Seudoacondroplasia: descripción de un caso de novo y otro familiar / Pseudoachondroplasia: Descriptions of a de novo and familial case

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Use of procalcitonin in the diagnosis of tuberculosis in infants and preschool children.

Normal procalcitonin (PCT) levels have been reported in adult pulmonary tuberculosis (TB) but have not been previously investigated in children. We aimed to assess PCT levels at diagnosis of TB in young children in a low-burden setting. In a cross-sectional observational study in a referral pediatric center in Barcelona (Spain), we assessed the value of PCT and other inflammatory markers (leucocyte counts, C-reactive protein, and erythrocyte sedimentation rate) in the diagnosis of TB in pre-school children (< 6 years at diagnosis, n = 45), as compared with two control groups (pneumococcal pneumonia, n = 25; and healthy controls, n = 49). Normal PCT levels were observed at diagnosis of TB in most cases, while C-reactive protein values and leucocyte counts were slightly elevated when compared to healthy controls. All three inflammatory biomarkers were significantly higher in children with pneumococcal pneumonia. CONCLUSIONS: In our study, PCT was not a useful diagnostic test for TB in young children. In a low-burden TB setting, PCT may be of some value in distinguishing pulmonary TB from pneumococcal pneumonia. What is Known: • Diagnosis of pediatric tuberculosis on clinical evidence is difficult, particularly in infants and small children. • Studies in adults with tuberculosis have mostly reported normal procalcitonin levels at diagnosis. What is New: • In pre-scholars with tuberculosis, erythrocyte sedimentation rate and white blood cell counts were higher than in healthy controls, but procalcitonin was not. • Procalcitonin may be useful in the differential diagnosis of intrathoracic tuberculosis and pneumococcal pneumonia.

Osteomielitis aguda per Staphylococcus aureus sensible a la meticil·lina productor de leucocidina de Panton-Valentine associada a trombosi venosa i èmbols sèptics pulmonars / Osteomielitis aguda por Staphylococcus Aureus meticilin-sensible productor de leucocidina de Panton-Valentine asociada a trombosis venosa y émbolos sépticos pulmonares / Acute osteomyelitus due to Panton-Valentine leukocidine-producing methicilin-susceptible Staphylococcus Aureus with deep vein thrombosis and pulmonary septic emboli in a child

Introducció: la leucocidina de Panton-Valentine (LPV) és un factor de virulència identificat en infeccions per Staphyloccus aureus (SA), més freqüent en resistents a meticil•lina (MRSA), nosocomials i adults. Es presenta un cas d'osteomielitis aguda (OA) per SA sensible a la meticil•lina (MSSA) productor de LPV adquirit en la comunitat. Cas clínic: nen de 7 anys remès a urgències per febre i dolor de l'extremitat inferior esquerra amb eritema, edema i actitud antiàlgica. Presentava leucocitosi (28.100/mm3), neutrofília (78%) i elevació de la proteïna C reactiva (199 mg/L) i de la procalcitonina (1,86 ng/mL). La ressonància magnètica feta mostrà OA greu de tíbia amb cel•lulitis, miositis i abscés de 18 cm. Va ser intervingut quirúrgicament i s'aillà MSSA productor de LPV a hemocultiu i ma-terial purulent. Es confirmà trombosi venosa profunda po-plítia amb estudi de trombofília i immunitari normals. Presentava condensació pulmonar basal esquerra amb vessament pleural (6 mm) i ecocardiografia normal. Va rebre antibioteràpia endovenosa sis setmanes (més dues més oral) amb bona evolució en el seguiment posterior. Comentaris: els primers casos d'OA per MSSA productor de LPV en edat pediàtrica al nostre país es van publicar l'any 2011. S'alerta de la possibilitat d'emergència d'aquest gèrmen com a productor d'OA en infants. Està associat a malaltia més greu, resposta sistèmica més extensa i risc de trombosi. Requereix antibioteràpia més perllongada, més necessitat de cirurgia i més risc de complicacions. La tríada OA, trombosi venosa profunda i èmbols sèptics pulmonars és característica i cal un alt índex de sospita per fer un abordatge i un tractament precoços

