[Tuberculous meningitis: a review of 27 years]. / Meningitis tuberculosa: revisión de 27 años.

OBJECTIVES: To analyze the features and outcome of children with tuberculous meningitis (TM) in a tertiary hospital in Madrid, with special emphasis on the possible influence of HIV infection, immigration and withdrawal of the Bacille-Calmette-Guérin (BCG) vaccine in Madrid in 1987. METHODS: We reviewed the medical records of patients with TM diagnosed over a 27-year period (1977-2003). TM was diagnosed on the basis of compatible cytochemical findings in cerebrospinal fluid (CSF), plus a) isolation of Mycobacterium tuberculosis in CSF or gastric fluid; b) positive Mantoux test, or c) previous contact with active tuberculosis. RESULTS: Twenty-eight cases of TM were diagnosed. There were 24 cases (85 %) in the first 14 years versus only four cases (15 %) in the last 13 years. None of the children was co-infected with HIV. The median age was 3 years and 4 months. Only two of these had received the BCG vaccine. The source of infection was identified in 64 %. At admission, 57 % had nuchal rigidity, 46 % had neurological focality, and 54 % had an abnormal chest roentgenogram. The Mantoux purified protein derivative (PPD) test was positive in 89 % at diagnosis. Zhiel-Nielsen smear in CSF was positive in 3.5 %, and a positive culture from CSF was obtained in 32 %. Computed tomography scan was performed in 22 children and showed hydrocephalus in 90 %. All patients were treated with four drugs, with no significant adverse events. Corticoids (89 %), ventricular-peritoneal shunt (43 %) and antiepileptic drugs (39 %) were widely used as complementary treatments. Mortality was 12 %. Half of the patients had sequels, which were mostly permanent. The most frequent and severe complication was neurodevelopmental delay (21 %). Severe sequels occurred in children with more advanced stages of illness. CONCLUSIONS: The frequency of TM has decreased in the last 15 years, despite the emergence of HIV and immigration from countries where tuberculosis is endemic. These data are in agreement with the general reduction of the incidence of TM in our environment. Withdrawal of the BCG vaccine in Madrid in 1987 did not increase cases of TM in our hospital; on the contrary, these have decreased. A considerable percentage of children with advanced stages of TM show severe sequels.

Meningitis tuberculosa: revisión de 27 años / Tuberculous meningitis: a review of 27 years

Objetivos: Analizar las características de los pacientes con meningitis tuberculosa en un hospital terciario, con especial interés en el posible impacto de la supresión de la vacuna de bacilo de Calmette-Guérin (BCG) (1987), la inmigración y de la infección por el virus de la inmunodeficiencia humana (VIH). Métodos: Se revisaron las historias clínicas de los casos de meningitis tuberculosa diagnosticados a lo largo de 27 años (1977-2003). Se consideró meningitis tuberculosa cuando existía un líquido cefalorraquídeo (LCR) con una citoquímica compatible, más: a) aislamiento de Mycobacterium tuberculosis en jugo gástrico o LCR; b) prueba de tuberculina positiva, o c) contacto con tuberculosis activa. Resultados: Se diagnosticaron 28 casos de meningitis tuberculosa. Durante los primeros 14 años hubo 24 casos (85 %), y durante los últimos 13 años tan sólo 4 casos (15%). No hubo ningún niño coinfectado por el VIH. La mediana de la edad fue 3 años y 4 meses. En dos de ellos existía vacunación previa con BCG. En el 64 % de los casos se localizó el foco de contagio. Al ingreso, el 57 % presentaba signos meníngeos, el 46 % focalidad neurológica y el 54 % radiografía de tórax anormal. La prueba de tuberculina fue positiva en el 89% de los casos. La tinción de Ziehl-Neelsen en LCR fue positiva en el 3,5 %. Se cultivó el bacilo en LCR en el 32 % de los pacientes. La tomografía computarizada (TC), practicada en 22 pacientes, mostró hidrocefalia en el 91 % de los niños. Todos fueron tratados durante un año, sin efectos secundarios significativos. Como tratamientos complementarios se han utilizado corticoterapia (89 %), derivación ventriculoperitoneal (43 %) y anticomiciales (39 %). Fallecieron 3 pacientes (12 %). El 50 % de los casos tuvo secuelas, en su mayoría permanentes; la más grave y frecuente fue el retraso psicomotor (21 %), principalmente en niños con estadios avanzados de la enfermedad. Conclusiones: La meningitis tuberculosa ha disminuido durante los últimos 15 años, a pesar de la emergencia del VIH y a la inmigración desde países endémicos para tuberculosis. Estos datos se corresponden con la disminución general de la incidencia de meningitis tuberculosa en nuestro medio. La supresión de la vacuna BCG en 1987 en Madrid no ha llevado a un aumento en los casos vistos en nuestro hospital; al contrario, han disminuido. Hay un porcentaje importante de secuelas graves en niños con estadios avanzados

