The tuberculosis spectrum: Translating basic research into pediatric clinical practice.

Recent studies suggest that the classical dichotomous classification of "active" and "latent" tuberculosis (TB) is no longer acceptable since "TB infection" encompasses a wide spectrum of conditions ranging from asymptomatic to lethal disease. In an attempt to address these issues from a pediatric clinical perspective, we describe two children with microbiologically confirmed TB but lacking any clinical and radiological evidence of disease. These two cases highlight the hypothesis that TB cannot be divided in two simple categories, but it covers a wide spectrum of manifestations ranging from asymptomatic to lethal TB. The implications of these results in the context of the new TB spectrum and the related clinical issues are discussed.

How to manage TB in children? Problems and solutions in four cases.

Children bear a substantial part of the tuberculosis (TB) epidemic worldwide, and it is estimated that there were ≅ 500.000 childhood TB cases globally in 2010, although accurate data are problematic to obtain given the many difficulties associated with TB diagnosis in children and the weaknesses of surveillance systems in countries where TB is endemic. The World Health Organization is working hard in order to reduce the TB prevalence rates and deaths by half by 2015. In this challenge, general practitioners and pediatricians play a key role in detecting early cases of suspected TB and sending them to experts in infectious diseases. This will reduce delayed diagnosis and the spread of disease, which is especially important now that the prevalence of multidrug resistant TB is increasing. For this reason, the purpose of this report was to delineate the characteristic clinical features of the most common forms of pediatric TB and to suggest a rational and practical approach to the disease underlining the role of patients and parents personal and clinical history.

IVIG treatment for VZV-related acute inflammatory polyneuropathy in a child.

Acute inflammatory polyneuropathy is an inflammatory demyelinating disease triggered by an autoimmune mechanism. It follows an infection or an immunisation after a free interval of 2-30 days. We report a case of a 14-year-old boy who develops an acute rapidly progressive paraplegia, urine incontinence and positive Lasegue a week after a characteristic chickenpox rash. Spinal MRI showed diffuse thickening and leptomeningeal enhancement of cauda equina nerve roots. Intravenous immunoglobulins were given and yielded a dramatic clinical and radiological improvement. The patient was discharged without any clinical problems 1 month after the onset of symptoms. We performed a review of the literature, discussing the different forms of varicella-zoster virus-related central and peripheral nervous system complications and management strategies for acute postinfectious encephalomyelitis/radiculitis.

Chest wall TB and low 25-hidroxy-vitamin D levels in a 15-month-old girl.

Parietal chest wall tuberculosis is an extremely rare manifestation of tuberculosis (TB) in children. We present the case of a 15 month-old girl presenting with a chest wall lesion initially thought to be of neoplastic origin and eventually diagnosed as chest wall TB, which was treated with surgical debridement and specific antitubercular therapy. The girl had not-measurable 25-hidroxy-vitamin D levels, an increasingly recognized risk factor for the development of active TB. To our knowledge, in the English literature there are no similar described cases in such young infants. This case highlight the possibility of dealing with TB and its different manifestations also in low TB burden countries, due to continuously increasing migration flows. A detailed history is a key point to reach the diagnosis. Moreover, our case confirm the possible non casual relationship between TB and low 25-hidroxy-vitamin D levels, pointing out the importance of measuring its levels in all TB patients and considering its supplementation in addition to specific antitubercular therapy.

Determinants of bone mineral density, bone mineral content, and body composition in a cohort of healthy children: influence of sex, age, puberty, and physical activity.

