The Contribution of Chest Radiography to the Clinical Management of Children Exposed to Tuberculosis.

Rationale: Although World Health Organization guidelines emphasize contact investigation for tuberculosis (TB)-exposed children, data that support chest radiography as a useful tool are lacking. Objectives: We evaluated the diagnostic and prognostic information of chest radiography in children exposed to TB and measured the efficacy of isoniazid preventive therapy (IPT) in those with relevant radiographic abnormalities. Methods: Between September 2009 and August 2012, we enrolled 4,468 TB-exposed children who were screened by tuberculin skin testing, symptom assessment, and chest radiography. Those negative for TB disease were followed for 1 year for the occurrence of new TB diagnoses. We assessed the protective efficacy of IPT in children with and without abnormal chest radiographs. Measurements and Main Results: Compared with asymptomatic children with normal chest films, asymptomatic children with abnormal radiographs were 25.1-fold more likely to have coprevalent TB (95% confidence interval [CI], 1.02-613.76) and 26.7-fold more likely to be diagnosed with incident TB disease during follow-up (95% CI, 10.44-68.30). Among the 29 symptom-negative and CXR-abnormal child contacts, 20% (3/15) of the isoniazid recipients developed incident TB, compared with 57% (8/14) of those who did not receive IPT (82% IPT efficacy). Conclusions: Our results strongly support the use of chest radiography as a routine screening tool for the evaluation of child TB contacts, which is readily available. Radiographic abnormalities not usually considered suggestive of TB may indicate incipient or subclinical disease, although TB preventive treatment is adequate in most cases.

Etiology and the challenge of diagnostic testing of community-acquired pneumonia in children and adolescents.

BACKGROUND: Pneumonia is the leading cause of mortality in pediatric population. The etiology of pneumonia in this population is variable and changes according to age and disease severity and where the study is conducted. Our aim was to determine the etiology of community-acquired pneumonia (CAP) in children aged 1 month to 17 years admitted to 13 Colombian hospitals. METHODS: Prospective cohort study. Hospitalized children with radiologically confirmed CAP and ≤ 15 days of symptoms were included and followed together with a control group. Induced sputum (IS) was submitted for stains and cultures for pyogenic bacteria and Mycobacterium tuberculosis, and multiplex PCR (mPCR) for bacteria and viruses; urinary antigens for pneumococcus and Legionella pneumophila; nasopharyngeal swabs for viruses, and paired serology for atypical bacteria and viruses. Additional cultures were taken at the discretion of primary care pediatricians. RESULTS: Among 525 children with CAP, 71.6% had non-severe pneumonia; 24.8% severe and 3.6% very severe pneumonia, and no fatal cases. At least one microorganism was identified in 84% of children and 61% were of mixed etiology; 72% had at least one respiratory virus, 28% pyogenic bacteria and 21% atypical bacteria. Respiratory syncytial virus, Parainfluenza, Rhinovirus, Influenza, Mycoplasma pneumoniae, Adenovirus and Streptococcus pneumoniae were the most common etiologies of CAP. Respiratory syncytial virus was more frequent in children under 2 years and in severe pneumonia. Tuberculosis was diagnosed in 2.3% of children. IS was the most useful specimen to identify the etiology (33.6%), and blood cultures were positive in 3.6%. The concordance between all available diagnostic tests was low. A high percentage of healthy children were colonized by S. pneumoniae and Haemophilus influenzae, or were infected by Parainfluenza, Rhinovirus, Influenza and Adenovirus. CONCLUSIONS: Respiratory viruses are the most frequent etiology of CAP in children and adolescents, in particular in those under 5 years. This study shows the challenges in making an etiologic diagnosis of CAP in pediatric population because of the poor concordance between tests and the high percentage of multiple microorganisms in healthy children. IS is useful for CAP diagnosis in pediatric population.

Acute Intrathoracic Tuberculosis in Children and Adolescents with Community-Acquired Pneumonia in an Area with an Intermediate Disease Burden.