Introducción. La leucocidina de Panton-Valentine (LPV) es un factor de virulencia identificado en infecciones por Staphyloccus aureus (SA), más frecuente en resistentes a meticilina (MRSA), nosocomiales y adultos. Se presenta un caso de osteomielitis aguda (OA) por SA meticilin-sensible (MSSA) productor de LPV adquirido en la comunidad. Caso clínico. Niño de 7 años remitido a urgencias por fiebre y dolor de la extremidad inferior izquierda con eritema, edema y actitud antiálgica en flexión y rotación. Presentaba leucocitosis (28.100/ mm3), neutrofilia (78%) y elevación de proteína C reactiva (199 mg/L) y procalcitonina (1,86 ng/mL). La resonancia magnética mostró OA grave de tibia con celulitis, miositis y absceso de 18 cm. Se intervino quirúrgicamente y se aisló MSSA productor de LPV en hemocultivo y material purulento. Se confirmó trombosis venosa profunda poplítea con estudio de trombofilia e immunitario normales. Presentaba condensación pulmonar basal izquierda con derrame pleural (6 mm) y ecocardiografía normal. Recibió antibioterapia endovenosa seis semanas (más dos oral) con buena evolución en el seguimiento posterior. Comentarios. Los primeros casos de OA por MSSA productor de LPV en edad pediátrica en nuestro país se publicaron en el año 2011. Se alerta de la posibilidad de emergencia de este germen como productor de OA en niños. Está asociado a enfermedad más grave, respuesta sistémica más extensa y riesgo de trombosis. Requiere antibioterapia más prolongada, más necesidad de cirugía y mayor riesgo de complicaciones. La tríada OA, trombosis venosa profunda y émbolos sépticos pulmonares es característica y se precisa de un alto índice de sospecha para realizar abordaje y tratamiento precoces (AU)

Introduction. The Panton-Valentine leukocidin (PVL) is a virulence factor identified in Staphylococcus aureus (SA) infections, more commonly in methicillin-resistant (MRSA), nosocomial infections, and adults. We report a case of community acquired acute osteomyelitis (AO) by PVL-producing methicillin-susceptible SA (MSSA). Case report. A 7-year-old boy was referred to the emergency department because of fever and pain in the left lower extremity, with associated erythema and edema. Laboratory evaluation showed leukocytosis (28,100/mm3), neutrophilia (78%), and elevated C-reactive protein (199 mg/L) and procalcitonin (1.86 ng/mL). The magnetic resonance imaging showed severe AO of the tibia with cellulitis, myositis and bone abscess. He underwent surgery and PVL-producing MSSA was isolated from the blood and bone cultures. A popliteal deep vein thrombosis (DVT) was documented, and thrombophilia and immunology work-up were unremarkable. The patient was noted to have left basal pulmonary consolidation with pleural effusion and normal echocardiography. He received intravenous antibiotic therapy for six weeks, followed by two weeks of oral therapy, with a good clinical outcome. Discussion. The first cases of AO by PVL-producing MSSA in children in our country were published in 2011; this prompted concerns about the possible emergence of this new pathogen in AO. This agent is associated with more severe disease, a more extensive systemic involvement, and higher rate of complications, including DVT. It requires prolonged antibiotic therapy and more need for surgery. The occurrence of the triad AO, DVT, and pulmonary septic emboli should cause a high index of suspicion and aid in early diagnosis and treatment (AU)

Association of procalcitonin with acute pyelonephritis and renal scars in pediatric UTI.

