Evaluation of cases of pediatric extrapulmonary tuberculosis: a single center experience.

AIM: Extrapulmonary tuberculosis is observed more frequently and leads to complications with a higher rate in children compared with adults because the risk of lymphohematogen spread is higher. In this study, the clinical, laboratory, and radiologic findings and treatment outcomes were evaluated in pediatric patients who were followed up in our clinic with a diagnosis of extrapulmonary tuberculosis. MATERIAL AND METHODS: Seventy patients aged 0-18 years who were followed up with a diagnosis of extrapulmonary tuberculosis between 2008 and 2017 in the Division of Pediatric Infectious Diseases in our hospital were examined retrospectively. RESULTS: The median age of the patients was 8,8 (range, 0,4-17) years and 47.1% were female (n=33). Twenty-seven patients (38.6%) were aged 0-4 years, 15 (21.4%) were aged 5-9 years, and 28 patients (40%) were aged 10-18 years. Forty-four patients (62.9%) were diagnosed as having extrapulmonary tuberculosis and 26 (37.1%) had pulmonary + extrapulmonary tuberculosis. The most common form of extrapulmonary tuberculosis was extrathoracic lymphadenopathy, which was found in 22 patients (31.4%). The other patients were diagnosed as having musculoskeletal system tuberculosis (n=10, 14.3%), gastrointestinal system tuberculosis (n=9, 12.9%), miliary tuberculosis (n=8, 11.4%), intrathoracic lymphadenopathy (n=7, 10%), renal tuberculosis (n=6, 8.6%), central nervous system tuberculosis (n=5, 7.1%), and pleural tuberculosis (n=3, 4.3%). Among a total of 58 patients in whom tuberculin skin test and interferon gamma release tests were studied together, tuberculin skin test positivity (n=37, 63.8%) was found with a higher rate compared with interferon gamma release test positivity (n=32, 55.2%), but the difference was not statistically significant (p=0.35). The median treatment period was 12 (range, 6-24) months. Among the patients whose treatments were terminated, improvement was observed in 52 patients (74.2%) and the development of sequela was observed in six patients (8.5%). Two patients who were diagnosed as having central nervous system tuberculosis (2.8%) died. CONCLUSION: Clinical, laboratory, and radiologic data should be evaluated together when making a diagnosis of extrapulmonary tuberculosis in children. Interferon gamma release tests alone are not superior to tuberculin skin test, but should be considered to be used in combination in the diagnosis.

AMAÇ: Çocuklarda, lenfohematojen yayilim riskinin yüksek olmasi nedeniyle akciger disi tüberküloz eriskinlere göre daha sik gözlenmekte ve daha fazla komplikasyona yol açmaktadir. Bu çalismada, klinigimizde akciger disi tüberküloz tanisi ile izledigimiz çocuk olgularin klinik, laboratuvar ve radyolojik bulgulari ile tedavi sonuçlari degerlendirilmistir. GEREÇ VE YÖNTEMLER: Hastanemiz Çocuk Enfeksiyon Hastaliklari Bilim Dali'nda 2008­2017 yillari arasinda akciger disi tüberküloz ile izlenen 0­18 yas arasi 70 olgu geriye dönük olarak incelendi. BULGULAR: Yas ortancasi 8,8 (0,4­17) yil olan olgularin %47,1'i kiz (n=33) idi. Sifir­4 yas arasi 27 olgu (%38,6), 5­9 yas arasi 15 olgu (%21,4), 10­18 yas arasi 28 olgu (%40) vardi. Kirk dört olgu (%62,9) akciger disi tüberküloz, 26 olgu (%37,1) akciger+akciger disi tüberküloz tanisi almisti. Yirmi iki olguda (%31,4) en sik toraks disi lenfadenopati saptandi. Diger olgular siklik sirasina göre; kas-iskelet sistemi (n=10, %14,3), gastrointestinal sistem (n=9, %12,9), miliyer (n=8, %11,4), toraks içi lenfadenopati (n=7, %10), renal (n=6, %8,6), merkezi sinir sistemi- (n=5, %7.1) ve plevra tüberkülozu (n=3,%4.3) tanilari almisti. Tüberkülin deri testi ve interferon gamma salinim testi birlikte çalisilan toplam 58 olguda, tüberkülin deri testi pozitifligi (n=37, %63,8) interferon gamma salinim testi pozitifligine göre (n=32, %55,2) daha fazlaydi, ancak istatiksel olarak anlamli bulunmadi (p=0,35). Olgularin ortanca tedavi süresi 12 (6­24) ay idi. Tedavisi sonlandirilan olgularin 52'sinde (%74,2) iyilesme, altisinda (%8,5) sekel gelisimi izlendi. Merkezi sinir sistemi tüberkülozu tanili iki olgu (%2,8) yasamini kaybetti. ÇIKARIMLAR: Çocuklarda akciger disi tüberküloz tanisi konulurken klinik, laboratuvar, radyolojik veriler birlikte degerlendirilmelidir. Interferon gamma salinim testleri tek basina tüberkülin deri testine üstün olmayip, tanida birlikte kullanilmasi düsünülmelidir.