Tuberculosis (TB) in the pediatric population is a major challenge. Our objective was to describe the clinical and microbiological characteristics, radiological patterns, and treatment outcomes of children and adolescents (from 1 month to 17 years) with community-acquired pneumonia (CAP) caused by TB. We performed a prospective cohort study of a pediatric population between 1 month and 17 years of age and hospitalized in Medellín, Colombia, with the diagnosis of radiologically confirmed CAP that had ≤ 15 days of symptoms. The mycobacterial culture of induced sputum was used for the bacteriological confirmation; the history of TB contact, a tuberculin skin test, and clinical improvement with treatment were used to identify microbiologically negative TB cases. Among 499 children with CAP, TB was diagnosed in 12 (2.4%), of which 10 had less than 8 days of a cough, 10 had alveolar opacities, 9 were younger than 5 years old, and 2 had close contact with a TB patient. Among the TB cases, 50% (6) had microbiological confirmation, 8 had viral and/or bacterial confirmation, one patient had multidrug-resistant TB, and 10/12 had non-severe pneumonia. In countries with an intermediate TB burden, Mycobacterium tuberculosis should be included in the etiological differential diagnosis (as a cause or coinfection) of both pneumonia and severe CAP in the pediatric population.

Induced sputum as an adequate clinical specimen for the etiological diagnosis of community-acquired pneumonia (CAP) in children and adolescents.

OBJECTIVES: This study aimed to evaluate the utility of induced sputum (IS) for the diagnosis of community-acquired pneumonia (CAP) in pediatric population. METHODS: This cross-sectional study included pediatric population aged between 1 month and 17 years who were hospitalized with a diagnosis of CAP in 13 hospitals in Colombia, in whom an IS sample was obtained. Gram staining, aerobic bacterial and mycobacterial culture tests, and polymerase chain reaction (PCR) for 6 atypical bacteria and 15 respiratory viruses were performed. We evaluated the quality of IS samples. RESULTS: IS samples were collected in 516 of 525 children included in this study. The median age was 32 months, 38.6% were younger than 2 years, and 40.9% were between 2 and 5 years. Two patients had transient hypoxemia during the procedure. The quality of the IS obtained was good in 48.4% and intermediate in 24.5%. Identification of a respiratory pathogen was achieved with an IS sample (with Gram staining, culture test, and PCR) in 372 of 516 children with CAP. CONCLUSION: Our study shows that IS is an adequate sample for the diagnosis of CAP in pediatric population that required hospitalization. The procedure was safe, well tolerated, and with better diagnostic yields compared with the rest of the samples obtained.

A systematic approach to diagnosing intra-thoracic tuberculosis in children.

Children suffer a huge and often underappreciated burden of disease in tuberculosis (TB) endemic countries. Major hurdles include limited awareness among health care workers, poor integration of TB into maternal and child health approaches, diagnostic difficulties and a lack of child-friendly treatment options. Accurate disease diagnosis is particularly difficult in young and vulnerable children who tend to develop paucibacillary disease and are unable to produce an expectorated sputum sample. In addition, access to chest radiography is problematic in resource-limited settings. Differentiating between TB exposure and M. tuberculosis infection, and especially between M. tuberculosis infection and TB disease is crucial to guide clinical management. TB represents a dynamic continuum from well-contained "latent" infection to incipient and ultimately severe disease. The clinical spectrum of disease in children is broad and can be confused with a myriad of common infections. We provide a pragmatic 4-step approach to diagnose intra-thoracic TB in children and demonstrate how classifying clinical, radiological and laboratory findings into recognised clinical syndromes may provide a more refined diagnostic approach, even in resource-limited settings.

Tuberculosis exposure, infection and disease in children: a systematic diagnostic approach.

The accurate diagnosis of tuberculosis (TB) in children remains challenging. A myriad of common childhood diseases can present with similar symptoms and signs, and differentiating between exposure and infection, as well as infection and disease can be problematic. The paucibacillary nature of childhood TB complicates bacteriological confirmation and specimen collection is difficult. In most instances intrathoracic TB remains a clinical diagnosis. TB infection and disease represent a dynamic continuum from TB exposure with/without infection, to subclinical/incipient disease, to non-severe and severe disease. The clinical spectrum of intrathoracic TB in children is broad, and the classification of clinical, radiological, endoscopic, and laboratory findings into recognized clinical syndromes allows a more refined diagnostic approach in order to minimize both under- and over-diagnosis. Bacteriological confirmation can be improved significantly by collecting multiple, high-quality specimens from the most appropriate source. Mycobacterial testing should include traditional smear microscopy and culture, as well as nucleic acid amplification testing. A systematic approach to the child with recent exposure to TB, or with clinical and radiological findings compatible with this diagnosis, should allow pragmatic classification as TB exposure, infection, or disease to facilitate timely and appropriate management. It is important to also assess risk factors for TB disease progression and to undertake follow-up evaluations to monitor treatment response and ongoing evidence supporting a TB, or alternative, diagnosis.

