Management and prevention of imported malaria in children. Update of the French guidelines.

Since the 2007 French guidelines on imported Falciparum malaria, the epidemiology, treatment, and prevention of malaria have changed considerably requiring guidelines for all Plasmodium species to be updated. Over the past decade, the incidence of imported malaria has decreased in all age groups, reflecting the decrease in the incidence of malaria in endemic areas. The rates of severe pediatric cases have increased as in adults, but fatalities are rare. The parasitological diagnosis requires a thick blood smear (or a rapid immunochromatographic test) and a thin blood film. Alternatively, a rapid antigen detection test can be paired with a thin blood film. Thrombocytopenia in children presenting with fever is highly predictive of malaria following travel to a malaria-endemic area and, when detected, malaria should be strongly considered. The first-line treatment of uncomplicated P. falciparum malaria is now an artemisinin-based combination therapy (ACT), either artemether-lumefantrine or artenimol-piperaquine, as recommended by the World Health Organization in endemic areas. Uncomplicated presentations of non-falciparum malaria should be treated either with chloroquine or ACT. The first-line treatment of severe malaria is now intravenous artesunate which is more effective than quinine in endemic areas. Quinine is restricted to cases where artesunate is contraindicated or unavailable. Prevention of malaria in pediatric travelers consists of nocturnal personal protection against mosquitoes (especially insecticide-treated nets) combined with chemoprophylaxis according to the risk level.

[Bilateral pulmonary embolism mimicking acute chest syndrome in an adolescent with sickle cell disease]. / Embolie pulmonaire bilatérale mimant un syndrome thoracique aigu chez un adolescent drépanocytaire.

Pulmonary embolism is a life-threatening and potentially lethal disease. Its incidence in children with sickle cell disease is probably underestimated and pediatric case reports in the literature are rare. Moreover, symptoms can mimic an acute chest syndrome. We report on the case of a 17-year-old boy with SS sickle cell disease, admitted for chest pain with dyspnea and tachycardia. Pulmonary angiography revealed a partial bilateral obstructive pulmonary embolism. We did not find any deep venous thrombosis or thrombophilia. The progression was rapidly favorable with anticoagulant therapy. We recommend a pulmonary angiography for any chest pain that does not evolve favorably in a child with sickle cell disease. Large series of pediatric patients would be useful to establish diagnostic and therapeutic guidelines.

[Evaluation of pre-travel prevention and morbidity in child travelers]. / Enquêtes auprès des familles d'enfants voyageurs : évaluation des conseils de prévention et prévalence des maladies rencontrées lors d'un séjour hors d'Europe.

UNLABELLED: International travel is growing, but few data exist on prevention for children traveling. The aim of this study was to describe a population of children traveling from France to countries outside Europe and to evaluate the quality of prevention and healthcare services provided for these travelers. MATERIALS AND METHODS: We conducted a retrospective epidemiological study in three pediatric emergency departments in Paris from August to October 2009 and 2012. Data were collected retrospectively from anonymous questionnaires proposed to families consulting emergency services, irrespective of their reason, who had recently traveled (in the year preceding travel outside the European Union). RESULTS: Of the 166 children included, who for the most part had traveled to visit relatives and friends in Sub-Saharan Africa and North Africa, 76% of their families were from the destination countries, 78% had received prevention counseling, mostly with their doctor. They had been vaccinated against yellow fever, but the hepatitis A vaccine was neglected. The preventive measures had been difficult to achieve in practice. During travel, 54% of children had health problems (39% diarrhea, 29% vomiting, 31% fever) prompting medical care in 28%, 5% were admitted to a hospital, and 4% had return to France earlier than planned. In epidemic areas, 13% of children had malaria. CONCLUSION: There is poor counseling on basic prevention (hygiene, diarrhea, malaria, immunization). Time constraints in pediatricians and competing priorities could explain this problem. The challenge for healthcare providers to reduce these pathologies is to provide services of sufficient quality and clarity. All medical stakeholders have an important role to play.

[Superficial skin infections and bacterial dermohypodermitis]. / Infections superficielles de la peau et dermo-hypodermites bactériennes.

Staphylococcus aureus and Streptococcus pyogenes are the two main bacteria involved in skin infections in children. Mild infections like limited impetigo and furonculosis should preferentially be treated by topical antibiotics (mupirocine or fucidic acid). Empiric antimicrobial therapy of dermohypodermitis consists in amoxicillin-clavulanate through oral route (80 mg/kg/d) or parenteral route (150 mg/kg amoxicillin per d. in 3-4 doses) for complicated features: risk factors of extension of the infection, sepsis or fast evolution. Clindamycin (40 mg/kg/d per d. in 3 doses) should be added to the beta-lactam treatment in case of toxinic shock, surgical necrotizing soft tissues or fasciitis infections.