Resistant gram-negative infections in a pediatric intensive care unit: a retrospective study in a tertiary care center.

AIM: Healthcare-associated infections cause increased morbidity and mortality in intensive care units. In this study, it was aimed to compare infections with multi-drug resistance and extended drug resistance, while evaluating the characteristics of resistant Gram-negative infections in the pediatric intensive care unit in our university hospital. MATERIAL AND METHODS: In this study, pediatric patients who were found to have Gram-negative infections during hsopitalization in the pediatric intensive care unit in our faculty between January 2011 and December 2015, were evaluated retrospectively. RESULTS: One thousand thirty patients were internalized in our unit in the study period. The incidence for healthcare-associated infection was found as 17.2% and the incidence density was found as 32.7 per 1000 patient days. The incidence for healthcare-related infection per 1000 device days and the rate for device use were calculated as 66.9 and 0.59, respectively. One hundred thirty Gram-negative infection episodes were found in 79 patients whose median age was 22 (1-205) months. The most common infections included ventilator-related pneumonia (n=78, 60%) and bloodstream infections (n=38, 29.2%). The most common causative agents included Pseudomonas aeruginosa (n=50, 38.5%), Kleibsiella pneumonia (n=32, 24.6%) and Acinetobacter baumannii (n=28, 21.5%). Among A. baumannii isolates, the rates for resistance against piperacillin-tazobactam and meropenem were found as 96.4% and 89.3%, respectively. Empirical use of carbapenems, aminoglycosides, and fluoroquinolones, the presence of total parenteral nutrition and history of Gram-negative bacterial infections prior to pediatric intensive care unit admission were significantly more common among extended-drug Gram-negative bacterial infections. The late mortality rate was found to be higher in presence of extended drug resistance. History of Gram-negative infection was found to be an independent risk factor in terms of extended drug resistance. CONCLUSION: Healthcare-associated infections are an important health problem and it is important for infection control committees of hospitals to determine and apply strategies according to hospital colonization in prevention.

AMAÇ: Saglik bakimi iliskili enfeksiyonlar yogun bakim birimlerinde yüksek hastalik ve ölüme neden olmaktadir. Bu çalismada, üniversite hastanemiz çocuk yogun bakim birimindeki dirençli gram negatif enfeksiyonlarin özellikleri degerlendirilirken; çok ilaca dirençli ve genisletilmis ilaç direnci olan enfeksiyonlarin karsilastirilmasi amaçlanmistir. GEREÇ VE YÖNTEMLER: Bu çalismada Ocak 2011­Aralik 2015 yillari arasinda, fakültemiz çocuk yogun bakim biriminde yatisi sirasinda gram negatif enfeksiyon saptanan çocuk hastalar geriye dönük olarak degerlendirildi. BULGULAR: Çalisma döneminde birimimize 1 030 hasta yatirildi; saglik bakimi iliskili enfeksiyon sikligi %17,2, siklik yogunlugu 1 000 hasta günü basina 32,7 idi. 1 000 cihaz günü basina saglik bakimi iliskili enfeksiyon sikligi ve cihaz kullanim orani sirasiyla 66,9 ve 0,59 olarak hesaplandi. Yas ortancasi 22 (1­205) ay olan 79 hastada, 130 gram negatif enfeksiyon atagi saptandi. En sik saptanan enfeksiyonlar, ventilatör iliskili pnömoni (n=78, %60) ve kan akim enfeksiyonu (n=38, %29,2) idi. En sik etkenler Pseudomonas aeruginosa (n=50, %38,5), Kleibsiella pneumonia (n=32, %24,6) ve Acinetobacter baumannii (n=28, %21,5) idi. A. baumannii izolatlari arasinda piperasilin-tazobaktam ve meropenem direnci sirasi ile %96,4 ve %89,3 saptandi. Ampirik karbapenem, aminoglikozid ve florokinolon kullanimi, total parenteral nütrisyon varligi, yogun bakim öncesi geçirilmis gram negatif enfeksiyon öyküsü anlamli olarak daha yüksekti. Geç dönem ölüm hizi genisletilmis ilaç direnci varliginda daha yüksek saptandi. Geçirilmis gram negatif enfeksiyon öyküsü, genisletilmis ilaç direnci açisindan bagimsiz risk etmeni olarak bulundu. ÇIKARIMLAR: Saglik bakimi iliskili enfeksiyonlar önemli bir saglik sorunudur ve önlemede mümkünse her hastanenin kendi enfeksiyon kontrol kurulunun hastane kolonizasyonuna göre stratejiler belirleyip uygulamasi önemlidir.