Objectives: To analyze the features and outcome of children with tuberculous meningitis (TM) in a tertiary hospital in Madrid, with special emphasis on the possible influence of HIV infection, immigration and withdrawal of the Bacille-Calmette- Guérin (BCG) vaccine in Madrid in 1987. Methods: We reviewed the medical records of patients with TM diagnosed over a 27-year period (1977-2003). TM was diagnosed on the basis of compatible cytochemical findings in cerebrospinal fluid (CSF), plus a) isolation of Mycobacterium tuberculosis in CSF or gastric fluid; b) positive Mantoux test, or c) previous contact with active tuberculosis. Results: Twenty-eight cases of TM were diagnosed. There were 24 cases (85 %) in the first 14 years versus only four cases (15 %) in the last 13 years. None of the children was co-infected with HIV. The median age was 3 years and 4 months. Only two of these had received the BCG vaccine. The source of infection was identified in 64 %. At admission, 57 % had nuchal rigidity, 46 % had neurological focality, and 54 % had an abnormal chest roentgenogram. The Mantoux purified protein derivative (PPD) test was positive in 89 % at diagnosis. Zhiel-Nielsen smear in CSF was positive in 3.5 %, and a positive culture from CSF was obtained in 32 %. Computed tomography scan was performed in 22 children and showed hydrocephalus in 90%. All patients were treated with four drugs, with no significant adverse events. Corticoids (89 %), ventricular-peritoneal shunt (43 %) and antiepileptic drugs (39 %) were widely used as complementary treatments. Mortality was 12 %. Half of the patients had sequels, which were mostly permanent. The most frequent and severe complication was neurodevelopmental delay (21 %). Severe sequels occurred in children with more advanced stages of illness. Conclusions: The frequency of TM has decreased in the last 15 years, despite the emergence of HIV and immigration from countries where tuberculosis is endemic. These data are in agreement with the general reduction of the incidence of TM in our environment. Withdrawal of the BCG vaccine in Madrid in 1987 did not increase cases of TM in our hospital; on the contrary, these have decreased. A considerable percentage of children with advanced stages of TM show severe sequels

Aumento de la incidencia de neumonía de posible origen bacteriano en el último trienio / Increased frequency of pneumonia of possible bacterial etiology during the last three years

Objetivo: Estudiar a los pacientes ingresados por neumonía en el último trienio, considerando sólo la neumonía definida previamente como típica o bacteriana. Métodos: Se estudiaron retrospectivamente todas las neumonías típicas adquiridas en la comunidad ingresadas durante los años 1998, 1999 y 2000. Se consideró como neumonía típica o de origen bacteriano aquella que cumplía 3 de 5 criterios: Fiebre >39 °C y de presentación brusca, dolor de costado o equivalentes (dolor abdominal o meningismo); auscultación de condensación, radiología de consolidación; leucocitosis >-12.000 mm3 con neutrofilia >-6.000 mm. Resultados: Se diagnosticaron un total de 271 neumonías, 75 en 1998, 85 en 1999 y 111 en 2000. La incidencia por 100.000 niños al año <5 años de nuestra Area Sanitaria era de 87,9, 98,6 y 126,3, respectivamente, y el porcentaje de ingresos por neumonía típica en relación con el número total de ingresos al año en la Unidad era de 5,8, 6,8 y 8 por ciento, respectivamente. Se realizó hemocultivo en 155 pacientes, que era positivo en 8 casos (5 por ciento): Streptococcus pneumoniae (n= 6), Haemophilus in fluenzae (n= 1) y Streptococcus pyogenes (n= 1): En la radiología, el 93,4 por ciento de los pacientes tenía una consolidación y el 6,6 por ciento presentaba un infiltrado. Se diagnóstico un derrame pleural en el 10 por ciento de los casos. Conclusiones: Existe un aumento de la frecuencia de niños ingresados en nuestro hospital por neumonía de características bacterianas en el último trienio. Consideramos que este aumento es debido, fundamentalmente, a neumonías causadas por neumococo (AU)

