Neumonía adquirida en la comunidad: tratamiento ambulatorio y prevención / Community acquired pneumonia in children: Outpatient treatment and prevention

La neumonía adquirida en la comunidad (NAC) en la edad pediátrica ha sufrido, en la última década, una serie de cambios epidemiológicos, clínicos, etiológicos y de resistencias a antibióticos, que obligan a replantear su abordaje terapéutico. En este documento, dos de las principales sociedades de especialidades pediátricas involucradas en el diagnóstico y tratamiento de esta entidad, como son la Sociedad Española de Infectología Pediátrica y la Sociedad Española de Neumología Pediátrica, así como el Comité Asesor de Vacunas de la AEP, proponen unas pautas consensuadas de tratamiento y prevención, con el fin de proporcionar a todos los pediatras una guía actualizada. En esta primera parte del consenso, se aborda el tratamiento de los pacientes sin enfermedades de base relevantes con NAC que no precisan ingreso hospitalario, así como la prevención global de esta patología con vacunas. En un siguiente documento se expondrá el abordaje terapéutico tanto de aquellos pacientes en situaciones especiales como de las formas complicadas de la enfermedad

There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes relate to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating CAP. In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a next second part, special situations and complicated forms will be addressed

Neumonía adquirida en la comunidad: tratamiento de los casos complicados y en situaciones especiales. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y Sociedad Española de Neumología Pediátrica (SENP) / Community acquired pneumonia in children: Treatment of complicated cases and risk patients. Consensus statement by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Chest Diseases (SENP)

Desde hace más de una década, los casos complicados de neumonía adquirida en la comunidad, fundamentalmente con empiema pleural o formas necrosantes, comenzaron a ser más frecuentes en niños, según la amplia documentación procedente de numerosos países. El abordaje terapéutico óptimo de estos casos, tanto desde el punto de vista médico (antibióticos, fibrinolíticos) como técnico-quirúrgico, (drenaje pleural, videotoracoscopia) continúa siendo controvertido. En este documento, la Sociedad Española de Infectología Pediátrica y la Sociedad Española de Neumología Pediátrica revisan la evidencia científica y proponen unas pautas consensuadas de tratamiento de estos casos, fundamentalmente para el abordaje del derrame pleural paraneumónico en niños, así como la actuación en situaciones especiales, sobre todo en la cada vez más frecuente población pediátrica con enfermedades de base o inmumodepresión

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression

[Community acquired pneumonia in children: Treatment of complicated cases and risk patients. Consensus statement by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Chest Diseases (SENP)]. / Neumonía adquirida en la comunidad: tratamiento de los casos complicados y en situaciones especiales. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y Sociedad Española de Neumología Pediátrica (SENP).

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.

[Community acquired pneumonia in children: Outpatient treatment and prevention]. / Neumonía adquirida en la comunidad: tratamiento ambulatorio y prevención.

There have been significant changes in community acquired pneumonia (CAP) in children in the last decade. These changes relate to epidemiology and clinical presentation. Resistance to antibiotics is also a changing issue. These all have to be considered when treating CAP. In this document, two of the main Spanish pediatric societies involved in the treatment of CAP in children, propose a consensus concerning therapeutic approach. These societies are the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases. The Advisory Committee on Vaccines of the Spanish Association of Paediatrics (CAV-AEP) has also been involved in the prevention of CAP. An attempt is made to provide up-to-date guidelines to all paediatricians. The first part of the statement presents the approach to ambulatory, previously healthy children. We also review the prevention with currently available vaccines. In a next second part, special situations and complicated forms will be addressed.

La bronquiolitis grave en lactantes menores de seis meses es un factor de riesgo para las sibilancias recurrentes / Severe bronchiolitis in infants under six months is a major risk factor for recurrent wheezing

