Bacterial croup and toxic shock syndrome

An 8-year-old boy with bacterial tracheitis, treated by endotracheal intubation, humidification, airway toilet and antibiotics, experienced a toxic shock syndrome on the day after his admission. The course was favourable. Staphylococcus aureus was isolated from tracheal secretions. Bacterial tracheitis is an infrequent cause of non-menstrual toxic shock syndrome. The diagnosis of bacterial tracheitis should be suspected in a child with toxicity and croup who is not responding to the usual therapy. Endoscopy should be performed allowing for removal of the secretions. The maintenance of a clear airway is the main purpose of the treatment.Abbreviations TSS toxic shock syndrome - CNS central nervous system - CRP C-reactive protein - ICU intensive care unit     

Bacterial tracheitis in Down's syndrome.

Four children with Down''s syndrome and bacterial tracheitis are described. In three the infection was due to Haemophilus influenza. In patients with Down''s syndrome presenting with stridor tracheitis should be considered and appropriate treatment started.     

Pediatric acute lung injury

Among ventilated children, the incidence of acute lung injury (ALI) was 9%; of that latter group 80% developed the acute respiratory distress syndrome (ARDS). The population-based prevalence of pediatric ARDS was 5.5 cases/100.000 inhabitants. Underlying diseases in children were septic shock (34%), respiratory syncytial virus infections (16%), bacterial pneumonia (15%), near-drowning 9%, and others. Mortality ranged from18% to 27% for ALI (including ALI-non ARDS and ARDS) and from 29% to 50% for ARDS. Mortality was only 3%–11% in children with ALI-non ARDS. As risk factors, oxygenation indices and multi-organ failure have been identified. New insights into the pathophysiology (for example the interplay between intraalveolar coagulation/fibrinolysis and inflammation and the genetic polymorphism for the angiotensin-converting enzyme) offer new therapeutic options. Lung protective mechanical ventilation with optimal lung recruitment is the mainstay of supportive therapy. New therapeutic modalities refer to corticosteroid and surfactant treatment. Well-designed follow up studies are needed.     

Severe upper airway obstruction in the tropics requiring intensive care

BACKGROUND: The clinical profile of severe upper airway obstruction, a challenging acute pediatric emergency, has not been extensively documented in the developing nations of the tropics. METHODS: The diagnostic categories, severity of illness and outcome from 63 episodes of severe upper airway obstruction in 56 children admitted to the Pediatric Intensive Care Unit between January 1994 and December 1999 were reviewed. Outcome variables studied included requirement for ventilation, mortality and complications. Severity of illness was determined with the Pediatric Risk of Mortality (PRISM) II score. RESULTS: Viral croup (29%) was the most common diagnosis, followed by mediastinal malignancy (13%), bacterial tracheitis (11%) and Pierre Robin syndrome (11%). There were no admissions for acute epiglottitis. Thirty episodes (48%) required ventilation for a median duration of 4.0 days. Bacterial tracheitis (100%) and subglottic stenosis (100%) were the most likely diagnoses requiring ventilation. Difficulty in intubation was encountered in 13 episodes (43%) involving, in particular, patients with bacterial tracheitis (83%; P = 0.006). Only two patients required a tracheostomy. The overall mortality was 11%. The PRISM score for all categories was generally low (mean 10.3 +/- 1.0; median 9.0). Non-survivors had a significantly higher PRISM II score than survivors (27.4 +/- 9.7 vs 8.1 +/- 4.9, respectively; P = 0.002) and were more likely to include children with bacterial tracheitis and mediastinal malignancy. CONCLUSIONS: There is marked heterogeneity in the causes of upper airway obstruction in the tropics with viral croup remaining the most common. A significant proportion required ventilation, but outcome is generally favorable, except in those with bacterial tracheitis and mediastinal malignancy.     

Clinical features, complications and atypical manifestations of children with severe forms of dengue hemorrhagic fever in South India