[Incidence and clinical characteristics of Kawasaki's disease]. / Incidencia y características clínicas de la enfermedad de Kawasaki.

OBJECTIVE: The aim of this study was to analyze the incidence and clinical spectrum of Kawasaki's disease in children attended in our hospital. PATIENTS AND METHODS: Retrospective review of all children with Kawasaki's disease evaluated in the Department of Infectious Diseases of Hospital La Paz (Madrid, Spain) from January 1999 to June 2002. Information included clinical manifestations, age, sex, seasonal occurrence, treatment, development of cardiovascular abnormalities, and incidence rate. RESULTS: Forty-five patients with Kawasaki's disease were analyzed during the study period. Age ranged between 4 months and 13 years. Thirty-seven children were aged 5 years old or less and 15 children were younger than 2 years. The most common symptom was fever in 98 % of the patients. Five patients developed coronary aneurysms. Of these, four were aged less than 2 years and three were treated after the first week of onset of fever. The annual incidence rate in our health area was estimated at 15.1 cases per 100,000 children aged 5 years or less. CONCLUSIONS: The annual incidence rate for Kawasaki's disease in our area was similar to that in Europe and the United States. Coronary aneurysms were more common in children aged less than 2 years and in patients who received treatment after 1 week of the onset of fever.

Incidencia y características clínicas de la enfermedad de Kawasaki / Incidence clinical characteristics of Kawasaki´s disease

Conocer la situación de la enfermedad de Kawasaki en nuestro medio. Pacientes y métodos: Revisión retrospectiva de pacientes diagnosticados de enfermedad de Kawasaki desde enero de 1999 hasta junio del 2002 en la Unidad de Enfermedades Infecciosas del Hospital La Paz (Madrid, España). Se analizó la sintomatología, edad, sexo, estación del año, tratamiento realizado, complicaciones cardiovasculares e incidencia de la enfermedad. Resultados: Se revisaron retrospectivamente 45 enfermos diagnosticados de enfermedad de Kawasaki desde enero de 1999 a junio del 2002. El rango de edad estuvo comprendido entre 4 meses y 13 años. Tenían igual o menos de 5 años 37 niños y 15, menos de 2 años. El síntoma más frecuente fue la fiebre (98 por ciento). Cinco enfermos desarrollaron lesión coronaria. De ellos, cuatro tenían menos de 2 años y tres habían sido tratados después de la primera semana del inicio de la fiebre. Según la población infantil de nuestra área sanitaria, la incidencia acumulada de la enfermedad en menores de 5 años fue de 15,1 casos/100.000 niños <= 5 años/año. Conclusiones: La enfermedad de Kawasaki presenta en nuestro medio una incidencia semejante a la comunicada en Europa y Estados Unidos. Las complicaciones coronarias son frecuentes en menores de 2 años o en niños tratados después de una semana de fiebre (AU)

[Acute mastoiditis: an increasing entity]. / Mastoiditis aguda: una entidad emergente.