Interventions directed to the recognition of abnormal bone mineral density, bone mineral content, and body composition in the pediatric age require the definition of factors influencing bone mass acquisition during growth. We have evaluated in a cross-sectional manner by dual-energy X-ray absorptiometry the impact of sex, age, puberty, and physical activity on total body areal bone mineral density, regional (lumbar and femoral) bone mineral densities, bone mineral content, and body composition (fat mass and lean mass) in a cohort of 359 healthy Italian children aged 3-14 years and investigated their specific contribution to bone mass accrual. Statistical multiple regression analysis was performed dividing the population in pre- and post-pubertal groups. Bone mineral density at the lumbar spine has resulted equally distributed in both sexes before puberty while has resulted higher at the femoral necks in males at whatever age. A significant effect on bone mass acquisition was exerted by male sex and lean mass. In the areas where the cortical bone is prevalent, males of the pre-pubertal group have presented the highest values; in the areas where the cancellous bone is prevalent, both sexes were equivalent until the age of 9 years, but after this age, females have presented higher increases, probably related to the inferior dimensional development of lumbar vertebrae. Conclusively, male sex and lean mass seem to represent independent predictors of bone mass accrual in the cortical bone of the examined children, while female sex and pubertal maturation are independent predictors of bone mass accrual in the trabecular bone.

GDNF plasma levels in spina bifida: correlation with severity of spinal damage and motor function.

Glial-derived neurotrophic factor (GDNF) is one of several powerful survival factors for spinal motoneurons that play a key role in sprouting, synaptic plasticity, and reorganization after spinal cord damage. The aim of this study was to investigate the expression of GDNF in plasma of children with spina bifida (SB) and to determine its correlation with both the severity of spinal cord damage and the motor function of these patients. To measure the GDNF expression, we collected plasma samples from 152 children with SB and in 149 matched controls. Endogenous GDNF levels were quantified using a two-site immuno-enzymatic assay. The statistical analysis was performed using the Mann-Whitney two-tailed two-sample test. In children with SB the mean levels of GDNF (131.2 +/- 69.6 pg/mL) were significantly higher (p < 0.001) with respect to the mean levels of the control group (102.7 +/- 6.8 pg/mL). Moreover, in open SB, the GDNF levels (139.2 +/- 81.1 pg/mL) were significantly higher (p < 0.05) with respect to closed SB (117.2 +/- 41.3 pg/mL). In terms of the motor function of patients, we found that in children with poorer motor function, the GDNF levels (134.5 +/- 67.4 pg/mL) were higher, but not statistically significant (p < 0.1), than in patients with better motor outcome (122.3 +/- 72.2 pg/mL). Our study demonstrates GDNF over-expression in children with SB. This upregulation is significantly associated with the severity of spinal cord damage in SB patients and appears to correlate with poor motor function of children, representing an important biochemical marker of the severity of spine injury.

Patient-controlled analgesia with fentanil and midazolam in children with postoperative neurosurgical pain.

BACKGROUND: Pain is the most common discomfort experienced by children undergoing major operations. It is most often not adequately treated because of inexperience and unfounded fears related to the use of opioid drugs. In adults, patient-controlled analgesia (PCA) is widely administered, while in children, its use with opioid drugs is still under evaluation for safety and efficacy. OBJECTIVES: The objective of the study is to evaluate the safety and efficacy of an opioid drug (fentanil) administered by PCA associated with a sedative-adjuvant drug (midazolam) administered by continuous infusion in children having undergone major neurosurgical procedures. MATERIALS AND METHODS: Sixteen children with moderate to severe postoperative pain were treated with fentanil by PCA (booster doses of 1 microg/kg) plus continuous infusion of midazolam (2 microg/kg per min) by an intravenous route. To evaluate safety and efficacy of this analgesic protocol, different subjective and objective parameters were monitored at 4-h intervals. In addition, patients' satisfaction was assessed by a questionnaire at the end of the treatment. MAIN RESULTS: All children experienced a good degree of analgesia and did not require any other analgesic drug during the treatment. Both subjective and objective parameters improved after starting pain-relieving treatment, and no major side effects occurred. The analysis of the answers of the questionnaire administered to the children showed a high grade of satisfaction. CONCLUSIONS: PCA with fentanil plus continuous infusion of midazolam is a safe and efficacious method for analgesia in children with moderate to severe postoperative neurosurgical pain. The association of midazolam to fentanil also contributes to control anxiety and stress in this subset of patients and does not show any important side effects.