Objective To review clinical features and outcome of children with severe forms of dengue hemorrhagic fever (DHF) presenting to a pediatric intensive care unit (PICU) with particular focus on clinical presentation and outcome. Methods Retrospective chart review of patients admitted to the Pediatric Intensive Care Unit (PICU) of a referral children's hospital in South India with DHF over 1.5 years (2001–January 2003). Results Of 858 patients with dengue fever/DHF admitted to the hospital during the study period, 109 cases with severe forms of disease required PICU admission, of which 9 patients died. 77 were under 5 years of age. The commonest indication for PICU admission was persistent shock (39 patients) followed by requirement for positive pressure ventilation in 29 patients (10 of whom had Acute Respiratory Distress Syndrome [ARDS]) and neurological symptoms in 24 patients. An important finding was the presence of diastolic dysfunction in 3 children. Six deaths of refractory shock included 4 who had ARDS and DIC and 2 who had shock with DIC 3 patients had abdominal compartment syndrome (ACS) has not been previously described in children with DSS and may lead to fluid refractory shock if not corrected. All patients had thrombocytopenia which was a defining feature of the syndrome, while 74 were also coagulopathic and 6 had severe fatal DIC. Hepatic dysfunction was more severe in children with prolonged shock, however, only a fifth of cases (5/24) with neurological manifestations were in shock. Other significant reasons for neurological presentation included cerebral edema, and encephalopathy secondary to hepatic dysfunction. 2 children had features of Acute Disseminated Encephalomyelitis (ADEM), previously only described in adults with dengue. Conclusion It was found that complications such as DIC, diastolic dysfunction, abdominal compartment syndrome, ARDS and hepatic dysfunction were more frequent in severe established shock. However, most neurological events were unrelated to the perfusion status. Children referred late were harder to resuscitate. There were 9 PICU deaths (case fatality rate of 8.35%). Severe refractory shock, DIC, ARDS, hepatic failure and neurological manifestations singly or in combination were the commonest causes of death in the present study.     

Genetic dilemma: eNOS gene intron 4a/b VNTR polymorphism in sepsis and its clinical features in Turkish children

The role of endothelial nitric oxide synthase gene intron 4 a/b (eNOS4a/b) variable number of tandem repeats (VNTR) polymorphism in various diseases was investigated. We investigated whether this polymorphism is associated with susceptibility to sepsis and its clinical features such as acute respiratory distress syndrome (ARDS), multiorgan dysfunction syndrome (MODS) and shock. eNOS4a/b VNTR polymorphism was determined by the polymerase chain reaction in 100 children with sepsis and in 134 healthy controls. The genotype distribution of eNOS4 was not different between the patients and controls (p=0.44). There was no statistically significant association between genotypes/allele frequency and outcomes like mortality, MODS, ARDS, and shock (p>0.05). This is the first study that evaluates the effect of eNOS4a/b polymorphism in sepsis. We were unable to show a relationship between eNOS gene intron 4 a/b VNTR polymorphism and MODS, ARDS, mortality and shock. Larger studies that do research on the interaction of such genes are needed to clarify the association between eNOS4a/b polymorphism and sepsis.     

Complement fragment C3a in plasma of asphyxiated neonates

Recent clinical studies with adult polytrauma patients indicate that elevated plasma levels of anaphylatoxin C3a correlate with the subsequent development of the adult respiratory distress syndrome (ARDS). However, there are no parameters which allow a reliable diagnosis of ARDS in neonates. As the most predisposing condition for ARDS seems to be shock, plasma C3a was determined in 30 ventilated premature infants and neonates with respiratory distress syndrome (birth weights 660–3350 g) within the first 24 h post partum or 6–24 h after acute asphyxia or shock during the neonatal period. The range of C3a, measured by ELISA, was between 57 and 1000 ng/ml. In the asphyxia group (n=15) peak levels of C3a in plasma (mean 388 ng/ml) were significantly higher (P<0.001) than in the control group (mean 153 ng/ml). In some neonates with suspected ARDS, additional samples were taken. A rise in C3a between days 2 and 8 was associated with a fatal outcome of the disease. As in adults, C3a might be a useful indicator for ARDS in neonates.     

重度胎粪吸入综合征并发急性呼吸窘迫综合征临床特征及转归分析

目的 探讨新生儿重度胎粪吸入综合征（meconium aspiration syndrome,MAS）并发急性呼吸窘迫综合征（acute?respiratory?distress syndrome,ARDS）的临床特征及转归,为临床诊治提供参考。 方法 回顾性收集2017年1月至2019年12月收治的60例重度MAS新生儿的临床资料,根据是否并发ARDS分为ARDS组（45例）与非ARDS组（15例）,比较两组患儿的临床特征及转归。 结果 60例重度MAS患儿中,45例（75%）发生ARDS。ARDS组出生后1 h动脉血气分析显示中位氧合指数显著高于非ARDS组（4.7 vs 2.1,P<0.05）;两组间入院时白细胞计数、C-反应蛋白、白细胞介素-6水平及住院期间降钙素原、C-反应蛋白、白细胞介素-6的峰值水平比较差异无统计学意义（P>0.05）。ARDS组休克发生率高于非ARDS组（84% vs 47%,P<0.05）,两组间持续性肺动脉高压、气胸、肺出血、缺氧缺血性脑病、颅内出血和弥漫性血管内凝血的发生率比较差异无统计学意义（P>0.05）。ARDS组较非ARDS组中位机械通气时间更长（53 h vs 3 h,P<0.05）。ARDS组治愈出院43例（96%）,死亡2例（4%）;非ARDS组治愈出院15例（100%）。 结论 重度MAS并发ARDS患儿呼吸窘迫出现早,机械通气时间长,休克发生率更高;建议在管理重度MAS患儿过程中密切监测氧合指数,及时诊断及治疗ARDS,同时密切评估组织灌注,积极防治休克。 引用格式:     