BACKGROUND: Mastoiditis used to be the most common complication of acute otitis media. However, once antibiotics became widely available, it was rarely reported. Recently, this complication has become more frequent. OBJECTIVES: To determine the frequency of acute mastoiditis in our center in the last few years and to analyze the clinical and bacteriologic characteristics of the patients with this diagnosis. METHODS: Retrospective analysis of all patients admitted to our hospital with a diagnosis of acute mastoiditis from 1994-2001. RESULTS: One hundred patients were diagnosed with acute mastoiditis during the study period. The mean age was 2 years and 10 months (range: 2 months-13 years) and the median age was 15 months. The mean number of episodes was 12.5 cases of acute mastoiditis per year, but 52 % of the cases occurred from 1999-2001. Culture of middle ear effusions was performed in 47 patients, revealing Streptococcus pneumoniae in 17, Haemophilus influenzae in 3, and other pathogens in 10 children. Cultures were sterile in 17 patients. Three children did not respond to medical therapy and required mastoidectomy. CONCLUSIONS: In the last few years, the incidence of acute mastoiditis in our population has increased considerably. This complication is more common in children aged less than 2 years.

Mastoiditis aguda: una entidad emergente / Acute mastoiditis: an increasing entity

Antecedentes: La mastoiditis es la complicación más frecuente de la otitis media aguda. Sin embargo, con la introducción de los antibióticos pasó a ser una complicación excepcional. Recientemente se describe un incremento de su frecuencia. Objetivos: Estudiar la frecuencia de mastoiditis aguda diagnosticada en nuestro hospital en los últimos años y analizar los cambios clínicos y bacteriológicos. Métodos: Estudio retrospectivo de todos los casos de mastoiditis aguda diagnosticados durante el período 1994 a 2001. Resultados: Se analizan un total de 100 casos de mastoiditis aguda. La edad media de los pacientes fue de 2 años y 10 meses, con unos límites entre los 2 meses y los 13 años y la edad mediana de 15 meses. La media de mastoiditis aguda por año fue de 12,5 casos. Sin embargo, el 52% de los casos se presentaron en los últimos 3 años. En 47 casos se obtuvo cultivo del oído medio, aislándose Streptococcus pneumoniae en 17 casos, Haemophilus influenzae en 3 casos, otros patógenos en 10 y en 17 casos el cultivo fue estéril. Se realizó mastoidectomía por mala respuesta al tratamiento clínico en 3 niños. Conclusiones: Los casos de mastoiditis aguda diagnosticados en nuestro centro han aumentado de forma significativa en los últimos años. Esta patología se presenta con mayor frecuencia en niños menores de 2 años (AU)

Etiología de la gastroenteritis aguda en niños hospitalizados menores de 5 años / Etiology of acute gastroenteritis in children under 5 years of age requiring hospitalization

Objetivos: Estudiar la etiología de la gastroenteritis aguda en niños menores de 5 años que precisan hospitalización. Conocer la frecuencia y las características clínicas de la gastroenteritis por rotavirus de origen comunitario y de adquisición nosocomial en nuestro medio. Material y métodos: Se revisaron de forma retrospectiva todos los casos de gastroenteritis aguda en niños menores de 5 años ingresados en el Servicio de Enfermedades Infecciosas durante un periodo de tres años (1995-1997). Las muestras de heces se procesaron en el Servicio de Microbiología para cultivo bacteriológico, búsqueda de parásitos intestinales y detección de antígenos virales. Se incluyeron los niños con gastroenteritis comunitaria ingresados desde el Servicio de Urgencias y los niños con gastroenteritis nosocomial por rotavirus (adquirida después de tres días de estancia hospitalaria o en los diez días posteriores al alta). Resultados: Durante el periodo de estudio, fueron hospitalizados 169 niños menores de 5 años con gastroenteritis aguda, lo que representó el 6,7 por ciento del total de ingresos en nuestra unidad. En 105 pacientes (62 por ciento) se identificó algún enteropatógeno en el coprocultivo. Rotavirus fue el principal patógeno encontrado (44 por ciento), seguido por Salmonella sp. (38 por ciento) y Campylobacter sp. (9,5 por ciento). De forma adicional, 42 niños fueron diagnosticados de gastroenteritis nosocomial por rotavirus, lo que supone que el 47 por ciento de las infecciones por este virus en nuestra unidad fueron de origen nosocomial. La gastroenteritis nosocomial afectó a niños más pequeños (edad media de 6,5 meses frente a 12,7 meses en la adquirida en la comunidad, [p<0,05]), y la clínica fue menos severa, con un porcentaje significativamente menor de vómitos y deshidratación. El tiempo medio de estancia fue superior en los niños con gastroenteritis nosocomial (12 frente a 8 días, [p <0,051). Conclusiones: Rotavirus es la principal causa de hospitalización en niños menores de 5 años con gastroenteritis aguda y, asi mismo, representa el principal enteropatógeno en la gastroenteritis nosocomial en nuestro medio. La gastroenteritis nosocomial por este virus afecta a niños mas pequeños y prolonga de forma significativa la estancia hospitalaria, aunque la clínica es más leve que la de la adquirida en la comunidad (AU)