Granulomatous amebic encephalitis caused by Acanthamoeba in an immuncompetent child.

Sütçü M, Aktürk H, Gülümser-Sisko S, Acar M, Erol OB, Somer A, Bilgiç B, Salman N. Granulomatous amebic encephalitis caused by Acanthamoeba in an immuncompetent child. Turk J Pediatr 2018; 60: 340-343. Acanthamoeba may lead to granulomatous amebic encephalitis (GAE) with high mortality rates generally in patients with immunosupression and/or chronic disease. Here, we present a rare GAE case, who was a previously healthy child. A Georgian 9 year old boy presented with focal seizure on his left arm and confusion. Since computed tomography (CT) demonstrated hypodense lesion on right occipital lobe, brain biopsy was performed. Histopathological examination of the biopsy material revealed Acanthamoeba cysts and trophozoites together with granulomatous inflammation. The patient, who had no clinical and laboratory findings consistent with immunedeficiency, was diagnosed as GAE. He was treated with a combination drug therapy. Even if it is very rare, amebic meningoencephalitis may also be seen in immunocompetent children, as in our case. Definitive diagnosis is made by microbiological and histopathological examination of brain biopsy material.

Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey.

OBJECTIVES: The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey. METHODS: A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed. RESULTS: A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies. CONCLUSION: The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.

Evaluation of Short-Term Neurological Outcomes in Children with Brain Abscesses.

AIM: To evaluate the neurological outcomes of children diagnosed with brain abscesses in the early post-treatment period. < b > MATERIAL and METHODS: This study was a retrospective analysis of pediatric brain abscess patients between January 2000 and December 2015, during a 16-years period. Patients were divided into two groups according to their outcome at the end of the treatment. The patients with "good outcome" were the ones without any neurological sequelae [Glasgow Outcome Scale (GOS) score 5]. "Unfavorable outcome" was defined as having any kind of neurological deficit (GOS score 1-4). RESULTS: A total number of 31 patients (22 male, 71%) with the median age at diagnosis of 84 months (range, 1-202 months) were enrolled in this study. The most common presenting symptom was fever being encountered in 71% of the patients (n=22), followed by focal neurological deficit (FND)(n=17, 54.8%), vomiting (n=14, 45.2%), headache (n=13, 41.9%), seizure (n=13, 41.9%), change in mental status (n=12, 38.7%) and visual disturbance (n=2, 6.5%). Twenty-four patients (77.4%) had predisposing factors. The most common pathogens were gram-positive cocci (n=9, 29%). Seventeen patients (54.8%) had unfavorable outcome; 2 patients (6.4%) died. All patients were treated with parenteral antibiotherapy with median duration of 73 days (range, 28-540 days). Surgical procedures were performed in 83.9% (n=26) of patients [isolated aspiration (n=19, 61.3%), only resection (n=5, 16.1%), aspiration and resection (n=2, 6.5%)]. CONCLUSION: Glasgow coma scale score below 12 and the presence of FND on admission were found to be independent risk factors for unfavourable neurological outcome in children with brain abscesses.

Evaluation of Candida species and antifungal susceptibilities among children with invasive candidiasis.

AIM: Non-albicans Candida species and resistant microorganisms have been more commonly isolated in invasive candidiasis in recent years. The aim of this study was to evaluate the distrubution of Candida spp and antifungal resistance in our clinic. MATERIAL AND METHODS: Fifty-four Candida isolates and antifungal susceptibility results obtained from patients diagnosed as having invasive candidiasis between December 2012 and June 2016 were included. Clinical and laboratory data were retrospectively analyzed. E-test method was used in order to determine antifungal susceptibilities of Candida spp for amphotericin B, fluconazole, voriconazole, ketoconazole, itraconazole, anidulafungin, caspofungin, and flucytosine. RESULTS: The clinical diagnoses of the patients were candidemia (n=27, 50%), catheter-related blood stream infection (n=1, 1.8%), urinary tract infection (n=13, 24%), surgical site infection (n=4, 7.4%), intraabdominal infection (n=3, 5.5%), empyema (n=2, 3.7%), and pneumonia (n=4, 7.4%). The most common isolated agent was C. albicans (n=27, 50%) and the others were C. parapsilosis (n=13, 24%), C. tropicalis (n=6, 11.1%), C. glabrata (n=3, 5.6%), C. lusitaniae (n=2, 3.7%), and unspecified Candida spp. (n=3, 5.6%). Fluconazole resistance was 7.4% among all isolates. Resistance against itraconazole, ketoconazole, anidulafungin, voriconazole and caspofungin were 33.3%, 12.5%, 11.1%, 5%, and 2.5%, respectively. Isolates presented intermediate resistance against itraconazole (41.7%), voriconazole (5.6%), and amphotericin B (3.7%) to varying extents. All of the isolates were susceptible to flucytosine. CONCLUSIONS: In our clinic, C. albicans and non-albicans Candida species were equally distributed and antifungal susceptibilities against major antifungal agents such as fluconazole, amphotericin B, and caspofungin were found considerably high.