Cardiac Beriberi (Shoshin Beriberi) Caused by Excessive Intake of Isotonic Drink

A 21 month old female had voluntarily ingested 0.5–1.51 of isotonic sports drink daily from 10 months of age. She developed hyponatremia and beriberi heart disease, which resulted in metabolic acidosis and cardiogenic shock (shoshin beriberi). Mechanical ventilation was applied for pulmonary edema. Right heart failure was improved after administering vitamin Bi. However, 5 days after the shock, hypoxemia and diffuse radiographic infiltrates progressed, and a diagnosis of adult respiratory distress syndrome (ARDS) was made. After the occurrence of an air leak, the patient died of respiratory failure. The cardiogenic shock and pulmonary edema due to cardiac beriberi may have triggered the ARDS.     

Bacterial tracheitis caused by Corynebacterium diphtheriae

Diphtheria has become a rare disease in Germany. We report on an unimmunized 3.5-year-old German girl with a 7-day history of respiratory distress and fever, presenting a clinical picture mimicking typical bacterial tracheitis without pharyngeal and laryngeal manifestation. Diagnosis of diphtheria was not made until culture of tracheal secretions yielded growth of a toxigenic strain of Corynebacterium diphtheriae. The patient died from toxic cardiac failure despite treatment with diphtheria antitoxin. This is the second reported case of isolated bacterial tracheitis caused by Corynebacterium diphtheriae. Conclusion The observation of a lethal course of diphtheric tracheitis emphasizes the paramount im-portance of immunization against diseases like diph-theria. Received: 4 July 1996 / Accepted: 24 September 1996     

Dengue Shock Syndrome with Two Atypical Complications

The authors present 2 cases of dengue shock syndrome with unusual complications. In the first case, a 14-y-old boy with dengue shock syndrome who required aggressive fluid resuscitation, developed abdominal compartment syndrome (ACS). Patient developed severe shock, increased ventilator requirement and oliguria as a consequence of ACS. Patient responded well to abdominal paracentesis draining 2.7 l of fluid and made rapid recovery. In the second case, 8-y-old girl was treated for dengue shock syndrome, including mechanical ventilation for ARDS. In the second wk of illness, she developed severe neurological manifestations including frequent episodes of convulsions, hallucinations and altered sensorium. She was diagnosed to have acute demyelinating encephalomyelitis from CT brain findings. She responded well to pulse steroid therapy with complete neurological recovery.     

Extracorporeal life support for children with meningococcal septicaemia

Objective: To describe the short-term outcome of children with meningococcal sepsis treated with extracorporeal membrane oxygenation (ECMO) in a single centre. Design: Retrospective analysis of case notes. Setting: The Heartlink ECMO Centre, Glenfield Hospital, Leicester. Patients: Eleven children (8 boys) out of a total caseload of 800 patients were treated for meningococcal sepsis with ECMO. Interventions: Extracorporeal membrane oxygenation. Results: All children with meningococcal sepsis treated with ECMO had a Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS) ≥12 (positive predictive risk of death of approximately 90%). Five children had adult respiratory distress syndrome (ARDS) and six had refractory shock with multi-organ dysfunction syndrome (MODS) at presentation for ECMO. All five children in the ARDS group survived, four of five receiving veno-venous (VV-) ECMO therapy. In contrast, only one of six children with refractory shock with MODS survived, all of whom required veno-arterial (VA-) ECMO therapy.

Conclusions: Most children with meningococcal sepsis and severe ARDS can be successfully treated with VV-ECMO. In contrast, children with refractory shock and MODS die despite treatment with VA-ECMO. This report does not resolve whether ECMO therapy offers any advantage over conventional therapy in treating severe meningococcal sepsis.     