Introducción y objetivos: diversos factores de riesgo se han asociado con las sibilancias recurrentes después de la bronquiolitis aguda (BA). El objetivo es conocer los factores de riesgo asociados con las sibilancias recurrentes en lactantes (menores de seis meses) previamente sanos hospitalizados con BA en nuestro medio. Material y métodos: estudio observacional, retrospectivo desde enero de 2009 hasta diciembre 2010. Se incluyeron 80 pacientes. Resultados: la media de edad de los niños fue de 69±42 (rango 7-180) días. En el análisis crudo de riesgo relativo (RR) se obtuvo un aumento del RR de sibilancias recurrentes en los pacientes que acudían la guardería (p=0,03; RR: 1,9; intervalo de confianza del 95% [IC 95%]: 1,1 a 3,3), aquellos con hermanos mayores (p=0,03; RR: 2,2; IC 95%: 0,9 a 5,1), pacientes con necesidad de sistemas de alto flujo humidificado y calentado (p=0,05; RR: 2,1; IC 95%: 1,3 a 3,6), ingresados en Cuidados Intensivos (p=0,01; RR: 2,5; IC 95%: 1,06 a 3,08), y con ventilación mecánica (p=0,05; RR: 2,7; IC 95%: 2,0 a 3,7). Tras el análisis multivariante, la asistencia a guardería (odds ratio [OR]: 6,06; IC 95%: 1,4 a 25; p=0,013) y tener hermanos mayores (OR: 4,1; IC 95%: 1,1 a 14,5; p=0,029) resultaron ser factores de riesgo independientes para las sibilancias recurrentes. Conclusiones: la asistencia a la guardería y tener hermanos mayores se asociaron de forma independiente con el diagnóstico de sibilancias recurrentes. Se sugiere que la gravedad de la bronquiolitis es un factor de riesgo notable para desarrollar sibilancias recurrentes un año después de la BA (AU)

Background: several individual and epidemiological risk factors have been associated with recurrent wheezing after acute bronchiolitis (AB). Few research studies focus on very young infants under six months old. Objectives: to find what risk factors are associated with recurrent wheezing in young infants (<6 month-old) hospitalized with moderate to severe acute bronchiolitis (AB) at our setting. Material and methods: a prospective-retrospective, observational study was designed and carried out from January 2009 to December 2011 in a secondary care hospital. Eighty previously healthy patients aged 7-180 days, hospitalized with a first episode of acute moderate AB, were studied. Results: the mean age of infants was 69±42 (range 7-180) days. Crude analysis of relative risk (RR) for recurrent wheezing showed an increased RR in males (p=0.05, RR=1.7 CI 95%: 0.9-3.1), patients in daycare (p=0.03, RR=1.9 CI 95%: 1.1-3.3), with elder siblings (p=0.03, RR=2.2 CI 95%: 0.9-5.1), high-flow therapy (p=0.05, RR=2.1 CI 95%: 1.3-3.6), critical care (p=0.01, RR=2.5 CI 95%: 1.6-3.8), and mechanical ventilation (p=0.05, RR=2.7 CI 95%: 2.0-3.7). After multivariate analysis, daycare attention (OR: 6.06, CI 95%: 1.4-25; p=0.013) and having elder siblings (OR: 4.1, CI 95% 1.1-14.5, p=0.029) were found to be independent risk factors for recurrent wheezing. Conclusions: daycare attendance and having elder siblings were independently associated with recurrent wheezing. We suggest that severity of bronchiolitis (needing PICU, high flow therapy and mechanical ventilation) is a remarkable risk factor for recurrent wheezing one year after AB (AU)

Brote de 22 casos de sarampión autóctono en la zona norte de Madrid / Outbreak of measles in the population of Spanish origin in North Madrid

Tras estar prácticamente erradicado en Europa, en los últimos 3 años han aparecido miles de casos de sarampión autóctono. Se describen los casos ocurridos en la zona norte de Madrid (enero-junio de 2011).Se informa de 22 casos, 18 de ellos agrupados en 2 brotes (2 escuelas infantiles). La tasa de ataque del principal fue del 29%.Todos fueron en pacientes no vacunados (mediana=14 meses). El genotipo predominante fue el D4 (95%). Hubo un 45% de complicaciones y un 45% de ingresos. El Servicio de Salud Pública recomendó aislar a los casos y vacunó anticipadamente a los contactos susceptibles. En los centros sanitarios se estableció un circuito específico para atender a los casos sospechosos. Se ha adelantado la vacunación triple vírica de los 15 a los 12 meses en la Comunidad de Madrid. El sarampión es una enfermedad re-emergente en Europa. El manejo coordinado entre Salud Pública y los centros asistenciales es fundamental para limitar los brotes(AU)