Hallazgos a la biomicroscopía ultrasónica en opacidades del cristalino / Ultrasound biomicroscopy findings in lens opacities

Propósito: Presentar los hallazgos ultrabiomicroscópicos observados en distintos tipos de catarata. Materiales y Métodos: Se correlacionan los hallazgos clínicos en la biomicroscopía con los obtenidos en la Biomicroscopía ultrasónica utilizando una sonda de 48 Mhz de Accutome. Resultados: Se incluyeron 32 ojos de 16 pacientes, de ellos 3 cataratas polares posteriores donde se observan imágenes ecodensas en el polo posterior con adelgazamiento de la cápsula sin compromiso del vítreo anterior. En los 15 casos de catarata corticonuclear se observan imágenes hiperecoicas en cortical anterior siendo mayor la densidad de la misma a mayor compromiso cortical con un núcleo poco ecoíco e incluso en 8 casos de opacidad netamente nuclear no se evidenciaron mayores alteraciones. En los 13 casos de catarata madura, con opacidades corticonucleares totales y blanquecinas se observaron imágenes de mayor densidad y homogéneas en la cortical anterior y posterior y si presentaron vacuolas o contenido acuoso se observaron áreas hipoecoicas inmediatamente subcapsulares anteriores. Por último, en 2 casos de catarata morganiana se observó engrosamiento irregular de la cápsula anterior con la presencia de un núcleo libre en el polo posterior del cristalino. En Conclusión, la Biomicroscopía ultrasónica ofrece detalles morfométricos del cristalino que son útiles en la planificación y abordaje quirúrgico de la catarata con la finalidad de minimizar las posibles complicaciones perioperatorias.

Purpose: To present the findings observed in different types of cataract by Ultrasonic Biomicroscopy. Materials and Methods: The clinical findings were correlated with those obtained by ultrasound using an ultrasonic probe of 48 Mhz by Accutome. Results: 32 eyes of 16 patients, 3 cases of posterior polar cataract with an image of echodense mass was observed at the posterior pole with slightly thinning of posterior capsule without involvement of anterior vitreous. In the 15 cases of moderate corticonuclear cataract hyperechoic images where observed in the anterior cortical region being of greater density as higher cortical compromise, with some or non-echoic activity in nucleus as observed in 8 cases of nuclear opacity without major cortical alterations. In the 13 cases of mature cataract, with total corticonuclear white opacities, compact images of high density and homogeneous were observed in anterior and posterior cortical region with some hypoechoic areas beneath the anterior capsule. Finally, in two cases of organian cataract irregular thickening of the anterior capsule with the presence of a free nucleus at the posterior pole of the lens was observed. In conclusion, the ultrasound ultrabiomicroscopy offers morphometric details of the lens which are useful in planning the surgical approach minimizing potential for intraoperative complications.

Trauma: una etiología infrecuente del pseudoquiste pulmonar / Trauma: an unusual cause of pulmonary pseudocyst

El pseudoquiste pulmonar secundario a trauma cerrado de tórax es una lesión cavitaria rara en el parénquima del pulmón, que carece de revestimiento epitelial. Es más frecuente en niños y adolescentes cuya pared torácica es menos rígida. Las manifestaciones clínicas son usualmente benignas y se resuelve espontáneamente en dos a cuatro meses después del trauma. Presentamos la evolución de un niño con un trauma cerrado de tórax en calidad de peatón, luego del cual apareció una lesión quística poco sintomática en el parénquima pulmonar, que se resolvió espontáneamente.

Pulmonary pseudocyst secondary to blunt chest trauma is a rare cavitary lesion in the lung parenchyma that lacks an epithelial lining. It is more common in children and adolescents in whom the chest wall is less rigid. Clinical manifestations are usually benign and resolve spontaneously in two to four months after the trauma. We present the evolution of a child who suffered a closed chest trauma as a pedestrian, after which a cystic lesion appeared in the lung parenchyma, without very obvious symptoms; subsequently the cystic image resolved when he was already asymptomatic.