[Antibiotic prophylaxis for bites in children]. / Antibioprophylaxie des morsures chez l'enfant.

Children are often victims of dog or cat bites, but human bites are rarer. Infection is the most frequent complication. A very large number of bacterial species, anaerobic and aerobic often associated, are found in local samples. Antibiotic therapy is not systematic and should be discussed on a case-by-case basis taking into account the risk factors: the type of animal bite, the location and depth of the bite, and the time to treatment. Immunodepressed patients or those having undergone splenectomy are at a high risk of severe infections or from unusual bacteria and should be treated preventively. The association of amoxicillin and clavulanic acid is the most active antibiotic on the majority of bacteria responsible for infections. Treatment should be initiated rapidly and continue for 3-5 days with monitoring of local signs.

[Should a lumbar puncture be performed in any child with acute peripheral facial palsy and clinical suspicion of Lyme borreliosis?]. / Doit-on faire une ponction lombaire devant toute paralysie faciale suspecte de borréliose de Lyme chez l'enfant ?

Lyme borreliosis should be considered in any child affected with acute peripheral facial palsy without obvious cause in endemic areas, especially if it happens from May to November, with a history of erythema migrans, tick bite, or possible exposure during the previous weeks. The clinical appearance of Lyme borreliosis differs between adults and children and according to the geographical origin of the infection: therefore it is difficult to interpret and follow the recommendations for the management and treatment of this disease. Neuroborreliosis is more frequent in Europe than in the United States, and meningitis associated to facial palsy occurs earlier and is more frequent among the European pediatric population, too. When peripheral facial palsy occurs and there is suspicion of Lyme borreliosis, it seems necessary to perform a lumbar puncture in order to support the diagnosis with detection of intrathecal synthesis of specific antibodies, sometimes more abundant than in the serum, and thus to adapt the antibiotic therapy modalities. Parenteral antibiotherapy is recommended if any involvement is detected in the cerebrospinal fluid, while oral antibiotherapy should be prescribed for isolated facial palsies. Follow-up should be made according to clinical symptoms with a close collaboration between pediatricians, infection disease specialists, and ENT specialists.

[Orbital bone infarction in a child with homozygous sickle cell disease]. / Crise vaso-occlusive orbitaire chez un enfant drépanocytaire.

Vaso-occlusive crises are the most common complication of sickle cell disease. Orbital bone infarction is an unusual manifestation of sickling disorders. It is suspected in patients with acute painful periorbital swelling. Orbital compression syndrome with possible optic nerve injury is a rare but serious complication; therefore, this diagnosis should be considered. Orbital infarction can be difficult to distinguish from osteomyelitis or skin infections. Imaging can be helpful in differentiating infection from infarction. We report a case of orbital bone infarction in a 14-year-old boy with sickle cell disease. Under medical treatment, the clinical course resolved with no sequelae.

[Description and investigation of an outbreak of extended-spectrum beta-lactamase producing Escherichia coli strain in a neonatal unit]. / Description et investigation d'une épidémie nosocomiale de colonisations et d'infections à Escherichia coli producteur d'une bêta-lactamase à spectre étendu dans un service de néonatologie.

An outbreak of colonization and infection with an Escherichia coli strain producing extended-spectrum beta-lactamase (ESBL) occurred in a neonatal unit : a high rate of cases was observed, 27/59 neonates were colonized : one of them developed meningitis with favourable outcome and another baby developed conjunctivitis. Despite intensive efforts to control the outbreak by standard methods of hand hygiene, patients screening and isolation, the spread was uncontrolled and the unit was closed to all admission in order to stop the outbreak. The investigation was not able to identify a single outbreak's source. Emergence and spread of ESBL producing E. coli strains from community and hospital acquired infections are a significant public health problem with difficult choice of treatment for serious infections.

[Febrile torticollis: an atypical presentation of Kawasaki disease]. / Un torticolis fébrile: présentation atypique d'une maladie de Kawasaki.

Kawasaki disease is a form of idiopathic systemic vasculitis. Diagnosis is based upon specific clinical parameters. Cardiac manifestations explain the mortality rate. They can be reduced by early treatment using intravenous immunoglobulin. Atypical Kawasaki disease is difficult to diagnose and can delay diagnosis. We report a case of Kawasaki disease with arthritis in a 4-year-old girl whose initial presentation was a febrile torticollis. A literature review details the atypical early signs of Kawasaki disease revealed by torticollis.

[Managing children skin and soft tissue infections]. / Propositions thérapeutiques pour le traitement des infections cutanées bactériennes.