Clinical Findings of Pediatric HIV Infection in a Tertiary Center in Turkey.

BACKGROUND: Paediatric HIV infection is different from the adult type of disease in many ways, including transmission routes, clinical findings and treatment strategies. AIMS: To evaluate clinical data of paediatric patients with HIV disease. STUDY DESIGN: Retrospective cross-sectional study. METHODS: The charts of 22 paediatric patients diagnosed with HIV infection in our clinic during a 14 year period through 2001-2015 were retrospectively analysed. Clinical data, laboratory findings, treatment modalities and outcomes were recorded. RESULTS: The mean age of diagnosis 61.9±49.2 months and the mean follow-up period was 60.3±37.5 months. Seven patients (31.8%) were foreigners and the most common transmission route was vertical transmission (n=16, 72.7%). The most common presenting symptom and the sign were history of recurrent upper respiratory tract infections (n=8, 36.4%) and lymphadenopathy (n=12, 54.5%), respectively. Recurrent pneumonia (n=6, 27.3%), prolonged fever (n=5, 22.7%), recurrent otitis media (n=4, 18.2%), and gastroenteritis (n=4, 18.2%) were other clinical symptoms. Other than bacterial sinopulmonary infections, tuberculosis was the most frequent opportunistic infection (n=3, 13.6%). Mortality occurred in two patients (9.1%). CONCLUSION: Although mostly vertically transmitted, HIV infection may be diagnosed throughout the childhood. Frequently encountered signs and symptoms may be the reason for doctor admission. High clinical suspicion together with detailed anamnestic data and physical findings constitute the basis for pediatric HIV diagnosis.

Clinical differences of influenza subspecies among hospitalized children.

AIM: Clinical findings, mortality, and morbidity rates differ among influenza subspecies. Awareness of these differences will lead physicians to choose the proper diagnostic and therapeutic strategies and to foresee possible complications. The aim of this study was to evaluate the clinical differences of influenza subspecies among hospitalized children. MATERIAL AND METHODS: Hospitalized children with proven influenza infection by polymerase chain reaction on nasopharyngeal swab specimens in our clinic, between December 2013 and March 2016, were enrolled. These children were divided into 3 groups as Influenza A/H1N1 (n=42), Influenza A/H3N2 (n=23), and Influenza B (n=35). RESULTS: The median age of the children was 51.5 months (range, 3-204 months). The most common presenting symptoms were fever (n=83), cough (n=58), and difficulty in breathing (n=25). The most common non-respiratory findings were lymphadenopathy (n=18) and gastrointestinal system involvement (n=17). Sixty-two percent of the patients (n=62) had chronic diseases. H1N1 and H3N2 were significantly more common among patients with chronic neurologic disorders and renal failure, respectively. Leukopenia (n=32) and thrombocytopenia (n=22) were the most common pathologic laboratory findings. Neutropenia, elevated CRP levels, and antibiotic use were significantly more common among patients with H1N1 infection. Seven patients were transferred to the intensive care unit with diagnoses of acute respiratory distress syndrome (n=4), encephalitis (n=2), and bronchiolitis (n=1). Two patients with chronic diseases and H1N1 infection died secondary to acute respiratory distress syndrome. CONCLUSIONS: Influenza A/H1N1 infection represented more severe clinical disease.

Empyema due to Streptococcus Pneumoniae Serotype 9V in a Child Immunized with 13-Valent Conjugated Pneumococcal Vaccine.

BACKGROUND: Clinical vaccine failure is the occurence of the specific vaccine-preventable disease in an appropriately and fully vaccinated person after enough time has elapsed for protection against the antigens of the vaccine to develop. Fully immunized cases with pneumoccal vaccine may sometimes develop a complicated pneumonia with empyema caused by a vaccine serotype. CASE REPORT: A 2 year-old male patient was admitted with the complaints of fever. On the basis of findings and laboratory results, the patient was diagnosed as having empyema. He was successfully treated with parenteral antibiotics and chest tube drainage. The pleural fluid culture and hemoculture of the patient yielded penicillin-susceptible pneumococci and the isolate was identified as serotype 9V. The patient had been vaccinated with a 13-valent pneumococcal conjugate vaccine according to the Turkish national immunization schedule at 2, 4, 6 and 12 months of age. His medical history and basic immunological profile were inconsistent with a primary immunodeficiency. CONCLUSION: The failure of the PCV13 vaccine may results in a complicated pneumonia with empyema. It is important to investigate serotypes of pneumococci in these cases to determine other possible vaccine failures due to PCV13 and to study the underlying mechanisms.

The prevalence, serogroup distribution and risk factors of meningococcal carriage in adolescents and young adults in Turkey.