BACKGROUND AND OBJECTIVE: Urinary tract infections (UTIs) are common childhood bacterial infections that may involve renal parenchymal infection (acute pyelonephritis [APN]) followed by late scarring. Prompt, high-quality diagnosis of APN and later identification of children with scarring are important for preventing future complications. Examination via dimercaptosuccinic acid scanning is the current clinical gold standard but is not routinely performed. A more accessible assay could therefore prove useful. Our goal was to study procalcitonin as a predictor for both APN and scarring in children with UTI. METHODS: A systematic review and meta-analysis of individual patient data were performed; all data were gathered from children with UTIs who had undergone both procalcitonin measurement and dimercaptosuccinic acid scanning. RESULTS: A total of 1011 patients (APN in 60.6%, late scarring in 25.7%) were included from 18 studies. Procalcitonin as a continuous, class, and binary variable was associated with APN and scarring (P < .001) and demonstrated a significantly higher (P < .05) area under the receiver operating characteristic curve than either C-reactive protein or white blood cell count for both pathologies. Procalcitonin ≥0.5 ng/mL yielded an adjusted odds ratio of 7.9 (95% confidence interval [CI]: 5.8-10.9) with 71% sensitivity (95% CI: 67-74) and 72% specificity (95% CI: 67-76) for APN. Procalcitonin ≥0.5 ng/mL was significantly associated with late scarring (adjusted odds ratio: 3.4 [95% CI: 2.1-5.7]) with 79% sensitivity (95% CI: 71-85) and 50% specificity (95% CI: 45-54). CONCLUSIONS: Procalcitonin was a more robust predictor compared with C-reactive protein or white blood cell count for selectively identifying children who had APN during the early stages of UTI, as well as those with late scarring.

Procalcitonin is a predictor for high-grade vesicoureteral reflux in children: meta-analysis of individual patient data.

OBJECTIVE: To assess the predictive value of procalcitonin, a serum inflammatory marker, in the identification of children with first urinary tract infection (UTI) who might have high-grade (≥3) vesicoureteral reflux (VUR). STUDY DESIGN: We conducted a meta-analysis of individual data, including all series of children aged 1 month to 4 years with a first UTI, a procalcitonin (PCT) level measurement, cystograms, and an early dimercaptosuccinic acid scan. RESULTS: Of the 152 relevant identified articles, 12 studies representing 526 patients (10% with VUR ≥3) were included. PCT level was associated with VUR ≥3 as a continuous (P = .001), and as a binary variable, with a 0.5 ng/mL preferred threshold (adjusted OR, 2.5; 95% CI, 1.1 to 5.4). The sensitivity of PCT ≥0.5 ng/mL was 83% (95% CI, 71 to 91) with 43% specificity rate (95% CI, 38 to 47). In the subgroup of children with a positive results on dimercaptosuccinic acid scan, PCT ≥0.5 ng/mL was also associated with high-grade VUR (adjusted OR, 4.8; 95% CI, 1.3 to 17.6). CONCLUSIONS: We confirmed that PCT is a sensitive and validated predictor strongly associated with VUR ≥3, regardless of the presence of early renal parenchymal involvement in children with a first UTI.

Prediction of high-grade vesicoureteral reflux after pediatric urinary tract infection: external validation study of procalcitonin-based decision rule.

BACKGROUND: Predicting vesico-ureteral reflux (VUR) ≥3 at the time of the first urinary tract infection (UTI) would make it possible to restrict cystography to high-risk children. We previously derived the following clinical decision rule for that purpose: cystography should be performed in cases with ureteral dilation and a serum procalcitonin level ≥0.17 ng/mL, or without ureteral dilatation when the serum procalcitonin level ≥0.63 ng/mL. The rule yielded a 86% sensitivity with a 46% specificity. We aimed to test its reproducibility. STUDY DESIGN: A secondary analysis of prospective series of children with a first UTI. The rule was applied, and predictive ability was calculated. RESULTS: The study included 413 patients (157 boys, VUR ≥3 in 11%) from eight centers in five countries. The rule offered a 46% specificity (95% CI, 41-52), not different from the one in the derivation study. However, the sensitivity significantly decreased to 64% (95%CI, 50-76), leading to a difference of 20% (95%CI, 17-36). In all, 16 (34%) patients among the 47 with VUR ≥3 were misdiagnosed by the rule. This lack of reproducibility might result primarily from a difference between derivation and validation populations regarding inflammatory parameters (CRP, PCT); the validation set samples may have been collected earlier than for the derivation one. CONCLUSIONS: The rule built to predict VUR ≥3 had a stable specificity (ie. 46%), but a decreased sensitivity (ie. 64%) because of the time variability of PCT measurement. Some refinement may be warranted.