The skin infections are common in pediatrics, ranging from furonculosis or impetigo to the severe forms of necrotizing dermohypodermitis. The general antibiotic treatments are not always indicated but when they are, they must take into account the resistance of two main species of bacteria (Staphylococcus aureus and Streptococcus pyogenes), the pharmacokinetics-pharmacodynamic parameters and the severity and type of infection. Two situations should be treated by topical treatements: limited impetigo and furonculosis. The two topical antibiotics used preferentially are mupirocine and fucidic acid. Soon, a third topical antibiotic, reptamuline will complete these. For uncomplicated superficial skin infections justifying an oral antibiotic, amoxicillin-clavulanate offers the best guarantee of efficiency. Poor pharmacodynamic-pharmacokinetic must lead to not prescribe oral M penicillins. In case of allergy, a first-generation cephalosporin, a macrolide (if the susceptibility of the strain was checked) or pristinamycine (after 6 years of age) are acceptable alternatives. For dermohypodermitis bacterial antibiotic of choice remains amoxicillin-clavulanate through IV route, to be active against S. pyogenes but also S. aureus and anaerobic bacteria. The IV route is maintained until regression general signs and a relay orally by the same drug is then possible. For toxinic syndromes and necrozing fascitis clindamycin should be added to a beta-lactam because of its action on protein synthesis in particular reducing the toxins production.

[Vestibular neuronitis in a teenager with sickle cell disease. Treatment is urgent]. / Syndrome vestibulaire chez une adolescente drépanocytaire SC. Le traitement est urgent.

Vestibular syndrome is not frequently described in patients with sickle cell disease. We report the case of a teenager with sickle cell disease who had a vestibular syndrome with vertigo that successfully responded to exchange transfusion. We discuss guidelines and review the literature in view of this case report. Sensorineural disorders should be considered as stroke syndromes. They require urgent treatment consisting of exchange transfusion or maintaining optimal hydration associated with blood withdrawal. Treatment of vestibular syndrome in sickle cell disease is urgent.

[Treatment of pediatric genital condyloma]. / Traitement des verrues génitales de l'enfant en pratique clinique.

Condyloma, also known as venereal warts, are caused by human papillomavirus (HPV). Conventional wart therapies destroy infected keratinocytes rather than directly inhibiting viral infection or replication. No available drug therapy effectively eliminates HPV. Treatments are often disappointing for the patient, the family and the physician due to the duration of the disease and the frequency of recurrences in spite of treatment.

[Tolerance and efficacy of mefloquine as the first line treatment of uncomplicated P. falciparum malaria in children]. / Tolérance et efficacité de la méfloquine dans le traitement de première intention de l'accès palustre simple àP. falciparum d'importation chez l'enfant.

INTRODUCTION: Given the national therapeutic guidelines in France, halofantrine represents the first line treatment of uncomplicated Plasmodium falciparum (P. falciparum) malaria in children. But several disadvantages exist using halofantrine in paediatrics. OBJECTIVES: The primary objective of this study is to evaluate the tolerance and the efficacy of mefloquine as the first line treatment of uncomplicated P. falciparum malaria in a paediatric emergency department. The secondary objective of the study is to evaluate whether symptomatic measures may improve the gastrointestinal tolerance of mefloquine. PATIENTS AND METHODS: This retrospective observational cohort study includes all the patients who have been treated for acute uncomplicated P. falciparum malaria in the paediatric emergency department of the Hospital Trousseau (Paris, France) in 2003. RESULTS: First line treatment was mefloquine in 35 children. Early vomiting occurred in 22 (63%) cases. All children responded to mefloquine therapy except two children who had persistent vomiting early after mefloquine therapy and required intravenous quinine. Those two children had initial vomiting. Light meal and metopimazine prophylaxis did not precede mefloquine intake in those two children. CONCLUSION: This study suggests that mefloquine treatment of uncomplicated P. falciparum malaria is effective and well tolerated in children. Furthermore, a light meal and metopimazine prophylaxis preceding mefloquine intake may improve its gastrointestinal tolerance.

[Characteristics of meningococcal meningitis in children in France]. / Caractéristiques des méningites à méningocoque de l'enfant en France.