The serogroup epidemiology of invasive meningococcal disease (IMD), which varies considerably by geographic region and immunization schedule, changes continuously. Meningococcal carriage data are crucial for assessing IMD epidemiology and designing f potential vaccination strategies. Meningococcal seroepidemiology in Turkey differs from that in other countries: serogroups W and B are the predominant strains for IMD during childhood, whereas no serogroup C cases were identified over the last 10 y and no adolescent peak for IMD was found. There is a lack of data on meningococcal carriage that represents the whole population. The aims of this multicenter study (12 cities in Turkey) were to evaluate the prevalence of Neisseria meningitidis carriage, the serogroup distribution and the related risk factors (educational status, living in a dormitory or student house, being a household contact with Hajj pilgrims, smoking, completion of military service, attending bars/clubs) in 1518 adolescents and young adults aged 10-24 y. The presence of N. meningitidis DNA was tested, and a serogroup analysis was performed using polymerase chain reaction. The overall meningococcal carriage rate was 6.3% (n = 96) in the study population. A serogroup distribution of the 96 N. meningitidis strains isolated from the nasopharyngeal specimens revealed serogroup A in 5 specimens (5.2%), serogroup B in 9 specimens (9.4%), serogroup W in 64 specimens (66.6%), and serogroup Y in 4 specimens (4.2%); 14 were classified as non-grouped (14.4%). No serogroup C cases were detected. The nasopharyngeal meningococcal carriage rate was 5% in the 10-14 age group, 6.4% in the 15-17 age-group, and 4.7% in the 18-20 age group; the highest carriage rate was found in the 21-24 age group (9.1%), which was significantly higher than those of the other age groups (p < 0.05). The highest carriage rate was found in 17-year-old adolescents (11%). The carriage rate was higher among the participants who had had close contact with Hajj/Umrah pilgrims (p < 0.01) or a history of upper respiratory tract infections over the past 3 months (p < 0.05). The nasopharyngeal carriage rate was 6.3% among adolescents and young adults in Turkey and was similar to the recent rates observed in the same age groups in other countries. The most prevalent serogroup was W, and no serogroup C cases were found. In conclusion, the present study found that meningococcal carriage reaches its peak level by age 17, the highest carriage rate was found in 21 - to 24 - year-olds and the majority of the carriage cases were due to serogroup W. Adolescents and young adult carriers seem to be a potential reservoir for the disease, and further immunization strategies, including adolescent immunization, may play a role in the control of IMD.

Ataxia telangiectasia in Turkey: multisystem involvement of 91 patients.

BACKGROUND: Ataxia telangiectasia (AT) is a genetically based multisystemic disorder. We aimed to make a comprehensive evaluation of multisystem involvement in AT by describing clinical features and outcome of 91 patients. METHODS: Medical records of the patients who were diagnosed and followed by a multidisciplinary approach during a 27-year period (1988-2015) were reviewed retrospectively. RESULTS: Forty six female and 45 male patients with a mean follow-up period of 39.13±4.28 months were evaluated. The mean age at the time of symptom onset and diagnosis were 15.4±1.09 months and 73.61±4.11 months, respectively. Neurological abnormalities were progressive truncal ataxia, nystagmus, dysarthria, oculomotor apraxia and choreoathetosis. Thirty one patients (34.1%) became dependent on wheelchair at a mean age of 12.1±2.8 years. Eleven patients (12.1%) became bedridden by a mean age of 14.7±1.8 years. Cranial magnetic resonance imaging revealed pathological findings in 47/66 patients. Abnormal immunological parameters were determined in 51/91 patients: immunoglobulin (Ig)A deficiency (n=38), lymphopenia (n=30), IgG (n=15) and IgG2 (n=11) deficiency. Occurrence of recurrent sinopulmonary infections (n=45) and bronchiectasis (n=22) were found to be more common in patients with impaired immunological parameters (P=0.029 and P=0.023, respectively). Malignancy developed in 5 patients, being mostly lymphoreticular in origin and resulted in death of 4 patients. CONCLUSIONS: AT is a long lasting disease with multisystem involvement necessitating multidisciplinary follow up, as described in our cohort. Early diagnosis of malignancy and supportive treatments regarding pulmonary and neurological health may prolong survival and increase the quality of life.

Tuberculosis screening in pediatric patients receiving TNF-alpha inhibitor therapy.

