Neumonías recurrentes y persistentes. Manejo diagnóstico por el pediatra / Recurrent pneumonia and persistent pneumonia: diagnostic evaluation by the pediatrician

Se define como neumonía recurrente a aquella que presenta dos o más episodios diagnosticados en un año o un total de tres o más episodios. En cualquier paciente que cumpla estos criterios, está indicado iniciar un estudio etiológico. La elección de las pruebas complementarias se convierte en un reto para el clínico, dado que el diagnóstico diferencial es muy amplio. Se presenta un protocolo que pretende establecer una guía racional del manejo diagnóstico del paciente afectado por neumonías de repetición

Recurrent pneumonia is defined as two or more episodes in the same year or a lifelong total of three or more episodes. An investigation of the etiology should be carried out in any child that meets these criteria. The approach to this study represents a challenge for the physician given the wide differential diagnosis. We describe a protocol for the purpose of establishing guidelines for a rational diagnostic approach in the patient who presents recurrent pneumonia

Bronquiolitis: factores predictivos de la duración del ingreso hospitalario / Predictive factors of duration of hospital admission for bronchiolitis

Objetivo. Determinar qué parámetros son más útiles en el momento del ingreso de niños con bronquiolitis para prever la duración de la estancia hospitalaria. Metodología. Estudio retrospectivo por revisión de historias clínicas. Se incluyen los pacientes ingresados en nuestro centro por bronquiolitis durante el año 1999. Los enfermos se dividen en dos grupos según la duración de la estancia hospitalaria: el grupo I con una estancia de 3 días o menos y el II, con más de 3 días. Se analizan datos clínicos, analíticos y radiológicos según el protocolo realizado para este estudio. Resultados. Se incluyen un total de 271 pacientes, 73 pertenecen al primer grupo y 198 al segundo. Se objetivan diferencias estadísticamente significativas en la duración de la estancia hospitalaria con relación al antecedente de prematuridad, la edad del paciente, la existencia de VRS positivo, la presencia de fiebre, la puntuación en la escala de gravedad para bronquiolitis HSJD, el hallazgo de alteraciones radiológicas, la realización de analítica y la necesidad de tratamiento con antibióticos, oxígeno y alimentación por sonda nasogástrica. No hay diferencias en cuanto al sexo, los antecedentes de cardiopatía o displasia broncopulmonar (DBP), los resultados analíticos y la necesidad de tratamiento con broncodilatadores. La presencia de tres de los siguientes factores de riesgo: prematuridad, VRS positivo, fiebre, radiografía de tórax alterada, edad 6, tiene una sensibilidad del 63.5% y una especificidad del 79.5% como predictor de la duración superior a 72 horas de un ingreso por bronquiolitis. Si se tienen en cuenta sólo dos de los factores, aumenta la sensibilidad hasta el 89.8% en detrimento de la especificidad, que baja al 46.6%. Conclusión. Analizar conjuntamente determinados factores de riesgo en el momento del ingreso de una bronquiolitis mejora las previsiones en cuanto a la duración de la estancia en el hospital y facilita una distribución más adecuada de los recursos disponibles

Objectives. To determine the clinical factors that may help anticipate the length of hospital stay in children with bronchiolitis. Methods. Retrospective study based on the analysis of medical records of all children admitted to St Joan de Deu Hospital (SJDH) with the diagnosis of bronchiolitis in 1999. Patients were divided into two groups according to the duration of the admission. Group I: children who were hospitalized for >= 3 days. Group II: children who were hospitalised for > 3 days. Clinical, laboratory, and radiological data were reviewed. Results. 271 cases (Group I, 73; Group II, 198) were reviewed. We identified a significant relationship between the length of stay and the following parameters: prematurity, age, respiratory syncitial virus (RSV) infection, fever, high score in the SJDH bronchiolitis scale, abnormal imaging, need for laboratory evaluation, administration of antibiotics, need for oxygen supplementation, and need for nasogastric tube feeding. No relationship with duration of admission was found for gender, presence of congenital heart disease, bronchopulmonary dysplasia (BPD), results of laboratory evaluation, and need for bronchodilators. These results indicate a sensitivity of 63.5% and a specificity of 79.5% as predictor of admission > 72 hours if the patient has 3 of the following risk factors: prematurity, RSV infection, fever, radiological abnormalities, age < 2 months, and more than 6 points in the SJDH bronchiolitis score at the time of admission. The presence of two risk factors increases sensitivity to 89.8%, but the specificity decreases to 46.6%. Conclusion. The analysis of risk factors at the time of admission of patients with bronchiolitis may help in anticipating the duration of stay and facilitates the allocation of resources

[Headache in a short-stay unit. A retrospective study of 140 cases]. / Cefalea en una unidad de estancia corta. Estudio retrospectivo de 140 casos.