鄂西南地区新生儿急性呼吸窘迫综合征临床流行病学调查

目的 了解鄂西南地区新生儿急性呼吸窘迫综合征（ARDS）的临床特点及转归。方法 采用回顾性临床流行病学方法,根据新生儿ARDS蒙特勒诊断标准对2017年1~12月鄂西南地区17家二级或三级医院新生儿科/儿科收治的新生儿ARDS病例资料进行调查分析。结果 所纳入的鄂西南地区17家医院2017年1年内共收治新生儿7 150例,其中确诊新生儿ARDS 66例（0.92%）,包括轻度23例（35%）,中度28例（42%）,重度15例（23%）。新生儿ARDS的主要原发疾病包括：围生期窒息（23例,35%）、肺炎（18例,27%）、败血症（12例,18%）、胎粪吸入综合征（10例,15%）。66例ARDS患儿中,产妇年龄≥35岁10例（15%）,宫内窘迫30例（45%）,1 min Apgar评分0~7分32例（49%）,胎心监测异常24例（36%）,羊水胎粪污染21例（32%）。脑室内出血是最常见的合并症（12例）,其次为新生儿休克（9例）、动脉导管未闭（8例）。66例ARDS患儿在针对原发病治疗的基础上,均给予机械通气治疗。死亡10例,病死率为15%（10/66）;治愈、好转56例（85%）。结论 鄂西南地区新生儿ARDS以轻/中度为主;围生期窒息和感染可能是该地区新生儿ARDS的主要病因;脑室内出血是最常见的合并症;综合治疗后患儿存活率较高。     

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??Objective To analyze the clinical characteristics and prognosis of pneumonia complicated with acute respiratory distress syndrome??ARDS?? in pediatric hematological patients in order to improve the clinical treatment level. Methods The data of clinical symptoms??laboratory result??treatment??prognosis and risk factors of 35 hematological children with pneumonia and ARDS admitted between March 2012 and January 2015 in Department of Pediatrics??Sun Yat-sen Memorial Hospital??Sun Yat-sen University were retrospectively analyzed. Results The 35 hematological children with pneumonia and ARDS had high fever??71.4%????cough??85.7%????shortness of breath??88.6%????cyanosis??74.3%????three concave sign positive??74.3%?? and lung rale??65.7%??. The level of PaO2/FiO2 decreased??chest X-ray showed patchy or patchy infiltrates??and diffuse exudation and large consolidation in severe cases. A total of 29 strains of pathogens were isolated??including 22 strains of gram-negative bacteria. In 35 ARDS children??23 cases died??65.7%????and the main cause of death was MODS??in 12 cases??52.2%??. The death cause was related to no remission in primary disease??MODS??shock??severe chest infiltration and the use of mechanical ventilation??P??0.05????but not to the way of mechanical ventilation??P??0.05??. Logistic regression analysis showed that MODS and shock were the independent risk factors of death??P??0.05??. Conclusion The hematological children with pneumonia and ARDS should get more attention for its high mortality. It can be diagnosed early according to the clinical symptoms and signs??the blood gas analysis and chest X-ray. MODS and shock are the independent risk factors of death.     

Bacterial tracheitis in children: Approach to diagnosis and treatment

Bacterial tracheitis is due to a secondary bacterial infection of the trachea, resulting in the formation of mucopurulent exudates that may acutely obstruct the upper airway, resulting in a life-threatening condition. Bacterial tracheitis should be considered in the differential diagnosis of any child with acute upper airway obstruction. This diagnosis should also be considered in any child with viral croup that is nonresponsive to conventional therapy. The only definitive way to diagnose bacterial tracheitis is by direct visualization of the trachea via bronchoscopy; however, this may not be required in all cases. Management includes close observation and monitoring, early initiation of broad spectrum antibiotics, pain management and aggressive airway clearance techniques. The decision to intubate should be individualized based on the severity of symptoms, age of child and accessibility of personnel skilled at emergency intubation techniques. If diagnosed and treated early, complete recovery is expected.     

鄂西南地区新生儿急性呼吸窘迫综合征临床流行病学调查

目的 了解鄂西南地区新生儿急性呼吸窘迫综合征（ARDS）的临床特点及转归。方法 采用回顾性临床流行病学方法,根据新生儿ARDS蒙特勒诊断标准对2017年1~12月鄂西南地区17家二级或三级医院新生儿科/儿科收治的新生儿ARDS病例资料进行调查分析。结果 所纳入的鄂西南地区17家医院2017年1年内共收治新生儿7 150例,其中确诊新生儿ARDS 66例（0.92%）,包括轻度23例（35%）,中度28例（42%）,重度15例（23%）。新生儿ARDS的主要原发疾病包括：围生期窒息（23例,35%）、肺炎（18例,27%）、败血症（12例,18%）、胎粪吸入综合征（10例,15%）。66例ARDS患儿中,产妇年龄≥35岁10例（15%）,宫内窘迫30例（45%）,1 min Apgar评分0~7分32例（49%）,胎心监测异常24例（36%）,羊水胎粪污染21例（32%）。脑室内出血是最常见的合并症（12例）,其次为新生儿休克（9例）、动脉导管未闭（8例）。66例ARDS患儿在针对原发病治疗的基础上,均给予机械通气治疗。死亡10例,病死率为15%（10/66）;治愈、好转56例（85%）。结论 鄂西南地区新生儿ARDS以轻/中度为主;围生期窒息和感染可能是该地区新生儿ARDS的主要病因;脑室内出血是最常见的合并症;综合治疗后患儿存活率较高。     