Tumor necrosis factor-alpha inhibitors (TNFIs) increase the risk of tuberculosis (TB). The aim of this study was to evaluate pediatric patients who are under TNFIs regarding the emergence of TB, and to determine the effectiveness of screening methods. This was a retrospective observational study of 73 patients receiving TNFIs therapy for at least 6 months duration between January 2011 and January 2016. Detailed demographic and clinical data were gathered from patients` files. Seventy-three patients (female n=41, 56.2%) with a median age of 129 (38-215) months were enrolled. Median follow-up period was 18 (6-60) months. Median duration of primary illness prior to TNFI therapy was 24 (2-184) months. Sixteen patients (21.9%) with latent tuberculosis infection (LTBI) were given isoniazid (INH) prior to TNFI therapy. TNFIs were adalimumab (n=39, 53.5%), infliximab (n=22, 30.1%) and etanercept (n=12, 16.4%). During follow-up, 16 patients (21.9%) were started on INH treatment. Median time of starting INH was 20 (4-42) months. One patient (3.1%) who received INH had elevated liver transaminases. One patient (1.3%) developed active TB during follow-up. In conclusion, patients who are candidates for TNFI treatment should be screened for TB before and during therapy.

Acquired Immune Deficiency Syndrome in Differential Diagnosis of Hyper-IgE-Immunoglobulinemia: Pediatric Case Report.

Acquired immune deficiency syndrome can be encountered with hypereosinophilia and hyperimmunoglobulin E (hyper-IgE) values, though these levels are rarely so high to be compared with hyperimmunoglobulin E syndrome. A 9-year-old boy presented with the complaint of fatigue, weakness, weight loss and generalized pruritic rash lasting for a year. He had frequent respiratory tract infections, wheezing episodes and urticarial skin lesions before that. On admission, he was cachectic and he had generalized lymphadenopathy, hepatosplenomegaly, oral moniliasis and pruritic rash all over his body. Laboratory evaluation revealed marked lymphopenia and hypergammaglobulinemia with extremely high IgE values (IgE: 59 300 kU/l). He was diagnosed with stage 4 human immunodeficiency virus (HIV) infection and started on antiretroviral treatment. In conclusion, HIV infection can be presented with increased IgE values.

[Fournier's gangrene after anorectal surgery in infant: Two case reports]. / Süt çocugunda anorektal cerrahi sonrasi gelisen Fournier gangreni: Iki olgu sunumu.

Necrotizing fasciitis is a life-threatening soft tissue infection characterized by progressive necrosis of the skin, subcutaneous tissues and fascia. Fournier's gangrene (FG) is a serious and aggressive form of infective necrotizing fasciitis involving perineal region and genitalia. Presently described are 2 pediatric cases of FG with widespread necrosis of surrounding tissue following anorectal surgery, causing severe septic shock. Case 1: Six-month-old female patient with anal stenosis and duplication presented at emergency clinic with fever, somnolence, irritability, and feeding difficulty. Physical examination upon admission to Intensive Care Unit (ICU) with septic shock determined she had ecchymosis in anal region. At 12fth hour after admission, lesion had become necrotic and patient was started on broad-spectrum antibiotics after surgical debridement. Cultures were negative and patient had complete recovery 2 months after admission. Case 2: Nine-month-old male patient was admitted to ICU for convulsions and sepsis eight hours after fistulectomy. Scrotal, gluteal, and perianal edema and ecchymosis were observed on physical examination. Perianal debridement and colostomy were performed, and patient was given broad-spectrum antibiotics after basic life support strategies for septic shock. Complete recovery was achieved after hyperbaric oxygen treatment for perianal lesion and patient was discharged from the hospital in third month after admission. After anorectal surgery, every patient should be observed carefully for FG. Early debridement, proper antibiotics, and hyperbaric oxygen treatment can be life-saving.

[A pediatric case of HIV who diagnosed by virtue of disseminated cryptococcus infection]. / Yaygin kriptokok enfeksiyonu ile tani konulan pediatrik bir HIV olgusu.

Cryptococcus neoformans is an important opportunistic pathogen that causes serious mortality and morbidity in AIDS patients. Although its incidence has decreased with proper antiretroviral treatment (ART), it is still a major concern in areas with low socioeconomic HIV endemic countries with poor sources of therapy. In our country, pediatric HIV infection and so, HIV-related opportunistic infections are very rare. In order to pay attention to this unusual collaboration; herein, we presented a pediatric case who was diagnosed with HIV and disseminated cryptococcus infection concomitantly. A 6.5-year-old previously healthy girl has admitted to our hospital with the complaints of prolonged fever, cough and hemoptysis. On her physical examination she had oral candidiasis, generalized lymphadenopathy and hepatosplenomegaly. Laboratory findings were as follows; white blood cell count: 3170 µL (neutrophil: 2720 µL, lymphocyte: 366 µL), hemoglobin level: 7.8 gr/dl, hematocrit: 25.5% platelets: 170.000 µL, CRP: 15.2 mg/L and serum IgG level: 1865 mg/dl. Her anti-HIV test yielde,d positive result and confirmed by Western blot assay, together with a high viral load (HIV-RNA: 3.442.000 copies/ml). She was started ART (lamivudine, zidovudine and lopinavir/ritonavir combination) with the diagnosis of stage 3 HIV infection (AIDS). Posteroanterior chest radiograph showed mediastinal extension and nodular parenchyma. Since the patient was suspected to have pulmonary tuberculosis based on the clinical and radiological findings, empirical antituberculosis therapy was started. Because of the insistance of fever, three different blood specimens, bone marrow and gastric aspirates were collected for culture, in which all of them yielded C.neoformans growth. She was then diagnosed as disseminated cryptococcosis and treated with liposomal amphotericin B and fluconazole successfully. Although pediatric HIV infection is usually diagnosed secondary to maternal disease, it can rarely be presented later in life with opportunistic infections. In the case of unusual infectious diseases, in addition to primary immune deficiency syndromes, HIV infection should also be kept in mind. Herein, we discussed a pediatric case with two rare infectious agents reported in our country and wanted to focus on secondary immune deficiency related with pediatric HIV infection.