After being virtually eradicated in Europe, thousands of cases of measles in the population of Spanish origin have appeared in the last 3 years. We describe the cases diagnosed in the north of Madrid between January and June 2011. A total of 22 cases are reported, 18 of them grouped in 2 outbreaks (2 nurseries). The primary attack rate was 29% in the main outbreak. All cases were in unvaccinated patients (median = 14 months). Genotype D4 was predominant (95%). There was a 45% complication rate and 45% were admitted to hospitals. The Public Health Service recommended isolating cases and vaccinating susceptible contacts in advance. Health Centres established a specific protocol to respond to suspected cases. The Measles vaccination has been brought forward from 15 to 12 months in Madrid. Measles is a re-emerging disease in Europe. The coordinated management between public health and health facilities is essential to limiting outbreaks(AU)

[Outbreak of measles in the population of Spanish origin in North Madrid]. / Brote de 22 casos de sarampión autóctono en la zona norte de Madrid.

After being virtually eradicated in Europe, thousands of cases of measles in the population of Spanish origin have appeared in the last 3 years. We describe the cases diagnosed in the north of Madrid between January and June 2011. A total of 22 cases are reported, 18 of them grouped in 2 outbreaks (2 nurseries). The primary attack rate was 29% in the main outbreak. All cases were in unvaccinated patients (median = 14 months). Genotype D4 was predominant (95%). There was a 45% complication rate and 45% were admitted to hospitals. The Public Health Service recommended isolating cases and vaccinating susceptible contacts in advance. Health Centres established a specific protocol to respond to suspected cases. The Measles vaccination has been brought forward from 15 to 12 months in Madrid. Measles is a re-emerging disease in Europe. The coordinated management between public health and health facilities is essential to limiting outbreaks.

Parotiditis aguda supurativa neonatal / Acute neonatal suppurative parotitis

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[Parental perception of PICU end-of-life care and areas of improvement]. / Percepción subjetiva de los padres sobre los cuidados al final de la vida en una UCIP y cómo mejorarlos.

INTRODUCTION: We developed a study to investigate how end-of-life care is delivered in our PICU. It was based on questionnaires. Questionnaires are incomplete tools to study perceptions. Knowing this, information was completed by interviewing some parents. OBJECTIVE: To know in depth the parental perception on potential improvements relating to end of life care in the PICU. METHODS: Long and probing interviews with parents of deceased children. Answers were analyzed through content analysis (qualitative methodology). RESULTS: Eleven parents and/or mothers agreed to meet for an interview. They mentioned that end-of-life care may be improved in the following areas: information and communication, attention to families, death and after-death time, Unit organization, children care during admittance, and empathy from the staff. CONCLUSIONS: It is possible to obtain information about end-of-life care by asking parents. Content analysis provides us with useful knowledge to face child death and improve care. The main areas to improve are related with family-centered care.

Percepción subjetiva de los padres sobre los cuidados al final de la vida en una UCIP y cómo mejorarlos / Parental perception of PICU end-of-life care and areas of improvement

Introducción: Se llevó a cabo un estudio para examinar la idoneidad de los cuidados al final de la vida proporcionados en una unidad de cuidados intensivos pediátricos (UCIP), basado principalmente en cuestionarios. Los cuestionarios son una herramienta incompleta para estudiar percepciones y vivencias. Por ello, se complementó la información haciendo entrevistas largas a algunos padres. Objetivos: Conocer en profundidad la percepción de los padres sobre cómo mejorar los cuidados al final de la vida en la UCIP. Métodos: Entrevistas largas con padres de niños fallecidos en la UCIP. Análisis del contenido de las entrevistas (metodología cualitativa). Resultados: Accedieron a una entrevista 11 padres y/o madres. Refirieron que la atención al final de la vida podría mejorar en los siguientes aspectos: información y comunicación, atención a los familiares, los momentos del fallecimiento e inmediatos a éste, la estructura y funcionamiento de la unidad, cuidados del niño durante el ingreso y actitud de empatía por parte del personal. Conclusiones: Es posible obtener información de cómo se llevan a cabo los cuidados al final de la vida preguntando a los padres. El análisis del contenido de sus respuestas nos aporta un conocimiento útil para afrontar el fallecimiento de los niños. Los ámbitos fundamentales de mejora se refieren a la atención a las familias

