Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in São Paulo, Brazil.

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in children's nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.

[Efficacy and safety of nebulized L-epinephrine associated with dexamethasone in postintubation laringitis] / Eficácia e segurança do uso inalatório da adrenalina-L na laringite pós-intubação utilizada em associação com a dexamethasone.

OBJECTIVE: To assess the efficacy and safety of the use of nebulized L-epinephrine associated with dexamethasone in postintubation laryngitis. METHODS: We carried out a prospective, randomized, double-blind, placebo controlled study with two cohorts of patients with postintubation laryngitis graded 3 to 6 by Downes-Raphaelly score during two years. Our population was divided into two groups: A and B; both groups received intravenous dexamethasone and two doses of nebulized saline; however, only group B received L-epinephrine. The efficacy was assessed by Downes-Raphaelly score. The side effects of L-epinephrine were evaluated according to the occurrence of cardiac arrhythmia, increased blood pressure, and average heart rate of group B in comparison to group A. RESULTS: Twenty-two patients were included in group A (average score = 4.8) and 19 in group B (average score = 5.2). During treatment, 3 patients in group A presented a score of 8 and were reintubated. This group also showed higher mean clinical scores than group B during the first two hours of the protocol; these results were not statistically significant. No side effects were observed due to epinephrine. The gas blood measurements were adequate in both groups, but better in the control group. CONCLUSIONS: We did not observe increased efficacy for the treatment of postintubation laryngitis when nebulized L-epinephrine was used simultaneously with intravenous dexamethasone. Some indicators, however, did present a favorable trend when combined therapy was used and should be submitted to further evaluation.

Efficacy of IV aminophylline as a supplemental therapy in moderate broncho-obstructive crisis in infants and preschool children.

The aim of the present study was to investigate the efficacy of iv aminophylline as a supplemental therapy for wheezy infants and preschool children who still present moderate broncho-obstruction after treatment with nebulized fenoterol. A prospective randomized, double blind, placebo-controlled trial was conducted in a Paediatric Emergency Room. The major selection criteria for patients>> inclusion were age between 1 and 7 years, a wheezy episode lasting less than 2 days which failed to respond to three sequential fenoterol nebulizations, a Wood-Downes score between 3 and 6, and a history of at least two similar episodes. Exclusion criteria were radiologically-identified pulmonary condensation, recent use of corticosteroid and/or theophylline drugs, and previous diagnosis of chronic conditions. A sample of 43 cases was selected: 24 in Group A and 19 in Control Group B. All patients were submitted to nebulization with fenoterol and intravenous hydrocortisone for a maximum period of 24 h. Only Group A patients received iv aminophylline (6 mg/kg in bolus and 1.2 mg/kg per h for maintenance schedule). Treatment efficacy parameters established for the two groups were based on the Wood-Downes clinical score. Throughout the study, the average clinical scores and the discharge rate were similar for both groups. The average stay in the Emergency Room was 12.5 h for Group A and 14.6 h for Control Group B. In conclusion, the use of supplemental iv aminophylline for moderate broncho-obstructive crisis in wheezy infants and preschool children did not add therapeutically significant results to the usually prescribed combination of nebulized beta-adrenergic and intravenous corticosteroid drugs.

[Diagnosis and therapeutic management of sinusitis in children] / Conduta diagnóstica e terapêutica na sinusite da criança.

OBJECTIVE: The authors review the main aspects related to the diagnosis and management of sinusitis in children, according to the medical literature. METHODS: Literature review. RESULTS: Clinical criteria, microbiology, image diagnosis, medical and surgical management are presented, whenever sinusitis is considered. CONCLUSIONS: The standardization of the clinical approach in children's sinusitis allows optimization of the diagnosis and the appropriate subsidiary exams, as well the correct use of antimicrobials and others drugs, or surgery in selected cases.

[Viral infections in hospitalized children affected by acute lower respiratory tract disease] / Infecções virais em crianças internadas por doença aguda do trato respiratório inferior.