Noves i velles infeccions en nadons / No disponible

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Implicación de la infección por enterovirus en la hospitalización pediátrica de un hospital general / Implication of enterovirus infection on paediatric hospitalisation in a general hospital

Introducción. Los enterovirus originan un 80% de los casos de meningitisen niños y son causa frecuente de hospitalización por fiebreen menores de tres meses de edad.Objetivo. Evaluar la implicación de este agente etiológico en lahospitalización pediátrica en nuestro centro y describir las característicasclínicas.Método. Revisión retrospectiva de las historias clínicas de niños ingresadosen que se detectó genoma de enterovirus por reacciónen cadena de la polimerasa (PCR) entre abril de 2000 y diciembrede 2006.Resultados. Se obtuvieron 83 muestras (líquido cefalorraquídeo(LCR), heces, frotis faríngeo y sangre) de 62 pacientes. La edad mediafue de 8 meses (entre 5 días y 12 años). El 50% eran lactantesmenores de 3 meses. El principal motivo de consulta fue la fiebreseguida de cefalea y vómitos y el 29% presento signos meníngeos.La PCR por enterovirus en LCR resultó positiva en 27 casos, solamente17 tenían pleocitosis y en 5 también se detectó en heces yfrotis faríngeo. Se diagnosticó una infección bacteriana concomitanteen 13 pacientes. La estancia media en el hospital fue de 8días (DE=4,08).Conclusiones. 1. Los enterovirus son agentes frecuentemente implicadosen la hospitalización pediátrica por fiebre en menores detres meses de edad y son responsables de la mayoría de meningitisasépticas en los niños de nuestra serie. 2. En recién nacidos y lactantesel síntoma principal es la fiebre con irritabilidad, mientrasque en los escolares la fiebre se asocia a cefalea y signos meníngeos.3. La detección de enterovirus por PCR en LCR no siempre seacompaña de pleocitosis. 4. El resultado de la PCR más precoz podríareducir la utilización de antibióticos y la estancia hospitalaria(AU)

Introduction. Enterovirus is the cause of 80% of meningitis cases in children and is also a frequent cause of admission to hospital in infants under 3 months old with fever. Objective. To review the implication of this etiologic agent in children admitted to our centre and to describe the clinical characteristics. Method. Retrospective review of children's clinical records with positive detection of enterovirus genome by polymerase chain reaction (PCR) in the period between April 2000 and December of 2006. Results. Enterovirus genome was detected in 83 samples (cerebrospinal fluid (CSF), stools, throat culture, and blood) of 62 patients. The average age was 8 months (from 5 days to 12 years). 50% were nursing infants less than 3 months old. The most frequent symptom was fever, then headache and vomiting, and 29% with meningeal signs. Enterovirus was detected by PCR in CSF in 27 cases, 17 had pleocytosis, and in five the enterovirus was also positive in throat culture and stools. Bacterial infection was detected in 13 cases. The average hospital stay was eight days (SD=4.08). Conclusions. 1. Enterovirus is a common agent involved in patients younger than 3 months old with fever and is the most commonlyidentified cause of aseptic meningitis in our study. 2. In newborns and infants, the main symptoms are fever and irritability, while in school-age children, the fever is associated with headache and meningeal signs. 3. Enterovirus detection in CSF is not always accompanied by biochemical alteration. 4. Earlier enterovirus PCR result might decrease the length of hospital stays and unnecessary use of antibiotics(AU)

Retrobament amb la febre tifoide a Catalunya al segle XXI. Comentaris clínics i al tractament / No disponible

Fonament. La febre tifoide va ser una malaltia freqüental nostre país fins a la dècada dels vuitanta del segle XX. En l’actualitat el pediatre no està acostumat al diagnòstic clínic d’aquesta malaltia.Objectiu. Revisar els casos diagnosticats els darrers 6anys, a la vegada que revisar els aspectes més actuals de la malaltia i el seu tractamentMètode. Revisió retrospectiva dels casos diagnosticatsdurant el segle XXI amb l’anàlisi demogràfica, epidemiològica i clínica, les dades de laboratori, l’evolució i el tractamentResultats. S’han diagnosticat 10 casos entre el 2002-2006, només 2 van ser d’infants autòctons; els altres, excepte 1, havien arribat a Catalunya entre 2 i 15 dies abans. La febre, únic símptoma present en tots els casos, s’havia instaurat entre 3 i 15 dies abans. El diagnòstic es va fer per la positivitat de l’hemocultiu. Els microorganismes aïllats en 2 casos presentavenresistències. Es van tractar amb cefalosporines de3a generació iv o orals en 8 casos, 1 amb amoxicil·lina -àcid clavulànic i 1 amb azitromicina. L’apirèxia es va presentar entre els 3 i 15 dies amb una mitjana de 6.3 dies.Les complicacions, amb bona evolució: 4 hepatitis, 3 colecistitis alitiàsica, 1 coagulopatia, anèmia (que va necessitar transfusió) i pancreatitis. 1 recaiguda als 15 dies.Conclusions. a) El fet que en cap cas es pensa clínicament en aquest diagnòstic, excepte en la recaiguda. b) L’ajut que ofereix l’ecografia en el seguiment de possibles complicacions abdominals. c) L’actualització dels tractaments