Bacterial agents causing meningitis during 2013-2014 in Turkey: A multi-center hospital-based prospective surveillance study.

This is an observational epidemiological study to describe causes of bacterial meningitis among persons between 1 month and 18 y of age who are hospitalized with suspected bacterial meningitis in 7 Turkish regions. covering 32% of the entire population of Turkey. We present here the results from 2013 and 2014. A clinical case with meningitis was defined according to followings: any sign of meningitis including fever, vomiting, headache, and meningeal irritation in children above one year of age and fever without any documented source, impaired consciousness, prostration and seizures in those < 1 y of age. Single tube multiplex PCR assay was performed for the simultaneous identification of bacterial agents. The specific gene targets were ctrA, bex, and ply for N. meningitidis, Hib, and S. pneumoniae, respectively. PCR positive samples were recorded as laboratory-confirmed acute bacterial meningitis. A total of 665 children were hospitalized for suspected acute meningitis. The annual incidences of acute laboratory-confirmed bacterial meningitis were 0.3 cases / 100,000 population in 2013 and 0.9 cases/100,000 in 2014. Of the 94 diagnosed cases of bacterial meningitis by PCR, 85 (90.4%) were meningococcal and 9 (9.6%) were pneumococcal. Hib was not detected in any of the patients. Among meningococcal meningitis, cases of serogroup Y, A, B and W-135 were 2.4% (n = 2), 3.5% (n = 3), 32.9% (n = 28), and 42.4% (n = 36). No serogroup C was detected among meningococcal cases. Successful vaccination policies for protection from bacterial meningitis are dependent on accurate determination of the etiology of bacterial meningitis. Additionally, the epidemiology of meningococcal disease is dynamic and close monitoring of serogroup distribution is comprehensively needed to assess the benefit of adding meningococcal vaccines to the routine immunization program.

Influenza in the pediatric population in Istanbul: a one center experience 2009-2014.

INTRODUCTION: The aim of the study was to evaluate the clinical characteristics of pediatric patients with influenza infection. MATERIAL AND METHODS: The patients hospitalized with confirmed influenza between October 2009 and May 2014 were enrolled in this study. RESULTS: The mean age of the patients was 66 ± 53 months (1-204 months). Fifty-four percent of patients had a chronic underlying disease. Twenty-four patients needed mechanical ventilation support and a two-month-old patient with liver disease died. Except for the 2009-2010 season, all patients who received mechanical ventilation had underlying disease. The hospital admission months were December-February in 2010-2011 and January-March in 2011-2012 as well as in 2012-2013. Convulsion was observed frequently in influenza A cases, and influenza B tended to be detected in older patients (p = 0.024). The most common symptoms in pediatric patients were fever and cough. CONCLUSION: It is obvious that to protect against circulating influenza viruses, the risk-based strategy of annual influenza immunization should target school-aged children and children with underlying conditions, especially neurological and pulmonary diseases.

Epidemiologic and microbiologic evaluation of nosocomial infections associated with Candida spp in children: A multicenter study from Istanbul, Turkey.

BACKGROUND: The purpose of this study was to establish species distribution of Candida isolates from pediatric patients in Istanbul, Turkey, and to determine risk factors associated with nosocomial Candida infections. METHODS: This study was conducted between June 2013 and June 2014 by participation of 7 medical centers in Istanbul. Candida spp strains isolated from the clinical specimens of pediatric patients were included. Clinical features were recorded on a standardized data collection sheet. RESULTS: A total of 134 systemic Candida infections were identified in 134 patients. The patients were admitted in pediatric and neonatal intensive care units (41.8% and 9.7%, respectively) and in pediatric wards (48.5%). Candida albicans was the most prevalent species (47%), followed by Candida parapsilosis (13.4%), Candida tropicalis (8.2%), Candida glabrata (4.5%), Candida lusitaniae (3.7%), Candida kefyr (2.2%), Candida guilliermondii (1.5%), Candida dubliniensis (0.7%), and Candida krusei (0.7%). Types of Candida infections were candidemia (50.7%), urinary tract infection (33.6%), surgical site infection (4.5%), central nervous system infection (3.7%), catheter infection (3.7%), and intra-abdominal infection (3.7%). In multivariate analysis, younger age (1-24 months) and detection of non-albicans Candida spp was found to be risk factors associated with candidemia (P = 0.040; odds ratio [OR], 4.1; 95% confidence interval [CI], 1.06-15.86; and P = 0.02; OR, 2.4; 95% CI, 1.10-5.53, respectively). CONCLUSIONS: This study provides an update for the epidemiology of nosocomial Candida infections in Istanbul, which is important for the management of patients and implementation of appropriate infection control measures.