Paragonimiasis pulmonar en niños: reporte de dos casos / Lung paragonimiais in children: Report of two cases

La paragonimiasis es una zoonosis parasitaria, de transmisión alimentaria, causada por especies de tremátodos del género Paragonimus, presente en áreas tropicales y subtropicales de Asia, África y América. El ser humano se infecta mediante la ingestión de crustáceos de agua dulce crudos o mal cocidos. La infección afecta principalmente los pulmones, con desarrollo de múltiples manifestaciones clínicas y radiológicas, dependiendo del momento del ciclo vital del parásito. El diagnóstico diferencial más importante de esta enfermedad es la tuberculosis pulmonar. En este artículo se describe esta enfermedad en dos niñas con diferentes manifestaciones pulmonares. La paragonimiasis se debe sospechar en pacientes con tos crónica, esputo herrumbroso, dolor torácico, con o sin compromiso cerebral, que viven o han residido en una zona endémica y que presentan una eosinofília elevada, con cambios radiológicos sugestivos del síndrome de Loeffler.

Paragonimiasis is a parasitic, food-borne zoonosis, caused by species of trematodes of the genus Paragonimus, found in tropical and subtropical areas of Asia, Africa and America. Human beings become infected by ingestion of raw or undercooked freshwater shellfish. The infection primarily affects the lungs, with the development of multiple clinical and radiological manifestations, depending on the moment in the life cycle of the parasite. The most important differential diagnosis of this disease is pulmonary tuberculosis. We report two cases of lung paragonimiasis in aboriginal Colombian girls with different pulmonary manifestations. Paragonimiasis should be suspected in patients with chronic cough, rusty sputum, chest pain, with or without brain involvement, who live or have lived in endemic areas and have a high-level eosinophilia with radiographic changes suggestive of Loeffler's syndrome.

Fístula traqueoesofágica en niños: un diagnóstico para tener en cuenta. Reporte de dos casos y revisión de la literatura / Tracheo-esophageal fistula in children: a diagnosis to keep in mind. Two case reports and review of the literature

La fístula traqueoesofágica sin atresia esofágica es un tipo infrecuente de malformación del esófago, de etiología multifactorial, incluyendo factores ambientales y genéticos. Se manifiesta con tos y ahogo con los alimentos, cianosis y/o neumonía recurrente. El diagnóstico requiere un alto índice de sospecha clínica y su confirmación se hace por imágenes como el estudio de las vías digestivas superiores y la video-fluoroscopia, o por broncoscopia visualizando directamente la fístula, o con azul de metileno para observar el paso de este líquido. El tratamiento puede hacerse por vía endoscópica o quirúrgica, con buenos resultados.

Tracheo-esophageal fistula without esophageal atresia is a rare type of esophageal malformation. It has a multifactorial etiology including environmental and genetic factors. Common clinical manifestations are coughing and choking after meals, cyanosis and/or recurrent pneumonia. Diagnosis requires a high clinical suspicion index. Fistula confirmation is done with imaging studies including upper digestive series, video-fluoroscopy or with the use of bronchoscopy which allows direct visualization of the fistula or methylene blue passage through the abnormal communication. Fistula closure can be done endoscopically or surgically, in both cases with good results.

Aspergilosis broncopulmonar alérgica, una complicación del paciente con fibrosis quística: reporte de dos casos y revisión de la literatura / Allergic bronchopulmonary aspergillosis, a complication of patients with cystic fibrosis: Report of two cases and review of the literature

La aspergilosis broncopulmonar alérgica (ABPA) es la enfermedad pulmonar resultante de hipersensibilidad a Aspergillus, que lleva a alteración de la depuración mucociliar, impactación mucosa con obstrucción de la vía aérea e infiltración pulmonar. Se caracteriza clínicamente por disnea, sibilancias, fiebre, malestar general y expectoración de color marrón o negro, y por la mala respuesta clínica al tratamiento habitual instaurado para las exacerbaciones en pacientes con enfermedad pulmonar crónica. En los pacientes con fibrosis quística (FQ) puede ser difícil establecer el diagnóstico de ABPA debido a la superposición de las características clínicas, radiológicas e inmunológicas de las dos enfermedades y a la presencia frecuente de infecciones bacterianas pulmonares. Por ello, se recomienda que en el seguimiento de dichos pacientes se haga medición anual de la inmunoglobulina E (IgE) sérica total y, según su resultado y el contexto clínico, se plantee el diagnóstico de ABPA y se haga el tratamiento oportuno con esteroides con el cual mejoran los síntomas, la función pulmonar, la calidad de vida y el pronóstico. Presentamos dos pacientes pediátricos con diagnóstico de FQ de difícil control, en quienes se hizo el diagnóstico de ABPA y cuya sintomatología pulmonar mejoró con el tratamiento esteroide.