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Síndrome febril a urgències en infants menors de dos anys / Síndrome febril en urgencias en niños menores de dos años / Febrile syndromes in children younger than 2 years of age in the emergency department

Introducció. La febre és un dels motius de consulta més freqüents als serveis d’urgències pediàtriques. Com manejar-la en el lactant continua sent motiu de controvèrsia. Objectius. Analitzar les causes més freqüents de febre en el lactant. Determinar el seguiment de la pauta del lactant febril sense focus aparent al servei d’urgències i la seva relació amb l’evolució posterior del pacient. Material i mètodes. Estudi prospectiu d’infants menors de 24 mesos d’edat atesos per febre de menys de 72 hores d’evolució al nostre Servei d’Urgències. Resultats. S’inclouen 200 lactants amb una edat mitjana de 12.6±5.8 mesos. La temperatura màxima és de 39.3±0.5ºC amb un temps d’evolució de 23±19.4 hores. La simptomatologia acompanyant predominant és respiratò- ria (53.5%). S’objectiva el focus de la febre en el 67%. Els diagnòstics més freqüents són l’otitis mitjana aguda (40 casos) i la infecció respiratòria de vies altes (35 casos). L’exploració complementària més sol•licitada és el sediment urinari (31%). En els lactants amb febre sense focus (n= 66), l’adherència a la pauta és del 40% i el motiu principal per no seguir-la és la falta d’analítica sanguínia (45.5%). Ingressen 11 pacients (5.5%) i 24 infants (12%) tornen per persistència de la febre. Conclusions. Les infeccions de l’àrea ORL suposen les causes principals de febre en el lactant. El seguiment de la pauta de lactant febril sense focus a urgències és semblant al que es descriu a la bibliografia. La poca realització d’analítiques sanguínies suposa el motiu principal per no adherir-se a la pauta, sense influència negativa en l’evolució posterior del pacient (AU)

Introducción. La fiebre es uno de los motivos de consulta más frecuentes en los servicios de urgencias pediátricas. Su manejo en el lactante sigue siendo motivo de controversia. Objetivos. Analizar las causas más frecuentes de fiebre en el lactante. Determinar el seguimiento de la pauta del lactante febril sin foco aparente en el servicio de urgencias y su relación con la evolución posterior del paciente. Material y métodos. Estudio prospectivo de niños menores de 24 meses de edad atendidos por fiebre de menos de 72 horas de evolución en nuestro Servicio de Urgencias. Resultados. Se incluyen 200 lactantes con edad media de 12.6±5.8 meses. La temperatura máxima es de 39.3±0.5ºC con un tiempo de evolución de 23±19.4 horas. La sintomatología acompañante predominante es respiratoria (53.5%). Se objetiva foco de la fiebre en el 67%. Los diagnósticos más frecuentes son la otitis media aguda (40 casos) y la infección respiratoria de vías altas (35 casos). La exploración complementaria más solicitada es el sedimento urinario (31%). En los lactantes con fiebre sin foco (n= 66) la adherencia a la pauta es del 40% y el principal motivo de falta de seguimiento es la falta de analítica sanguínea (45.5%). Ingresan 11 pacientes (5.5%) y 24 niños (12%) vuelven a acudir por persistencia de la fiebre. Conclusiones. Las infecciones del área ORL suponen los principales causantes de fiebre en el lactante. El seguimiento de la pauta de lactante febril sin foco en urgencias es similar al descrito en la bibliografía. La poca realización de analíticas sanguíneas supone el motivo principal de no adherencia a la pauta, sin influir negativamente en la evolución posterior del paciente (AU)