[Whooping cough: a retrospective study of the cases diagnosed over a period of 15 years]. / Tos ferina: estudio retrospectivo de los casos diagnosticados en un período de 15 años.

OBJECTIVE: Our objective was to study the whooping cough cases diagnosed in a 15-year period in our hospital, referring to its clinical features, epidemiology and analytical findings. PATIENTS AND METHODS: A retrospective study based on 144 cases with a clinical diagnosis of whooping cough, from 1981 to 1995, was carried out. Special attention was paid to those cases with cultures positive for B. pertussis. RESULTS: Nasopharyngeal specimens for culture were taken in 119 cases. This was not carried-out in those with previous antibiotic therapy. Cultures were positive for B. pertussis in 46 patients (38.7%). The age varied between 20 days and 30 months. Twenty-one were female. The initial symptoms were: paroxysmal cough in 44 (95.7%), cyanosis in 34 (73.9%), inspiratory whoop in 27 (58.7%), respiratory distress in 12 (26.1%) and post-tussive vomiting in 10 (21.7%). Thirty-nine children (84.8%) of this group had not received any pertussis vaccine, the rest had received just the first dose. It had been contacted by persons having cough in 19 patients (41.3%). Leukocytosis (mean: 19,818/mm3), lymphocytosis (mean: 13,047/mm3) and high platelet count (mean 459,522/mm3) were common findings. CONCLUSIONS: Cultures were positive in 38.7% of the patients. There are similar findings by other authors. In this group, most of the children were unvaccinated, and less than 3 months of age. Typical symptoms of pertussis were observed in the majority of patients. In one forth of them respiratory distress was found, probably related to their young age. Vaccinated adults emerge as a contact group that should be studied.

[Bacterial meningitis in pediatrics. Study of 166 cases]. / Meningitis bacteriana en la edad pediátrica. Estudio de 166 casos.

OBJECTIVE: The purpose of this study was to evaluate the clinical and epidemiological characteristics of meningitis in our environment. PATIENTS AND METHODS: A retrospective study of 166 cases of meningitis diagnosed in our hospital during a 10 year period (1986-1995) was performed. The patients were between 1 month and 14 years of age. RESULTS: Sixty-six percent of the patients were male and 34% female. Eleven cases were younger than 2 months (6.6%), 122 cases (73.5%) were between 3 months and 5 years of age and 33 cases (19.9%) were older than 5 years. The most frequent symptoms and signs were fever (96%), vomiting (60%), impairment of consciousness (24%) and meningeal signs (49%). CSF cultures were positive in 52% and blood cultures in 32%. The pathogen isolated was N. meningitidis in 53 cases (32%), H. influenzae in 38 (23%), S. pneumoniae in 9 patients (5%) and others in 3 children (2%). Meningitis due to H. influenzae increased each year. No microorganism was isolated in blood and CSF in 63 cases (38%). Meningitis in children between 3 months and 5 years of age was due to N. meningitidis in 40 children (33%) and H. influenzae in 36 (29%). The mortality rate was 3%. The most frequent complications were sepsis (36%) and seizures (16%). CONCLUSIONS: The most frequently isolated agent in our study was N. meningitis. Meningitis due to H. influenzae is increasing such that H. influenzae and N. meningitis currently show similar frequency in children between 3 months and 5 years of age.

[Encephalitis due to measles]. / Encefalitis por sarampión.

