Surgical aspects of bacterial infection in African children

Infections and their complications requiring surgical intervention are a frequent presentation in African children. Surgical site infection (SSI) is common with rates over 20%, even after clean procedures. The high rates of SSI are due in part to lack of infection control and surveillance policies in most hospitals in Africa. SSI is attended by complications, long hospital stay, and some mortality, but the economic consequences are unestimated. Typhoid fever and typhoid intestinal perforation are major problems with perforation rates of approximately 10%, which is higher in older children. The ideal surgical treatment is arguable, but simple closure and segmental resection are the present effective surgical options. Because of delayed presentation, complications after surgical treatment are high with a mortality approaching 41% in some parts of Africa. Nutrition for these patients remains a challenge. Acute appendicitis, although not as common in African children, often presents rather late with up to 50% of children presenting with perforation and other complications, and mortality is approximately 4% is some settings. Pyomyositis and necrotizing fasciitis are the more common serious soft-tissue infections, but early recognition and prompt treatment should minimize the occasional mortality. Though common in Africa, the exact impact of human immunodeficiency virus infection on the spectrum and severity of surgical infection in African children is not clear, but it may well worsen the course of infection in these patients.     

The recognition and treatment of infective endocarditis

Infective endocarditis is a rare but serious illness in childhood. The majority of infections in childhood occur in children with congenital heart disease and normal heart endocarditis is rare in older children but is being increasingly recognized in preterm neonates undergoing intensive care. The Duke criteria are generally accepted as the most accurate for making a diagnosis of infective endocarditis. The principal infecting organisms are streptococcal species andStaphylococcus aureus . Transthoracic echocardiography is an important tool to clarify diagnosis and to look for the complications of infection. The cornerstone of treatment is a prolonged course of antibiotic treatment with an appropriate bactericidal regimen. Mortality remains high, generally between 10% and 20% in most paediatric series. Those that develop haemodynamic compromise, uncontrolled infection or pose an embolic risk should be assessed for suitability for surgical treatment. The reported results of surgical intervention are generally good. Prevention of recurrent infection is important.     

Comparison between serum alpha-glutathione S-transferase and aminotransaminases in detecting cytolysis in hepatitis C-infected children.

BACKGROUND: alpha-Glutathione S-transferase (alphaGST) has been proposed as a more sensitive indicator than serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in detecting hepatocellular damage due to chronic hepatitis C virus (HCV) infection. METHODS: The accuracy of alpha-GST was compared with that of ALT and AST in detecting cytolysis in 103 blood samples issued from 31 children positive for HCV RNA. RESULTS: alpha-GST had a lower sensitivity than ALT or AST (32% vs. 54.4% for each aminotransferase). The sensitivity of ALT and/or AST was 60.2%, whereas that of ALT and/or alpha-GST and AST and/or alpha-GST was lower (58.3% and 57.3%, respectively). Among 41 serum samples with negative ALT and AST, only 2 had positive alpha-GST, whereas alpha-GST failed to detect cytolysis in 31 samples with elevated ALT and/or AST. No correlation was found between alpha-GST, ALT, or AST and the Knodell score. CONCLUSIONS: The combination of ALT with AST is actually the best compromise in detecting cytolysis in untreated HCV-infected patients.     

Serum Aminotransferases in Thai Children With Dengue Infection

Background:

Hepatic manifestations are one of the unusual manifestations of dengue infection.

Objectives:

We conducted this study in order to study the pattern of serum aminotransferases and sequential changes before and after shock in Thai children with dengue infection.

Patients and Methods:

Children who were clinically and serologically diagnosed as dengue infection and were admitted to King Chulalongkorn Memorial Hospital during a peroid of one year were enrolled. They were clinically classified into a non-shock group and a shock group. The majority of serum aminotransferases including aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were obtained within a week after the onset of fever and until 3 days after shock in the shock group. Student t-test and median in boxplot form were used for statistical analysis.