Introduction: We developed a study to investigate how end-of-life care is delivered in our PICU. It was based on questionnaires. Questionnaires are incomplete tools to study perceptions. Knowing this, information was completed by interviewing some parents. Objective: To know in depth the parental perception on potential improvements relating to end of life care in the PICU. Methods: Long and probing interviews with parents of deceased children. Answers were analyzed through content analysis (qualitative methodology). Results: Eleven parents and/or mothers agreed to meet for an interview. They mentioned that end-of-life care may be improved in the following areas: information and communication, attention to families, death and after-death time, Unit organization, children care during admittance, and empathy from the staff. Conclusions: It is possible to obtain information about end-of-life care by asking parents. Content analysis provides us with useful knowledge to face child death and improve care. The main areas to improve are related with family-centered care

[End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and parental evaluation]. / Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres.

OBJECTIVES: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). METHODS: Retrospective study developed in a PICU. SUBJECTS: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. RESULTS: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. CONCLUSIONS: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments.

Cuidados al final de la vida en una unidad de cuidados intensivos pediátricos: evaluación por parte del personal y de los padres / End-of-life care in a Spanish Pediatric Intensive Care Unit: staff and Parental Evaluation

Objetivos: Evaluar los cuidados al final de la vida en una unidad de cuidados intensivos pediátricos (UCIP). Métodos: Estudio retrospectivo desarrollado en una UCIP. Los sujetos fueron 41 trabajadores de la UCIP y los padres de 26 niños fallecidos entre 2001 y 2005. Se diseñó un cuestionario para evaluar los cuidados al final de la vida proporcionados en este período. Resultados: La edad inferior a 1 año y las enfermedades crónicas o congénitas son las variables que se correlacionaron con una mayor percepción de incoherencia en la información. Cerca del 38 % de los padres estuvieron junto a sus hijos en el momento del fallecimiento; el 64 % de ellos consideran estar presentes algo positivo, y el 13 %, algo negativo. El 40 % del personal declaró que es positivo para los padres estar al lado de sus hijos en el momento del fallecimiento, y el 52 % no sabía si era positivo o negativo. El 73 % del personal, pero sólo el 29 % de los padres, desearía apoyo psicológico profesional para los padres. El 20 % de los niños fallecieron tras la retirada del soporte vital. Los factores más importantes para esta decisión fueron la posibilidad de supervivencia y la calidad de vida. La mayoría de los sanitarios expresaron que, a menudo, esta decisión debería haber sido tomada antes. Conclusiones: El análisis del personal subraya la importancia del cómo las noticias son comunicadas, del momento de retirada del soporte vital y la necesidad del apoyo psicológico. Los padres enfatizan más el papel de la familia en la UCIP y durante los últimos momentos (AU)

Objectives: To evaluate end-of-life care in a Paediatric Intensive Care Unit (PICU). Methods: Retrospective study developed in a PICU. Subjects: 41 workers from the PICU and parents of 26 deceased children (from 2001 to 2005). A questionnaire was designed to investigate end-of-life care. Results: An age < 1-year old and a chronic or congenital disease correlated with a perceived lack of consistency in information. Nearly 38 % parents were with their children at the time of death; 64 % of all parents consider this "positive", and 13 % consider it "negative". Forty per cent of staff stated that it is "positive" for parents to be by the side of their child at the time of death, and 52 % do not know. Seventy-three per cent of staff, but only 29 % of parents want further professional psychological support for parents. Twenty per cent of children died following withdrawal of life support. The most important factors for this decision were the possibility of survival and quality of life. The majority (73 %) of caregivers express the view that often, this decision should be taken earlier. Conclusions: Analysis of staff opinions underlines the importance of the way news is communicated, the timing of withdrawal of life support, and the need for psychological support. Parents emphasized the role of the family during time spent in a PICU and during the last moments (AU)

Disfunción faríngea congénita aislada / Congenital isolted pharyngeal dysfunction