Allergic bronchopulmonary aspergillosis (ABPA) is a lung disease resulting from hypersensitivity to Aspergillus, which leads to impaired mucociliary clearance, mucus impaction with obstruction of the airway, and pulmonary infiltration. Clinically it is characterized by dyspnea, wheezing, fever, malaise, brown or black expectoration, and poor clinical response to the standard therapy for exacerbations in patients with chronic lung disease. In patients with cystic fibrosis (CF) it may be difficult to establish the diagnosis of ABPA due to the overlapping of clinical, radiological and immunological features and to the high frequency of pulmonary bacterial infections. Therefore, annual monitoring of these patients is recommended by measuring the level of total immunoglobulin E (IgE); according to its result and to the clinical context, the diagnosis and treatment of ABPA with steroids should be considered. Such treatment leads to improvement of symptoms, lung function, quality of life and prognosis. We report two pediatric patients diagnosed with CF who were difficult to control; the diagnosis of ABPA was established and their pulmonary symptoms improved with the use of steroids.

Síndrome de antielevación posterior a transposición anterior de los músculos oblicuos inferiores en el tratamiento de la desviación vertical disociada / Antielavation syndrom posterior to anterior transposition of the inferior oblique muscles in the treatment of dissociated vertical deviation

Correlacionar la frecuencia del síndrome de antielevación (SAE) posterior a transposición anterior de los músculos oblicuos (TAOI) en el tratamiento de la desviación vertical disociada (DVD). Estudio retrospectivo, no comparativo en el que se estudian 18 pacientes con diagnóstico de DVD asociado hiperfunción bilateral de oblicuos inferiores que fueron sometidos a TAOI. Se examinó la mortalidad ocular antes y después de la cirugía. La técnica quirúrgica se realizó mediante la interiorización del músculo oblicuo inferior fijándose en un punto único en el borde temporal del recto inferior a la altura de su inserción. SAE fue observada en el 27.7 por ciento de los casos (5 pacientes). La reinserción del oblicuo inferior a nivel de la inserción del recto inferior en un solo punto, puede estar asociada a baja incidencia de SAE

Efectos de la dorzolamida latanoprost y combinación dorzolamida-timolol sobre la córnea / Effects of dorzolamida latanoprost and a dorzolamida-latanoprost combination on the cornea

En los últimos años, el desarrollo y comercialización de nuevas drogas hipotensoras oculares ha hecho que el oftalmológo cuente con mayores recursos terapéuticos para el glaucoma. Son pocos los estudios que relacionan los efectos que pueden tener la dorzolamida, latanoprost y la combinación de dorzolamida-maleato de timolol sobre la córnea. Se realiza un estudio experimental en conejos albino de Nueva Zelanda a los cuales se les administró dorzolamida, latanoprost, dorzolamida-meleato timolol y lágrimas artificiales como control, por espacio de tres meses. Se realizó una valoración previa del segmento anterior y microscopía especular y luego en forma seriada. Al tercer mes, se extrae el botón corneal y procesa para microscopía de luz electrónica. No se encontró diferencias entre las drogas antiglaucomatosas en el grosor corneal, tamaño, densidad celular, coeficiente de variación, ni a la microscopía de luz. Al estudio ultraestructural se describen alteraciones leves al epitelio mayores en el grupo de latanoprost y al endotelio más evidentes en los grupos que incluyen la dorzolamida. Estas drogas son clinicamente seguras pero que debemos estar en conocimiento de las alteraciones ultraestructurales que producen para su monitoreo clínico y la subsecuente detención del tratamiento en caso de tóxicidad

Valores normales de microscopia especular en conejos albinos de Nueva Zelanda / Normal values of specular microscopy in New Zealand albino rabbits

Presentar los valores normales de microscopia especular en conejos albinos de Nueva Zelanda. Se utilizó el biomicroscopio especular Topcon SP-2000P en 42 conejos saludables. Se incluyen las evaluaciones preliminares de tres proyectos de investigación realizadas en tres etapas entre marzo de 1999 y agosto 2000. El grosor corneal obtenido fue de 0,333 mm con una desviación estándar de 0,026. Se observó un patrón homogéneo en la morfología del endotelio. El tamaño celular promedio fue de 285,34 µm con una desviación estándar de 50,05. El coeficiente de variación fue de 39,65 con una desviación estándar de 23,63. POr último, la densidad celular obtenida fue de 3590,40 cel por mm² con una desviación estándar de 549,32. Los resultados morfológicos y numéricos obtenidos in vivo de córneas de conejos albinos de Nueva Zelanda difieren de los encontrados en humanos