BACKGROUND: In France, meningococcal meningitis account for 50% of bacterial meningitis in children. The GPIP/ACTIV (Groupe de Pathologie Infectieuse Pédiatrique and Association Clinique et Thérapeutique Infantile du Val de Marne) set up an active surveillance network to analyze the epidemiological, clinical and biological features of meningococcal meningitis. METHODS: From 2001 to 2007, 252 French paediatric wards working with 166 microbiology laboratories enrolled all children (0-18 years old) with bacterial meningitis. Risk factors, signs and symptoms, vaccination status, cerebrospinal fluid analysis, treatments and case fatality rate were recorded. RESULTS: During the period of the study, 1344 meningococcal meningitis were reported among 2951 (45.5%) bacterial meningitis. Mean age was 4.4 years (+/-4.7, median 2.5) and 2/3 cases occurred in children under 5 years (68.5%). Serogroup B (59.1%) was preponderant following by serogroup C (28.9%). 25% of children had received an antibiotic treatment 24hours before lumbar puncture. A shock was reported in 31.3% of cases. Cerebrospinal fluid culture was positive in 73% of cases. All N. meningitidis isolates were susceptible to cefotaxime and ceftriaxone while 41.6% and 25.7% showed reduced susceptibility to penicillin and amoxicillin respectively. Two cases of meningitis due to isolates of serogroups C and B were reported in two children that were respectively vaccinated using A+C plain saccharide vaccine or two doses of MenBvac vaccine. All patients had received beta-lactamin. Global case fatality rate was 6.6% but was higher (9.9%) for serogroup C than for serogroup B (5.5%) (p=0,007). CONCLUSION: This study is among the largest series of microbiologically documented meningococcal meningitis to date (more than 1300 cases). In France, meningococal is responsible for 50 % of meningitis. Effective meningococcal serogroup B vaccine and serogroup C vaccination recommendation could lessen considerably the burden of meningococal meningitis.

[Current management of acute pediatric rhinosinusitis in France]. / Etat actuel de la prise en charge des infections rhinosinusiennes aiguës de l'enfant en France.

A multidisciplinary panel of specialists and general practitioners provided definitions for the different forms of acute pediatric rhinosinusitis, with a description of the main symptoms and signs. They emphasized the role of concomitant systemic diseases, such as allergy and immunological disorders. Incidence, description, and management of complications are presented. They also provided the indications for radiological examination and microbiological investigations. The adequate medical management, particularly the place and the type of antibiotics, is analyzed and discussed, and guidelines for practical situations are suggested.

[Influenza vaccination coverage rate in children with underlying chronic disorders in 7 French pediatric wards]. / Couverture vaccinale vis-à-vis de la grippe chez les enfants de la région parisienne atteints d'une affection de longue durée.

UNLABELLED: In France, annual influenza vaccination is recommended and free of charge for children with chronic disease (chronic lung, heart or kidney disease, diabetes, haemoglobinopathy, immune deficiency). The national goal is to reach 75% influenza vaccination coverage by 2008, but data on coverage in high risk children are limited. OBJECTIVES: To estimate the influenza vaccination coverage in children with an underlying chronic health condition in the Paris region, during in- or out-patient visit at hospital. METHODS: A multicentre cross-sectional descriptive study was carried out over 2 months before the 2004-2005 flu vaccination campaign in 7 French paediatric hospitals (Paris region). Inclusion criteria for this survey were: children aged 6 months to 18 years, with an underlying chronic disease requiring annual influenza vaccination, with a vaccination card available, so as to check their vaccination status. Reasons for non vaccination were recorded. RESULTS: Data from 239 children were analysed. 56% of patients were males (mean age: 8.1 years). Two patients had 2 separate underlying chronic disorders; 69% had a haemoglobinopathy, 16.3% had a chronic respiratory disease, and 7.5% had diabetes. The influenza vaccination rate for 2003-2004 was 43.7% (haemoglobinopathy: 55.5%; chronic respiratory diseases: 12.8%). This rate increased from 20.4% to 43.7% between 1999 and 2003. Less than 16% of parents remembered having received a voucher for free vaccination from the National Health Insurance Agency. CONCLUSION: Efforts are still needed to achieve the 2008 objectives of 75% coverage.

[Causes of hospitalization of patients with ongoing varicella in a French children hospital: evolution between 1990 and 2001]. / Motifs d'hospitalisation des patients atteints de varicelle dans un établissement pédiatrique parisien: évolution entre 1990 et 2001.

AIMS OF STUDY: To describe the characteristics of paediatric varicella in patients admitted through the emergency department (ED) of the Armand-Trousseau Children hospital in Paris and the evolution of the causes of admission during the study period. STUDY DESIGN: Retrospective longitudinal cohort study from March 1990 to February 2001. RESULTS: One hundred and eight children were hospitalized for varicella during these 11 years. Sixty per cent were under 2 years of age and all but one were immunocompetent. The first cause of admission was the presence of at least 1 complication (83,3%) classified as: cutaneous (34%), digestive (19,8,%), respiratory (17,6%), neurological (15,3%) and ENT complications (8,8%). Over 11 years, the rate of overall complications remained stable but there was an important increase in varicella cases admitted through the ED mainly due to increase in cutaneous superinfections. CONCLUSION: These data confirm the potential severity of varicella and underline the emerging problem of increasing cutaneous complications. Additional studies are necessary to address this phenomenon and to determine optimal prophylactic measures.