Results:

We enrolled 127 children with a mean age of 7.6 ± 3.6 years. The incidence of abnormal AST and ALT levels was 97.4% and 50.0% in the shock group, and 91.8% and 44.9% in the non-shock group respectively. 29% and 15.4% of the patients in shock group and only 10.2% and 4.1% in non-shock group had the respective AST and ALT levels > 200 U/L. Serum aminotransferase levels were significantly higher in the shock group when compared to the non-shock group. AST tended to increase starting from one day before shock and continued to increase within a few days whereas ALT was less likely to be affected.

Conclusions:

Elevated serum aminotransferases are a common finding in children with dengue infection and the levels of AST are higher than those of ALT. Patients with shock have significantly higher aminotransferase levels that increase up to 3 days after shock.     

Concurrent reactivation of latent EBV with hepatitis A can affect clinical feature of childhood hepatitis

Aims: Some children with acute hepatitis A virus (HAV) infection have concurrent Epstein–Barr virus (EBV) reactivation serologically. We studied the frequency of EBV reactivation during HAV infection and determined whether simultaneous occurrence of EBV reactivation and HAV infection affected the clinical features of HAV infection. Methods: The medical records of patients under 19 years of age diagnosed with acute hepatitis A between January 1996 and June 2009 were reviewed. Results: Among 72 patients with acute hepatitis A, 22 patients (30.6%) had EBV reactivation. A markedly prolonged duration of full recovery from hepatitis was observed in reactivated group. The peak levels of AST and ALT in reactivated group were higher than non‐reactivated group (p = 0.012 and p < 0.001, respectively). Higher peak levels of AST and ALT in reactivated subgroups over 10 years old were observed compared to non‐reactivated subgroup (p = 0.027 and p = 0.001, respectively). Duration of recovery showed significant differences between two subgroups. Conclusions: Concurrent reactivation of latent EBV and HAV infections is common. EBV reactivation with HAV infection adversely affects the clinical feature of hepatitis. Therefore, we should keep in mind that the concurrence especially in older children may cause worse injury to the liver.     

Clostridium septicum infections in children: a case report and review of the literature

Clostridium myonecrosis is a rare and deadly infection that progresses very rapidly; thus, prompt diagnosis and treatment is vital. In adults, clostridial myonecrosis used to be a well-known complication of war wounds. Today, it is usually seen in settings of trauma, surgery, malignancy, skin infections/burns, and septic abortions. More recently, cases of nontraumatic or spontaneous clostridial myonecrosis have been reported in both adults and children. Clostridium perfringens and Clostridium septicum are responsible for the majority of the clinically relevant infections. Higher mortality rates are seen when C septicum is the causative agent. Here we present a child who survived a severe case of C septicum myonecrosis involving both abdominal and thoracic cavities. This rare infection has a high mortality rate and might be easily misdiagnosed in children, even by experienced clinicians, because of its nonspecific presentation. We also review all reported pediatric cases of C septicum infection and myonecrosis and discuss the surgical and medical interventions associated with improved survival. We identified a total of 47 cases of C septicum infection; of these, 22 (47%) were cases of C septicum associated with myonecrosis. Several factors, if available, were analyzed for each case: age, gender, infection location, previous diagnoses, presenting signs and symptoms, neutropenia, gross pathology of the colon, antibiotic use, surgical intervention, and final outcome. We found that conditions related with C septicum infection in children can be grouped into 3 major categories: patients with neutrophil dysfunction; patients with associated bowel ischemia; and patients with a history of trauma. Malignancies were found in 49% of the cases, cyclic or congenital neutropenia in 21%, hemolytic-uremic syndrome in 11%, structural bowel ischemia in 4%, and local extremity trauma in 6%. In addition, 6% of the cases had no known underlying disorder. Abdominal symptoms including vomiting, diarrhea, blood per rectum, abdominal pain, anorexia, and/or acute abdomen, were reported in 85% of the children. Fever was also a common finding. The mainstay of treatment for C septicum infection was parenteral antibiotics and/or surgical intervention. The mortality rate for children with C septicum infection and myonecrosis was 57% and 59%, respectively. Although 82% of all cases received antibiotics, only 43% underwent therapeutic surgical intervention. Several clinical factors were found to be associated with improved survival. Only 35% of the children with gastrointestinal tract involvement survived, compared with 86% of the children without gastrointestinal tract involvement. The survival rates for other conditions ranged from 0% to 50%. One hundred percent survival was reported in patients with no previously diagnosed conditions and those with infections resulting from trauma to the extremities. All survivors received antibiotic treatment, compared with only 68% of the nonsurvivors. Most survivors (84%) underwent therapeutic surgical intervention, compared with only 12% of nonsurvivors. Other treatments were used adjunctively, including hyperbaric oxygen, granulocyte colony-stimulating factor, granulocyte transfusions, and intravenous immunoglobulin. C septicum infections in children are often fatal; thus, one needs to have a high index of suspicion in at-risk patients. This review describes who these patients are, their clinical presentation, and the therapeutic strategies associated with improved survival.     