OBJECTIVE: To evaluate the frequency of the main respiratory viruses in hospitalized children affected by acute lower respiratory tract disease at a university hospital. METHODS: This is a prospective trial that included two cohorts of hospitalized children in the period from April to July 1996. The groups were selected according to the presence of lower respiratory tract disease on admission: Group A- with acute disease (history of less than 7 days) and B- without present or recent respiratory disease. The parameters for defining lower respiratory tract disease included physical and/or radiological pulmonary changes. Clinical and radiological criteria were established for the classification of lower respiratory tract diseases in group A. Nasopharyngeal swab was collected from all children on admission for viral detection by cellular cultures and direct immunofluorescence. RESULTS: 201 cases were selected, 126 in group A and 75 in group B. Viruses were identified in 71 children from groupA(56.4%) and only in 3 from group B (4.0%). The predominant agent in group A was respiratory syncytial virus, identified in 66 cases; adenovirus (4) and influenza (1) were detected in other patients. In group B two patients with respiratory syncytial virus and one with adenovirus were identified. The patients from group A affected by respiratory syncytial virus were younger (median age 3 months versus 13 months) and more wheezy on physical examination (78.7%) than the other patients of the group (33.3%). This virus was associated to most of the bronchiolitis cases (84%) and to half of the pneumonia cases (46.4%). CONCLUSION: The authors found a significant presence of viruses in the majority of children hospitalized with acute lower respiratory tract disease. The respiratory syncytial virus was the predominant agent identified. These results are similar to others previously reported both in developed and some developing countries. The authors emphasize that the present study evaluated only partially the possibility of simultaneous infection by other pathogens and that the present protocol was conducted during the season with the highest incidence of respiratory syncytial virus.

[Continuous nebulization with terbutaline sulfate under tent inhalation. Evaluation of the efficacy in children 2 to 5 years of age in asthmatic crises]. / Nébulisation continue avec sulfate de terbutaline sous tente d'inhalation. Evaluation de l'efficacité chez l'enfant de 2 á 5 ans en crise d'asthme.

This study investigated the efficacy of a system for continuous nebulization of terbutaline sulphate in the treatment of acute asthmatic crises in children. The equipment consisted of a condensation nebulizer attached to a 40 liter acrylic tent placed around the patient's head. A prospective, randomized and open clinical trial was conducted. Twenty eight children, 2 to 5 year-old, in acute asthmatic crises were selected. Fourteen were nebulized with terbutaline sulphate while in the control group the aerosolization was proceeded only with half diluted physiologic serum. All patients were administered aminophyline intravenously. The parameter used to evaluate the efficacy of the terbutaline sulphate nebulizing system was clinical improvement measured by the Wood-Downes Score. Two additional parameters indicating terbutaline sulphate absorption were used: reduction of potassium seric levels and positive chronotropic effect. The group treated with terbutaline sulphate showed greater clinical improvement than control group at the 12 hour protocol evaluation as well as lower seric potassium level. A positive chronotropic effect was also observed at the final protocol evaluation. The data showed, preliminarily, that (a) the system for continuous nebulization of terbutaline sulphate was effective in treatment of children's acute asthmatic crises, and (b) there was evidence attesting to the absorption of terbutaline sulphate by the children treatment with it.

[Therapeutic of septic children with purpuric presentation with two antibiotic schedules] / Terapêutica de crianças com sepse de apresentação purpúrica com dois esquemas antibióticos.

OBJECTIVE: The authors evaluate the therapeutic efficacy of two antibiotic schedules, ceftriaxone alone and the combined use of ampicillin and chloramphenicol, in the treatment of septic children with purpuric presentation.METHODS: A randomized open clinical trial was conducted including septic children with purpuric presentation treated at a pediatric intensive care unit from April 1988 to June 1992. All cases with systemic purpura standing for less than a week were included in one of two groups, except for those recently hospitalized or with previous hemorrhagic disturbs. Patients in group A received ampicillin and chloramphenicol and those in group B were given ceftriaxone. Quantitative parameters were adopted to compare the efficacy of the two antibiotic schedules: sensitivity of bacteria isolated at blood and liquor cultures, complications, therapeutic procedures, period of hospitalization, and sequelae.RESULTS: 19 cases were included in the group A and 16 in group B, both homogenous on clinical-laboratorial aspects. The parameters evaluated did not show different efficacy between the two antimicrobial schedules tested, except for the number of complications observed during hospitalization, which was higher among the children that received ampicillin and chloramphenicol. The overall mortality for the patients treated was 13.8%, excluded the undernourished. CONCLUSIONS: The authors verify similar clinical therapeutic efficacy with the combined use of ampicillin and chloramphenicol or ceftriaxone, as observed previously. It must be pointed that the number of complications detected during hospitalization were higher in the group that received the combined antibiotic schedule. Low mortality in the present study may be attributed to the early diagnosis and therapeutic measures adopted at the pediatric intensive care unit.