OBJECTIVE: We present seven cases of acute encephalitis following measles, which were diagnosed during the epidemic that occurred in Spain in 1986. PATIENTS AND METHODS: We studied seven patients diagnosed of encephalitis due to measles. The diagnosis of measles was a made by the presence of a characteristic morbiliform rash and the detection of specific IgM antibodies. The diagnosis of encephalitis was based on the symptoms and the routine examinations of blood, CSF, EEG, CT, ophthalmic exploration and the study of the audiovisual evoked potentials. RESULTS: The patients were between 5 and 9 years of age. None of them had been previously vaccinated for measles. The symptoms of encephalitis occurred 1 to 12 days after the appearance of the rash and the most frequent symptoms were drowsiness and vomiting. All of the patients had EEG abnormalities that returned to normal 1 to 18 months after the diagnosis. One patient presented CT abnormalities. CSF examination revealed an increase of the cell count in one case. The ophthalmic exploration was normal except in one of the patients which had optic neuritis. There were no abnormalities in the audiovisual evoked potentials. All of the cases showed good evolution. Five years later, all of the patients have had a normal development. CONCLUSIONS: The correct vaccination of measles can eradicate this disease.

[Kawasaki disease; complications and clinical course. Apropos of 38 cases]. / Enfermedad de Kawasaki; complicaciones y evolución. A propósito de 38 casos.

Between January 1978 and December 1991, 38 patients who fulfilled the CDC (Center for Disease Control) criteria for Kawasaki syndrome were admitted to our hospital. We reviewed the clinical data, laboratory tests, ECG and serial echocardiographic studies in order to establish the characteristics of the disease in our environment. There were 23 males and 15 females. The age at presentation ranged from 4 months to 10 years (mean 3.5 years). Extracardiac complications were as follows: arthritis in 12 patients, vesicular hydrops in 2, urinary tract infection in 1 and lymphocytic meningitis in 1. Cardiac involvement was frequent, with 35% of the patients being diagnosed with coronary pathologies (dilatation of coronary arteries in 9 and aneurysm formations in 4). The most usual location of these anomalies was in the left main coronary artery. By the end to the follow-up period, 71% of the lesions had disappeared. The time necessary for this regression was related to the size of the abnormalities. The high incidence of cardiac involvement make it necessary to follow these patients for a period of time in order to prevent or to treat the later occurring sequelae.

[Pulmonary tuberculosis in infants: apropos of 149 cases]. / Tuberculosis pulmonar en la infancia: a propósito de 149 casos.

One hundred and forty-nine cases of childhood pulmonary tuberculosis were analysed being a 77.6% of the 192 cases of tuberculosis diagnosed at the Pediatric Infectious Diseases Department of "La Paz" Hospital, in a ten year period. The children were aged 3 months to 14 years; 65% of them were less than 6 years of age. The source case was found in 67.1% of the children. The primary means of diagnosis was contact screening (38.1%), followed by a 27.5% that presented with non-specific symptoms, while 18.1% of the cases presented with respiratory symptoms. Gastric aspirates yield the organism in 25.8% of cases. Radiologically the following was found: 38.9% mixed patterns, 32.2% nodal patterns, 23.4% parenchymal patterns, 1.34 miliary tuberculosis, 1.34% caverns and 2.68% pleural effusions. Right lung location was more frequent in parenchymatous forms (68%), as well as in nodal forms (61.5%). The duration of the course of therapy changed along this ten years period: from twelve months initially to ten months posteriorly, subsequently becoming a six month course of treatment. All cases experienced full recovery.

[Short term treatment of infantile pulmonary tuberculosis]. / Tratamiento de corta duración de la tuberculosis pulmonar infantil.

Due to the scarcity of published articles on short-course chemotherapeutic regimens for pediatric pulmonary tuberculosis, the following study has been carried out: Twenty-five children diagnosed of pulmonary tuberculosis were administered a short course therapeutic regimen consisting of three tuberculostatics for the first two month (isoniazid, rifampicin and pyrazinamide) and only two (isoniazid and rifampicin) for the following four months. The results were compared with those obtained from a control group of twenty-five children receiving the "classical" therapy: two drugs (isoniazid and rifampicin) for a nine month period. The statistical analysis did not demonstrate any significant difference related to evolution, duration and complications of the disease, between both groups. Therefore, this short course therapeutic regimen could be accepted for pediatric pulmonary tuberculosis.