Introduction. Fever is one of the most frequent chief complaints in children presenting to the Emergency Department. The management of young children with fever in the emergency setting continues to be controversial. Objectives. To analyze the most frequent causes of fever in infants, and to evaluate the compliance with the guidelines for the management of young children with fever of unknown origin and its relationship with outcome. Material and methods. Prospective study of patients younger than 24 months presenting to our Emergency Department with fever of less than 72 hours of evolution. Results. Two hundred children (mean age 12.6± 5.8 months) were evaluated. Mean peak temperature was 39.3 ± 0.5oC, and mean evolution was 23 ± 19.4 hours. Main symptoms were respiratory (53.5%). The focus of infection was determined in 67% of the children. More frequent diagnoses were acute otitis media (40 patients), and upper respiratory tract infections (35 patients). Urinalysis was the diagnostic test most frequently performed (31%). The hospital guidelines for the management of young children with fever of unknown origin were followed in 40% of the 60 eligible cases. The main reason for not complying with the guidelines was the lack of blood work (45.5%). Eleven children (5.5%) were admitted to the hospital, and 24 children (12%) returned to the Emergency Department with persistent fever. Conclusions. Upper respiratory tract infections are the main cause of fever in young children presenting to the Emergency Department. The compliance with the guidelines for the management of febrile children without known origin is similar to other reports. The lack of blood work is the main deviation from the guidelines, although it does not seem to impact outcome (AU)

Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker.

BACKGROUND: Procalcitonin (PCT) is a potentially useful marker in pediatric Emergency Departments (ED). The basic objectives of this study were to assess the diagnostic performance of PCT for distinguishing between viral and bacterial infections and for the early detection of invasive bacterial infections in febrile children between 1 and 36 months old comparing it with C-reactive protein (CRP) and to evaluate the utility of a qualitative rapid test for PCT in ED. METHODS: Prospective, observational and multicenter study that included 445 children who were treated for fever in pediatric ED. Quantitative and qualitative plasma values of PCT and CRP were correlated with the final diagnosis. To obtain the qualitative level of PCT the BRAHMS PCT-Q rapid test was used. RESULTS: Mean PCT and CRP values in viral infections were 0.26 ng/ml and 15.5 mg/l, respectively. The area under the curve obtained for PCT in distinguishing between viral and bacterial infections was 0.82 (sensitivity, 65.5%; specificity, 94.3%; optimum cutoff, 0.53 ng/ml), whereas for CRP it was 0.78 (sensitivity, 63.5%; specificity, 84.2%; optimum cutoff, 27.5 mg/l). PCT and CRP values in invasive infections (PCT, 24.3 ng/ml; CRP 96.5 mg/l) were significantly higher than those for noninvasive infections (PCT, 0.32 ng/ml; CRP, 23.4 mg/l). The area under the curve for PCT was 0.95 (sensitivity, 91.3%; specificity, 93.5%; optimum cutoff, 0.59 ng/ml), significantly higher (P < 0.001) than that obtained for CRP (0.81). The optimum cutoff value for CRP was >27.5 mg/l with sensitivity and specificity of 78 and 75%, respectively. In infants in whom the evolution of fever was <12 h (n = 104), the diagnostic performance of PCT was also greater than that of CRP (area under the curve, 0.93 for PCT and 0.69 for CRP; P < 0.001). A good correlation between the quantitative values for PCT and the PCT-Q test was obtained in 87% of cases (kappa index, 0.8). The sensitivity of the PCT-Q test (cutoff >0.5 ng/ml) for detecting invasive infections and differentiating them from noninvasive infections was 90.6%, with a specificity of 83.6%. CONCLUSIONS: PCT offers better specificity than CRP for differentiating between the viral and bacterial etiology of the fever with similar sensitivity. PCT offers better sensibility and specificity than CRP to differentiate between invasive and noninvasive infection. PCT is confirmed as an excellent marker in detecting invasive infections in ED and can even make early detection possible of invasive infections if the evolution of the fever is <12 h. The PCT-Q test has a good correlation with the quantitative values of the marker.

Procalcitonina: una nueva herramienta diagnóstica en la infección bacteriana / Procalcitonin: a new diagnostic tool in bacterial infections

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