[Evaluation of the therapeutic efficacy of dexamethasone in meningococcal meningitis] / Avaliação da eficácia terapêutica da dexametasona na meningite meningocócica.

OBJECTIVE: To evaluate the efficacy of dexamethasone as an auxiliary therapeutic tool to the antibiotics in hospitalized children with meningococcal meningitis. METHODS: A retrospective clinical comparative study was undertaken with children from a pediatric ward affected by laboratory proved meningococcal meningitis at a university hospital. Cases of children in state of shock at admission or deceased in the first 24 hours were excluded. During the period from 1987 to 1989 33 children were treated only with antibiotics (group A), while from 1990 to 1993 other 66 children received additionally dexamethasone (12mg/m2/24h) by intravenous route during four days beginning at the admission to the hospital (group B). The two groups were evaluated at baseline through prognostic scores and analysis of their clinical and laboratorial characteristics obtained from data recorded at the admission. The parameters to evaluate dexamethasone efficacy were the comparative number of neurologic and systemic complications detected at the hospital, and the liquoric profile (leukocyte count, glucose and protein content) verified between day 9 and day 11 of hospitalization. RESULTS: The profile of the two groups (A and B) were homogeneously evaluated by the illness severity scores and their clinical and laboratorial characteristics. Nine complications were recognized in group A (27.2%) and 21 (31.8%) among those of group B, difference not significant. Likewise, there were not observed liquoric differences between the two groups related to the chimiocytologic pattern. CONCLUSIONS: No effect of dexamethasone therapy to prevent neurologic and systemic meningococcal meningitis complications was observed during hospitalization. Similarly no favorable effect in relation to the liquoric pattern verified between day 9 and day 11 of hospitalization was recognized.

[Primary psoas abscess in a child. Case report and review of the literature]. / Abscesso primário do psoas em criança: relato de caso e revisão da literatura.

Primary psoas abscess is an uncommon disease. In children, clinical manifestations is often inspecific leading to diagnostic delay. The authors relate a primary pyogenic abscess of the psoas muscle in a 7-year-old girl with secondary septic arthritis of the hip. Confirmation of diagnosis was established by computerized tomography (CT) of the abdominal and pelvic areas. A review of the literature is presented about clinical manifestations, pathogenesis, differential diagnosis, etiology, diagnostic and therapeutic management of this infrequent entity.

[Idiopathic primary pulmonary hemosiderosis: treatment with cyclophosphamide and prednisone]. / Hemossiderose pulonmar idiopática tratada com ciclofosfamida e prednisona.

The authors present the case of a child diagnosed as having idiopathic pulmonary hemosiderosis at five years of age who had a good clinical outcome at the age of ten years. Initially the patient was treated with prednisone and chloroquine with poor results. When cyclophosphamide was added to prednisone, the patient demonstrated clinical and radiological remission. To date, the patient has been followed for one year without any medication, and has had only one limited episode of hemosiderosis. The authors also suggest that the therapeutic regimen with cyclophosphamide and prednisone may be useful for some selected cases.

Parinaud syndrome caused by Bartonella henselae: case report.

The authors report a case of Parinaud syndrome (conjunctivitis with pre-auricular satellite adenitis) caused by Bartonella henselae, the etiologic agent of Cat Scratch Disease. The etiologic assessment of this case was performed by serum indirect immunofluorescence reaction and allowed for a better therapeutics and follow up, avoiding ineffective antibiotics and surgical interventions.

[Treatment of pediatric outpatients with complicated urinary tract infections]. / Tratamento ambulatorial de crianças com infecção urinária complicada.

In an open and prospective study involving outpatient children with complicated urinary tract infections (UTI), we evaluated the therapeutic efficacy of ceftriaxone administered intramuscularly, once-daily--50 to 70 mg/kg, during 8 to 10 days. Initially, the selected patients exhibited at least two of the following clinical criteria: age below 6 months, any degree of toxicity, fever, strong suspicion or proved abnormalities of their urinary tracts and lumbar pain in children older than 4 years. Significant bacteriuria was demonstrated by urine culture in 40 patients (21 boys, 19 girls), whose ages ranged from 15 days to 6 years 9 months (median 3 months). The radiological studies revealed vesicoureteral reflux in 6 patients, urethral posterior valve in 1, and neurogenic bladder in 4. The main causative agents were Escherichia coli isolated in 30 patients, Klebsiella (4) and Proteus (4). The treatment was found to be effective in 38 patients (95%). There was failure of treatment in 1 patient and a symptomatic reinfection in another one. It was concluded that children with complicated UTI could be treated alternatively by once daily ceftriaxone.