OBJECTIVE: Our objective was to study those patients that warranted admission to our Short-Stay Unit (Observation Unit) with an incoming diagnosis of headache so as to determine the characteristics of the headache, analyze complementary explorations and their use and to establish the causes of the problem. PATIENTS AND METHODS: A retrospective review of the clinical history of patients admitted for headache between 1992 and 1997 was done, recording specific data according to pre-set objectives. RESULTS: One hundred forty patients were admitted with headache (2% of total admittance to the Unit. Sixty-one percent were males. Seventy cases were between 11 and 15 years old. The most frequent accompanying symptoms were vomiting (61%), fever (31%) and various concurrent infections (21%). Seventy-two cases (51%) presented an evolution of less than 24 hours before admittance. Frontal headache was the most common localization, 30.6% of the patients were awaken by the pain and 32% calmed with analgesics. CAT scan/70%) and skull X-ray (59%) were the most used complementary explorations. Ten CAT scans and 3 X-rays showed anomalies. Evolution was favorable in most cases. The most frequent diagnoses were headache associated with infections (31%), tension headaches (29%) and migraine (21%). Fourteen percent were non-specific headaches. A central nervous system tumor was diagnosed in 6 patients, where 5 showed papilledema on initial exploration. CONCLUSIONS: Headache, especially in adolescents, is a common cause of consultations to the emergency room. When not accompanied by other symptoms it is not usually precluding a severe disease. In an emergency room exploration, a complete neurological exam must be undergone, including retinal exam, leaving further complementary exams for those cases where the patient history suggests an organic alteration.

[The middle lobe syndrome in pediatrics. A study of 27 cases]. / Síndrome del lóbulo medio en pediatría: estudio de 27 casos.

OBJECTIVE: The purpose of this study was to analyze the features, treatment and evolution of middle lobe syndrome (MLS) or atelectasis syndrome in children. PATIENTS AND METHODS: Between 1992 and 1996, all cases of MLS seen in our center by our staff were followed by using a prospective study protocol. RESULTS: Twenty-seven patients were studied. The average age at the onset of MLS was 3 years 1 month +/- 2 years 4 months. Recurrent pneumonia was seen in 66.7% and 44.4% had asthma and/or elevated IgE. Acute symptoms at the onset were seen in 74% of the cases, with persistent cough being the most common symptom. Complementary procedures (chest X-rays, computed tomography scans, bronchoscopy, V/P scintigraphy) demonstrated 16 cases of pneumonia, 13 of atelectasis, 7 of bronchiectasia and 4 cases with other abnormalities. Infectious etiology was the most predominant (66.7%) Bronchoscopy was performed in 8 cases and 5 of them improved immediately. Pulmonary scintigraphy was normal in those patients with radiographic residual images. All patients were initially medically treated. Three were lobectomized. Twenty-three patients healed. The younger the patient at the onset of MLS the better the cure rate. CONCLUSIONS: Infectious causes were dominant in our series. Early and aggressive medical treatment may cure the majority of cases. Bronchoscopy is helpful in the diagnosis and as a therapeutic procedure. Scintigraphy could be helpful as a resolution criterion when there are residual radiographic images.

[Acute ethmoiditis. A review of 38 cases]. / Etmoiditis aguda. Revisión de 38 casos.

OBJECTIVE: The purpose of this study was to assess the usefulness of computerized tomography (CT) scan in the diagnosis and management of the complications of acute ethmoiditis in children. MATERIALS AND METHODS: A retrospective revision of the records of pediatric patients admitted to Sant Joan de Déu Hospital from January 1985 to June 1994 was performed. RESULTS: Thirty-eight children (22 males and 16 females) between the ages of 18 months and 15 years (mean age 6.5 years) were studied. All of the patients had eyelid afflictions; 5 (13.2%) with eyelid edema and 33 (86.8%) with periorbital cellulitis. All of them were unilateral without side predominance. The signs and symptoms included fever (37) and orbital pain and headache (24), with 28 patients presenting other forms of sinusitis. CT scan was applied in 24 children (63%). Thirteen of these patients demonstrated complications of the orbit, 6 with orbital cellulitis, 4 subperiosteal abscess and 3 orbital abscesses. Surgery was performed in 3 cases. CONCLUSIONS: We conclude that the CT scan is a radiological procedure that must be applied when there are signs or symptoms compatible with orbital complications. Patients should also be scanned if their exam is worse or unchanged after 24-48 hours of antibiotic therapy. Early diagnosis and antibiotic treatment can prevent complications subsidiary of surgery.

[Acute osteomyelitis in childhood. Review of 66 cases]. / Osteomielitis aguda en la infancia. Revisión de 66 casos.

66 cases of acute osteomyelitis have been reviewed. The results obtained have been compared with those shown in the literature. There was a large predominance of males. Hematogenous inoculation was the most frequent. Clinical manifestations have been typical in children and polymorphic in infants and neonates. Leukocytosis with left deviation and elevated ESR, were frequent gammagraphic bone scan was positive in 88% of the cases so explored. The etiologic agents were isolated in 71% of the cases from blood cultures and needle aspiration from subperiosteal space and/or joint fluid cultures. S. aureus was found in 57.4% of all cases and in 86.4% of older children. The sequelae have been more frequent in neonates and infants.