Presentamos el caso de un paciente con disfagia congénita, cuyas características se corresponden con las de la disfunción faríngea congénita aislada: episodios de atragantamiento y/o aspiración con regurgitación nasal durante las tomas, facies hipomímica con ligeros rasgos dismórficos y moderado retraso psicomotor, sin apenas reseñable hipotonía. En él fueron excluidas las causas anatómicas o neurológicas de disfagia. Su evolución fue algo tórpida, con procesos respiratorios repetidos, y se apreció una clara mejoría a partir del año de edad. Su hermano presentó síntomas similares más leves, lo que apoyaría el posible carácter hereditario de esta enfermedad

We report the case of a patient with congenital dysphagia in which the clinical features were similar to those associated with congenital isolated pharyngeal dysfunction: episodes of airway obstruction and aspiration events with nasal regurgitation during oral feeding, hypomimic face with mildly dysmorphic features and slightly retarded psychomotor development; hypotonia was nearly undetectable. There was no evidence of anatomical or neurological causes. The patient suffered repeated episodes of respiratory distress, with clear improvement of all his symptoms after his first birthday. His brother developed similar, although milder, symptoms, a circumstance that indicates the hereditary nature of this condition

[Tuberculous meningitis: a review of 27 years]. / Meningitis tuberculosa: revisión de 27 años.

OBJECTIVES: To analyze the features and outcome of children with tuberculous meningitis (TM) in a tertiary hospital in Madrid, with special emphasis on the possible influence of HIV infection, immigration and withdrawal of the Bacille-Calmette-Guérin (BCG) vaccine in Madrid in 1987. METHODS: We reviewed the medical records of patients with TM diagnosed over a 27-year period (1977-2003). TM was diagnosed on the basis of compatible cytochemical findings in cerebrospinal fluid (CSF), plus a) isolation of Mycobacterium tuberculosis in CSF or gastric fluid; b) positive Mantoux test, or c) previous contact with active tuberculosis. RESULTS: Twenty-eight cases of TM were diagnosed. There were 24 cases (85 %) in the first 14 years versus only four cases (15 %) in the last 13 years. None of the children was co-infected with HIV. The median age was 3 years and 4 months. Only two of these had received the BCG vaccine. The source of infection was identified in 64 %. At admission, 57 % had nuchal rigidity, 46 % had neurological focality, and 54 % had an abnormal chest roentgenogram. The Mantoux purified protein derivative (PPD) test was positive in 89 % at diagnosis. Zhiel-Nielsen smear in CSF was positive in 3.5 %, and a positive culture from CSF was obtained in 32 %. Computed tomography scan was performed in 22 children and showed hydrocephalus in 90 %. All patients were treated with four drugs, with no significant adverse events. Corticoids (89 %), ventricular-peritoneal shunt (43 %) and antiepileptic drugs (39 %) were widely used as complementary treatments. Mortality was 12 %. Half of the patients had sequels, which were mostly permanent. The most frequent and severe complication was neurodevelopmental delay (21 %). Severe sequels occurred in children with more advanced stages of illness. CONCLUSIONS: The frequency of TM has decreased in the last 15 years, despite the emergence of HIV and immigration from countries where tuberculosis is endemic. These data are in agreement with the general reduction of the incidence of TM in our environment. Withdrawal of the BCG vaccine in Madrid in 1987 did not increase cases of TM in our hospital; on the contrary, these have decreased. A considerable percentage of children with advanced stages of TM show severe sequels.

Meningitis tuberculosa: revisión de 27 años / Tuberculous meningitis: a review of 27 years