血液病患儿肺炎合并急性呼吸窘迫综合征35例分析

目的 分析血液病患儿肺炎合并急性呼吸窘迫综合征（ARDS）的临床特征及预后相关因素,提高临床治疗水平。方法　收集2012年3月至2015年1月在中山大学孙逸仙纪念医院儿科住院的血液病患儿肺炎合并ARDS 35例患儿的临床资料,对症状、体征、辅助检查结果、治疗及转归、死亡危险因素等进行统计分析。结果　35例血液病患儿肺炎合并ARDS时表现为高热（71.4%）、咳嗽（85.7%）、气促（88.6%）、发绀（74.3%）、三凹征阳性（74.3%）、双肺啰音（65.7%）。血气分析提示氧合指数（PO2/FiO2）不同程度降低,胸部X线表现点片状、斑片状浸润影,严重者为弥漫性渗出、大片实变。所有病例均行血、痰液的病原体培养,共培养细菌29株,其中革兰阴性菌22株。35例ARDS患儿经治疗后死亡23例（65.7%）,导致死亡的主要原因为多器官功能障碍综合征（MODS）,共12例（52.2%）。死亡原因与原发病未缓解、合并MODS、休克、肺部浸润严重、使用机械通气有关（P＜0.05）,而与机械通气呼吸支持方式无关（P＞0.05）。经Logistic回归分析显示,MODS、休克为死亡独立危险因素（P＜0.05）。结论　血液病患儿肺炎合并ARDS时有较高的病死率,临床可通过症状体征、血气分析和胸部X线检查早期诊断,合并MODS及休克是死亡独立危险因素。     

Fulminant Branhamella catarrhalis tracheitis.

Branhamella catarrhalis, a well known commensal of the normal respiratory flora, is being increasingly implicated as an aetiological agent in various acute respiratory and non-respiratory infections. B. catarrhalis has demonstrated a particular predilection for turning pathogenic in the immunocompromised host. Bacterial tracheitis, presenting as an acute airway obstruction, is commonly caused by Staphylococcus aureus and Haemophilus influenzae. The unusual occurrence of a fulminant B. catarrhalis bacterial tracheitis in a previously normal and healthy Indian child is the subject of this communication.     

Acute upper airway obstruction

Acute upper airway obstruction continues to challenge medical practitioners who care for children. Whilst usually straightforward, management can be complicated by incorrect diagnosis, unexpected deterioration, difficulty in assessing the need for intubation, difficulty in providing optimal intubation skills and confusion over the value of various therapies.The highest priority is preventing death or hypoxic injury in those few children who progress to profound obstruction.In this overview, the term laryngotracheitis is used as a synonym for croup and laryngotracheobronchitis, epiglottitis is used as a synonym for supraglottitis, and bacterial tracheitis is used as a synonym for pseudomembranous croup. The term ‘intubation’ is used as an abbreviation for mechanical relief of airway obstruction.     

Generalized granuloma annulare. Report of two cases

We present a case of bacterial tracheitis in a 6.5 year old girl. Clinical signs and symptoms consisted of severe croup with high grade fever, which were preceded by upper respiratory tract prodrome. Initial treatment with steroids and nebulized epinephrine was unsuccessful. The patient was intubated a few hours after admission. Thick purulent secretions emerging from the trachea and the normal appearance of the epiglottis suggested the diagnosis of bacterial tracheitis, which was confirmed by isolation of Haemophilus influenzae in the culture of the tracheal secretions. The patient was administered a 14 day course of endovenous ceftriaxone and was kept on mechanical ventilation for 7 days. Fever and purulent tracheal secretions continued for the next 5 days. After 48 hours without these signs, laryngotracheobronchoscopy ruled out residual obstruction. Extubation was successfully performed. Fourteen days later physical examination showed no abnormalities and the patient was discharged. No complications were found during followup. The clinical, diagnostic and therapeutic aspects of this potentially life threatening entity that should taken into account in the differential diagnosis of severe croup are discussed.