Hepatic toxicity during chemotherapy for severe tuberculosis meningitis

The possible development of hepatotoxic effects as a result of high dosages of isoniazid, rifampin, pyrazinamide, and ethionamide was assessed in 56 young children (median age, 22 months) treated for severe tuberculous meningitis (TBM). Only one of the 56 children became jaundiced, probably as result of hepatitis A infection. Of 33 children observed for at least eight weeks, only five (15%) had normal serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyl transferase levels throughout, but in only three patients were AST or ALT values greater than 200 U/L, and enzyme levels tended to normalize toward the end of the period. In this group of 33 children, those at stage III TBM had higher enzyme levels than did those at stage II. The remaining 23 children were observed for a mean period of only four weeks, and 18 (75%) had at least one abnormal liver function test result.     

外科感染时的循环功能观察

采用国产无创伤心功能测试仪，分别检测小儿外科常见感染性疾病组和正常对照组的心血管功能（两组ｎ＝２１），结果表明，脉率、心搏指数、心搏功指数、脉压、主动脉排空系数、外周血管阻力、肺动脉楔压、血液粘度、微循环半更新率、微循环半更新时间、微循环平均滞留时间，两组有显著性差异（Ｐ＜０．０５）。急性感染早期和局部感染对心脏和血管功能影响不大，但反映微循环状态的多项指标在感染早期已发生明显变化。无创伤监测心血管功能，可根据病情反复测定，便于动态观察外科感染早期的循环功能，有利于指导外科感染的治疗和预防感染性休克。     

Toxic shock syndrome in children. Report of four cases

We report four children with toxic shock syndrome admitted in the pediatric intensive care unit of our hospital during the past year. All the children had the five criteria established by the Centers for Disease Control for the diagnosis of this syndrome. In all four there was a probable point of entry of the infection: maxillar sinusitis in one, pneumonia in two and surgical wound in the other. No bacteria that could have caused the infection were isolated in any of the children, which suggests a staphylococcal origin for this syndrome. Evolution was good in all of the children due to aggressive treatment that included inotropic support, volemic expansion and antibiotics. Two of the children, who suffered adult respiratory distress syndrome, required prolonged respiratory support.     

Urinary Infections in Children

Urinary tract infection (UTI) is a common infection in infants and children. During infancy, boys are more commonly affected than girls and thereafter, female preponderance is found. Presentation varies among different age groups. Clinical features in neonates and young infants are non-specific, manifest as septicemia where a high index of suspicion is needed. Older children typically present as simple or complicated UTI. Rapid diagnosis, institution of early treatment and further evaluation by imaging modalities are of utmost importance. The prevention of recurrent UTI and detection of congenital anomalies of kidney and urinary tract are major objectives in the management. Use of ultrasound is required to detect underlying congenital abnormalities, whereas voiding cystourethrogram and dimercaptosuccinic acid (DMSA) scan are useful in the diagnosis of obstructive uropathy and vesicoureteric reflux and renal scar, respectively. The children requiring surgical interventions are to be recognised early to prevent recurrent UTI. The treatment of vesicoureteric reflux by chemoprophylaxis in lower grades and surgical treatment in higher grades are important consideration in prevention of recurrent UTI. This is required to prevent renal parenchymal damage and scarring that can cause hypertension and progressive renal insufficiency in later life.     