Objetivos: Analizar las características de los pacientes con meningitis tuberculosa en un hospital terciario, con especial interés en el posible impacto de la supresión de la vacuna de bacilo de Calmette-Guérin (BCG) (1987), la inmigración y de la infección por el virus de la inmunodeficiencia humana (VIH). Métodos: Se revisaron las historias clínicas de los casos de meningitis tuberculosa diagnosticados a lo largo de 27 años (1977-2003). Se consideró meningitis tuberculosa cuando existía un líquido cefalorraquídeo (LCR) con una citoquímica compatible, más: a) aislamiento de Mycobacterium tuberculosis en jugo gástrico o LCR; b) prueba de tuberculina positiva, o c) contacto con tuberculosis activa. Resultados: Se diagnosticaron 28 casos de meningitis tuberculosa. Durante los primeros 14 años hubo 24 casos (85 %), y durante los últimos 13 años tan sólo 4 casos (15%). No hubo ningún niño coinfectado por el VIH. La mediana de la edad fue 3 años y 4 meses. En dos de ellos existía vacunación previa con BCG. En el 64 % de los casos se localizó el foco de contagio. Al ingreso, el 57 % presentaba signos meníngeos, el 46 % focalidad neurológica y el 54 % radiografía de tórax anormal. La prueba de tuberculina fue positiva en el 89% de los casos. La tinción de Ziehl-Neelsen en LCR fue positiva en el 3,5 %. Se cultivó el bacilo en LCR en el 32 % de los pacientes. La tomografía computarizada (TC), practicada en 22 pacientes, mostró hidrocefalia en el 91 % de los niños. Todos fueron tratados durante un año, sin efectos secundarios significativos. Como tratamientos complementarios se han utilizado corticoterapia (89 %), derivación ventriculoperitoneal (43 %) y anticomiciales (39 %). Fallecieron 3 pacientes (12 %). El 50 % de los casos tuvo secuelas, en su mayoría permanentes; la más grave y frecuente fue el retraso psicomotor (21 %), principalmente en niños con estadios avanzados de la enfermedad. Conclusiones: La meningitis tuberculosa ha disminuido durante los últimos 15 años, a pesar de la emergencia del VIH y a la inmigración desde países endémicos para tuberculosis. Estos datos se corresponden con la disminución general de la incidencia de meningitis tuberculosa en nuestro medio. La supresión de la vacuna BCG en 1987 en Madrid no ha llevado a un aumento en los casos vistos en nuestro hospital; al contrario, han disminuido. Hay un porcentaje importante de secuelas graves en niños con estadios avanzados

Objectives: To analyze the features and outcome of children with tuberculous meningitis (TM) in a tertiary hospital in Madrid, with special emphasis on the possible influence of HIV infection, immigration and withdrawal of the Bacille-Calmette- Guérin (BCG) vaccine in Madrid in 1987. Methods: We reviewed the medical records of patients with TM diagnosed over a 27-year period (1977-2003). TM was diagnosed on the basis of compatible cytochemical findings in cerebrospinal fluid (CSF), plus a) isolation of Mycobacterium tuberculosis in CSF or gastric fluid; b) positive Mantoux test, or c) previous contact with active tuberculosis. Results: Twenty-eight cases of TM were diagnosed. There were 24 cases (85 %) in the first 14 years versus only four cases (15 %) in the last 13 years. None of the children was co-infected with HIV. The median age was 3 years and 4 months. Only two of these had received the BCG vaccine. The source of infection was identified in 64 %. At admission, 57 % had nuchal rigidity, 46 % had neurological focality, and 54 % had an abnormal chest roentgenogram. The Mantoux purified protein derivative (PPD) test was positive in 89 % at diagnosis. Zhiel-Nielsen smear in CSF was positive in 3.5 %, and a positive culture from CSF was obtained in 32 %. Computed tomography scan was performed in 22 children and showed hydrocephalus in 90%. All patients were treated with four drugs, with no significant adverse events. Corticoids (89 %), ventricular-peritoneal shunt (43 %) and antiepileptic drugs (39 %) were widely used as complementary treatments. Mortality was 12 %. Half of the patients had sequels, which were mostly permanent. The most frequent and severe complication was neurodevelopmental delay (21 %). Severe sequels occurred in children with more advanced stages of illness. Conclusions: The frequency of TM has decreased in the last 15 years, despite the emergence of HIV and immigration from countries where tuberculosis is endemic. These data are in agreement with the general reduction of the incidence of TM in our environment. Withdrawal of the BCG vaccine in Madrid in 1987 did not increase cases of TM in our hospital; on the contrary, these have decreased. A considerable percentage of children with advanced stages of TM show severe sequels

[Fiberoptic bronchoscopy in childhood endobronchial tuberculosis]. / Fibrobroncoscopia en la tuberculosis endobronquial.

