IgG antibodies to C. pneumoniae were demonstrated in 20 children (24 %). Among children with bronchial asthma, positive antibody was present in 29 children (44 %; /p = 0,052/); of this number, 24 (36 %; /p = 0,06/) had IgM and IgG antibodies while 5 children (8 %) had IgA and IgG antibodies against C. pneumoniae. A group of non-atopic children with non-specific symptoms included 38 children (16 %) with antibody positivity; 27 children (11 %) with IgM and IgG antibodies and 11 children (5 %) with IgA and IgG antibodies against C. pneumoniae. CONCLUSIONS: Asthma in children was associated with elevated levels of IgM and IgG antibodies to C. pneumoniae.

Treatment of chronic cough in children with montelukast,a leukotriene receptor antagonist.

Twenty-two children (13 boys and 9 girls) with chronic cough were treated with the leukotriene receptor antagonist montelukast (Singulair tbl. 5 mg) administered once daily for four weeks. In 14 children (68%), the cough ceased during the third week of treatment. Children responding to montelukast were found to have higher blood levels of eosinophil cationic protein (S-ECP) in the pretreatment blood sample than children with no response (responders 14.88+/-2.651 microg/l versus nonresponders 6.62+/-0.948 microg/l; p<0.01). Blood S-ECP levels remained higher also in the post-treatment blood sample in responders (10.55+/-1.631 microg/l) compared to nonresponders (6.13+/-0.937 microg/l; p<0.05). The difference is statistically significant. There were also differences in absolute eosinophil blood count and IgE blood levels between the two groups in the pretreatment blood sample. Using 24-hour pH-metry, two children not responding to therapy were subsequently diagnosed to have gastroesophageal reflux. Judging from the results, one might deduct that patients with chronic cough who have increased levels of serum ECP and absolute eosinophil blood counts are likely to benefit from treatment with montelukast.