Oral palatine ulcers of a traumatic nature in infants: Bednar's aphthae.

The authors present five cases of large palatine ulcers of a traumatic nature in infants, with duration from two weeks to four months. Causal diagnosis was difficult at first until the possibility of trauma caused by non-orthodontic nipples (all cases) and dummies (4)--Bednar's aphthae--was considered. Other problems related to sucking were observed: a horizontal position for nursing (all) and very narrow nipple hole (4). The infants' mothers were advised to enlarge the orifice in the nipple and correct the position for nursing (3 cases) and, in addition, to suspend use of a dummy (1 case) and discontinue use of a bottle and dummy (1 case). All of the ulcers healed within a period from one to four weeks. Small scars remained in two of the children.

Aerobic bacteria, Chlamydia trachomatis, Pneumocystis carinii and Cytomegalovirus as agents of severe pneumonia in small infants.

The authors studied 58 infants hospitalized for pneumonia in a semi-intensive care unit. Age ranged from 1 complete to 6 incomplete months. The infants were sent from another hospital in 20 cases and from home in a further 38. Pulmonary involvement, which was alveolar in 46 cases and interstitial in 12, was bilateral in 31 children. The investigation was carried out prospectively on the etiological agents associated with respiratory infection to look for evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopy of tracheal aspirated material). The following infectious agents were diagnosed in 21 children (36.2%): Aerobic bacteria (8), Chlamydia trachomatis (5), Pneumocystis carinii (3), Cytomegalovirus (3), Cytomegalovirus and Chlamydia trachomatis (1), Aerobic bacteria and Cytomegalovirus (1). Seven cases of infection by Chlamydia trachomatis and/or Cytomegalovirus were diagnosed out of the 12 cases with pulmonary interstitial involvement.

PIP: This paper reports the results of a prospective study designed to evaluate the occurrence of potential pulmonary pathogens in a group of socioeconomically deprived infants hospitalized in a semi-intensive care unit for severe pneumonia. The study was conducted over a 2-year period and included infants ranging in age from 1 complete to 6 incomplete months. Inclusion criteria for this study were: a) history of acute respiratory disease; b) respiratory rate over 60 times/minute; and c) radiographic exam revealing alveolar or interstitial pulmonary alteration. A total of 58 infants were selected for the study, of which 33 (56.9%) were male and the 25 (43.1%) were female. Mean age was 2.3 months. Pulmonary involvement, which was alveolar in 46 (79.3%) patients and interstitial in 12 (20.7%) patients, was bilateral in 31 (53.4%) infants. The investigation of etiological agents associated with respiratory infection sought evidence of aerobic bacteria (blood cultures), Chlamydia trachomatis and Cytomegalovirus (serology), and Pneumocystis carinii (direct microscopic exam of tracheal aspirate). The following infectious agents were diagnosed in 21 (36.2%) patients: aerobic bacteria (8), C. trachomatis (5), P. carinii (3), Cytomegalovirus (3), Cytomegalovirus and C. trachomatis (1), aerobic bacteria and Cytomegalovirus (1). 7 of 12 (58.3%) cases with pulmonary interstitial involvement were infections by C. trachomatis and/or Cytomegalovirus. The authors recommend that the investigation of the role of other infectious agents for this age bracket should continue.

[Management of febrile infants younger than 2 months of age at the Emergency Care Unit: diagnosis aspects and therapeutics]. / Febre no lactente jovem atendido em Serviço de Emergência: aspectos diagnósticos e terapêuticos.

82 febrile young infants were studied, prospectively, at the Emergency Service in Hospital Universitário-University of São Paulo. All the children were kept at the Emergency ward for 24 hours. Clinical and laboratory investigations were performed and when necessary, administration of antibiotic agents were started. 18 infants exhibited potentially severe bacterial infections (21.9%). Several important disorders were recognized in 40 infants (48.8%). All infants were followed until the end of the febrile episode: 20 children as inpatients and 62 as outpatients. 38 infants received antibiotic therapy (46.3%). Evolution was satisfactory in all patients. The authors detected in young febrile infants potentially dangerous clinical conditions that need close observation, laboratorial investigation and frequently antimicrobial therapy. The observation period at the Emergency ward was important to allow these procedures and to decide about hospitalization need.