BACKGROUND: Endobronchial tuberculosis is a classical manifestation of primary tuberculosis in childhood. Fiberoptic bronchoscopy (FB) is an ancillary diagnostic tool, but its utility and indications are not well established. OBJECTIVES: To analyze the FB performed over 11 years (1992-2003) in children with a diagnosis of tuberculosis and to review the literature. A further aim was to establish the current usefulness of FB in children with tuberculosis and propose criteria to determine the indications for FB in this population. METHODS: We report a retrospective series (n 5 16). FB was indicated in children who showed any of the following findings in chest roentgenogram: a) persistent parenchymal consolidation; b) lymphadenopathy and consolidation; c) hyperinsufflation (emphysema); d) atelectasias, and e) airway narrowing caused by lymphadenopathies. Published series on the topic were reviewed and six studies were suitable for comparison with our own. RESULTS: Endobronchial tuberculosis was found in seven children (43 %) and extrinsic compression was found in three (18 %). The microbiological results obtained from FB samples were not superior to those obtained from classical diagnostic methods. The sensitivity of the proposed criteria for suspicion of endobronchial tuberculosis was 71 %. Endoscopic findings justified a change in therapy in 50 % of the children (addition of corticoids or surgery) and this percentage was similar to that reported in other series. CONCLUSIONS: FB does not usually improve microbiological diagnosis of tuberculosis but can be useful when choosing the most appropriate therapy in children with suspected endobronchial tuberculosis. In some cases, computed tomography may make FB unnecessary, but in others this procedure can be therapeutic (obstruction due to caseum, atelectasias). Establishing the indications for FB in childhood tuberculosis is difficult, but the proposed criteria may be an acceptable guide to identifying which patients could benefit most from this procedure. Not all children with endobronchial tuberculosis require corticoids.

Fibrobroncoscopia en la tuberculosis endobronquial / Fiberoptic bronchoscopy in childhood endobronchial tuberculosis

La tuberculosis endobronquial (TBE) es una manifestación típica de la tuberculosis primaria infantil. La fibrobroncoscopia es una técnica que ayuda a su diagnóstico, pero ni su utilidad ni sus indicaciones están claramente definidas. Objetivos Analizar las fibrobroncoscopias llevadas a cabo a lo largo de 11 años (1992-2003) en niños con diagnóstico de tuberculosis, y realizar una revisión de la literatura especializada. Intentar establecer la utilidad actual de la fibrobroncoscopia en la tuberculosis infantil, y proponer unos criterios para determinar la indicación de esta técnica en estos niños. Métodos Se presenta una serie retrospectiva de 16 pacientes. Se indicó fibrobroncoscopia a los niños que presentaban en la radiografía de tórax: a) consolidación parenquimatosa persistente; b) adenopatía y consolidación; c) hiperinsuflación (enfisema); d) atelectasia, o e) estrechamiento de las vías respiratorias por adenopatías. Se revisaron las series publicadas sobre este tema, rescatándose 6 con valor para la comparación con la nuestra. Resultados Se encontró TBE en 7 niños (43 por ciento) y en tres (18 por ciento) compresión exclusivamente extrínseca. Los resultados de la microbiología a través de la fibrobroncoscopia no mejoraron a los métodos diagnósticos clásicos. La sensibilidad de los criterios radiológicos utilizados para sospechar TBE fue del 71 por ciento. Los hallazgos endoscópicos justificaron un cambio en el tratamiento en el 50 por ciento de los niños (adición de corticoides o cirugía), cifra similar a otras series. Conclusiones La fibrobroncoscopia no suele mejorar el diagnóstico microbiológico de la tuberculosis, pero es una herramienta útil en nuestro medio para decidir el tratamiento más adecuado de los niños con sospecha de TBE. En algunos casos, la tomografía computarizada (TC) puede hacerla innecesaria, pero en otros la fibrobroncoscopia puede ser, además, terapéutica (obstrucción por caseum, atelectasias). Es difícil establecer indicaciones de fibrobroncoscopia en casos de tuberculosis infantil, pero los criterios propuestos pueden ser una guía aceptable para determinar qué pacientes se beneficiarían más. No todos los niños con TBE necesitan corticoides (AU)

Bacteriemia por Salmonella no typhi en niños: revisión de 11 años / Non-typhi salmonella bacteremia in children: an 11-year review