Results of Four-Year Rectal Vancomycin-Resistant Enterococci Surveillance in a Pediatric Hematology-Oncology Ward: From Colonization to Infection.

OBJECTIVE: To investigate the clinical impact of vancomycin-resistant enterococci (VRE) colonization in patients with hematologic malignancies and associated risk factors. MATERIALS AND METHODS: Patients colonized and infected with VRE were identified from an institutional surveillance database between January 2010 and December 2013. A retrospective case-control study was performed to identify the risk factors associated with development of VRE infection in VRE-colonized patients. RESULTS: Fecal VRE colonization was documented in 72 of 229 children (31.4%). Seven VRE-colonized patients developed subsequent systemic VRE infection (9.7%). Types of VRE infections included bacteremia (n=5), urinary tract infection (n=1), and meningitis (n=1). Enterococcus faecium was isolated in all VRE infections. Multivariate analysis revealed severe neutropenia and previous bacteremia with another pathogen as independent risk factors for VRE infection development in colonized patients [odds ratio (OR): 35.4, confidence interval (CI): 1.7-72.3, p=0.02 and OR: 20.6, CI: 1.3-48.6, p=0.03, respectively]. No deaths attributable to VRE occurred. CONCLUSION: VRE colonization has important consequences in pediatric cancer patients.

Carbapenem-resistant Klebsiella pneumoniae colonization in pediatric and neonatal intensive care units: risk factors for progression to infection

Abstract Background Little is known about factors associated with carbapenem-resistant Klebsiella pneumoniae infections in pediatric patients, who are initally colonized with carbapenem-resistant Klebsiella pneumoniae. Materials and methods A retrospective case–control study was conducted involving pediatric and neonatal intensive care units throughout a five-year period (January 2010–December 2014). Clinical and microbiological data were extracted from Hospital Infection Control Committee reports and patients’ medical records. Risk factors were assessed in carbapenem-resistant Klebsiella pneumoniae colonized patients who developed subsequent systemic infection (cases) and compared to carbapenem-resistant Klebsiella pneumoniae colonized patients who did not develop infection (controls). Results Throughout the study period, 2.6% of patients admitted to neonatal intensive care units and 3.6% of patients admitted to pediatric intensive care units had become colonized with carbapenem-resistant Klebsiella pneumoniae. After a mean of 10.6 ± 1.9 days (median: 7 days, range: 2–38 days) following detection of colonization, 39.0% of the carbapenem-resistant Klebsiella pneumoniae colonized patients in pediatric intensive care units and 18.1% of carbapenem-resistant Klebsiella pneumoniae colonized patients in neonatal intensive care units developed systemic carbapenem-resistant Klebsiella pneumoniae infection. Types of systemic carbapenem-resistant Klebsiella pneumoniae infections included bacteremia (n = 15, 62.5%), ventilator-associated pneumonia (n = 4, 16.6%), ventriculitis (n = 2, 8.3%), intraabdominal infections (n = 2, 8.3%), and urinary tract infection (n = 1, 4.1%). A logistic regression model including parameters found significant in univariate analysis of carbapenem resistant Klebsiella pneumoniae colonization and carbapenem resistant Klebsiella pneumoniae infection groups revealed underlying metabolic disease (OR: 10.1; 95% CI: 2.7–37.2), previous carbapenem use (OR: 10.1; 95% CI: 2.2–40.1), neutropenia (OR: 13.8; 95% CI: 3.1–61.0) and previous surgical procedure (OR: 7.4; 95% CI: 1.9–28.5) as independent risk factors for carbapenem-resistant Klebsiella pneumoniae infection in patients colonized with carbapenem-resistant Klebsiella pneumoniae. Out of 24 patients with carbapenem resistant Klebsiella pneumoniae infection, 4 (16.6%) died of carbapenem-resistant Klebsiella pneumoniae sepsis. Conclusion Asymptomatic colonization with carbapenem-resistant Klebsiella pneumoniae in intensive care units of pediatric departments should alert health care providers about forthcoming carbapenem-resistant Klebsiella pneumoniae infection. Those carbapenem-resistant Klebsiella pneumoniae colonized patients at risk of developing infection due to carbapenem-resistant Klebsiella pneumoniae may be targeted for interventions to reduce subsequent infection occurence and also for timely initiation of empirical carbapenem-resistant Klebsiella pneumoniae active treatment, when necessary.