Objetivos: Revisar los aspectos clínicos y bacteriológicos de los pacientes pediátricos con bacteriemia por Salmonella no typhi (SNT).Métodos Se revisaron las historias clínicas de niños menores de 14 años con hemocultivo positivo para SNT en un hospital de referencia de Madrid durante los últimos 11 años. Resultados: Se diagnosticaron un total de 29 casos de bacteriemia por SNT y fueron analizados 27 de ellos. La edad media fue de 11,1 meses (rango de 3 días a 11 años); 46 por ciento eran menores de un año. Once niños (41 por ciento) tenían una enfermedad de base. Éstas incluían 7 inmunodeficiencias (3 pacientes oncológicos, uno con déficit de IgA-IgG2, uno con enfermedad granulomatosa crónica, uno con infección por virus de la inmunodeficiencia humana (VIH) y uno con lupus eritematoso sistémico en tratamiento con corticoides), tres enfermedades hepáticas y una encefalopatía hipóxico-isquémica. Las manifestaciones clínicas en la primera visita fueron: fiebre superior a 39 °C (86 por ciento), diarrea (66 por ciento), y vómitos (37 por ciento). Dos pacientes presentaron bacteriemia oculta. Tres niños (11 por ciento) requirieron cuidados intensivos por sepsis grave. Cinco pacientes presentaron infecciones extraintestinales focales: 2 artritis, 1 osteomielitis, 1 infección del tracto urinario y 1 neumonía. Ninguno de los niños presentó meningitis o falleció como consecuencia de la infección por Salmonella. Los serogrupos más frecuentemente aislados fueron Salmonella D9 y B4-5 (38 por ciento cada una). Once cepas (38 por ciento) fueron resistentes a amoxicilina y 5 (17 por ciento) resistentes a cotrimoxazol. Sólo un paciente desarrolló bacteriemia persistente. Todos los niños se recuperaron completamente sin complicaciones. Conclusiones: La bacteriemia por SNT es una entidad infrecuente pero debe ser considerada en lactantes y niños inmunocomprometidos. Aunque pueden existir complicaciones focales, estos niños suelen recuperarse completamente con tratamiento antimicrobiano apropiado (AU)

[Non-typhi Salmonella bacteremia in children: an 11-year review]. / Bacteriemia por Salmonella no typhi en niños: revisión de 11 años.

OBJECTIVES: To review the clinical and bacteriological features of pediatric patients with non-typhi Salmonella (NTS) bacteremia. METHODS: We reviewed the medical records of children aged less than 14 years with culture-proven NTS bacteremia in the previous 11 years in a referral hospital in Madrid, Spain. RESULTS: A total of 29 cases of NTS bacteremia were diagnosed. Of these, 27 were used for study purposes. The mean age was 11.1 months (range: 3 days to 11 years); 48% were infants aged < 1 year. Eleven children (41%) had an underlying disease. These included immunodeficiency in seven (malignant disease in three, IgA-IgG2 deficit in one, chronic granulomatous disease in one, HIV infection in one, and systemic lupus erythematosus in one patient on steroid treatment), liver disease in three, and hypoxic-ischemic encephalopathy in one. Clinical manifestations at the initial visit included: fever > 39 C (85%), diarrhea (67%), and vomiting (37%). Seven patients had occult bacteremia. Three children (11 %) required intensive care management for severe sepsis. Five patients presented extraintestinal focal infections: arthritis in two, osteomyelitis in one, urinary tract infection in one, and pneumonia in one. None of the children had meningitis or died as a result of NTS infection. The most common serogroups isolated were Salmonella D9, and B4-5 (38% each). Eleven strains (38%) were resistant to amoxicillin and five (17%) were resistant to cotrimoxazole. Only one patient developed persistent bacteremia. All the children made a complete recovery without further complications. CONCLUSIONS: NTS bacteremia is an uncommon entity but it should be considered in infants and immunocompromised children. Although focal complications may occur, the usual outcome with appropriate antimicrobial treatment is a full recovery.

Curación de un síndrome PFAPA / Curing of the PFAPA syndrome

Se presenta el caso de una niña de 23 meses que presentaba episodios febriles con una periodicidad de 22+/-4 días. Se realiza diagnóstico diferencial entre las causas de fiebre periódica. Con el diagnóstico de síndrome PFAPA (fiebre periódica, aftas, faringitis y adenitis cervical), se trata con adenoide-amigdalectomía, obteniéndose un resultado excelente (AU)