An intra-oral approach for facial nontuberculous mycobacterial infection

In children with cervico-facial nontuberculous mycobacterial infection, the treatment of choice is excision of the whole node. The alternative surgical treatment modality is drainage and curettage via the cutaneous route. However, these approaches include the risks of nerve damage, scarring, and keloid formation. This paper describes an intra-oral approach to the facial node that can greatly reduce these risks.     

Cardiac echinococcosis with multivisceral involvement

Cardiac hydatid cyst is an uncommon lesion. The infection, often acquired by children during play with infected dogs, is most common in sheep-raising areas of the world. We report our clinical and surgical experience in the treatment of one of the youngest reported cardiac hydatidosis patients with multivisceral involvement.     

Growth and weight gain in children with vesicoureteral reflux receiving medical versus surgical treatment: 10-year results of a prospective, randomized study. International Reflux Study in Children (European Branch)

In children with vesicoureteral reflux (VUR) and urinary tract infection, retardation of growth and weight gain at the time of diagnosis and catch-up growth during follow-up, mostly after operating for VUR, have been reported. A controlled trial comparing the effect on growth of surgical treatment and long-term prophylactic antibiotic treatment has not been reported previously. Between 1980 and 1985, 306 children younger than 11 y with non-obstructive grade III or IV VUR, with a history of symptomatic urinary tract infection, were randomly allocated to surgical or medical treatment. Of these, 236 were followed for 10 y, 118 randomized to surgical treatment (mean age at entry 3.5 +/- 2.3 y) and 118 to medical treatment (mean age at entry 3.8 +/- 2.5 y). All children had renal function and blood pressure in the normal range. Body height, measured at start and after 1, 5 and 10 y, was transformed to standard deviation score of height for chronological age (SDSH-CA) and body weight to percentage of ideal body weight for height (%IBW). The evolution of SDSH-CA and %IBW was similar in both treatment groups (SDSH-CA: surgical: start, 0.23 +/- 1.4; 10 y, 0.40 +/- 1.0; medical: start, 0.14 +/- 1.2; 10 y, 0.44 +/- 1.2; %IBW: surgical: start, 99 +/- 9%; 10 y, 107 +/- 14%; medical: start, 98 +/- 10%; 10 y, 105 +/- 16%). While children starting the study below the age of 3 y (SDSH-CA 0.55 +/- 1.34) started significantly taller than those older than 3 y (SDSH-CA -0.1 +/- 1.39), the young ones demonstrated a significant drop in SDSH-CA during the 1st year (SDSH-CA 0.19 +/- 1.23), which was regained up to the 10th year (SDSH-CA 0.6 +/- 1.13), and the older ones steadily gained height up to an SDSH-CA of 0.28 +/- 1.05 at 10 y. During all of the study period, treatment protocol, grade of VUR, renal parenchymal scars at entrance and urinary tract infections did not influence growth and weight gain. Age at entry and gender were the only significant correlates with growth and weight gain.     

儿童复杂性泌尿道感染临床表现和预后分析

目的 了解儿童复杂性泌尿道感染临床特点及预后情况.方法 收集2015年1月至2019年12月住院的复杂性泌尿道感染(CUTI)患儿的临床资料,进行回顾性分析.结果 共128例患儿,男75例、女53例,多以发热(111例,86.7％)为主要临床表现,复杂因素中以膀胱输尿管反流(83例,64.8％)最为常见.与≥3岁组比较...     

Successful treatment of invasive aspergillosis in two patients with acute myelogenous leukemia

Invasive aspergillosis is a severe, devastating fungal infection that is seen in patients with hematologic malignancies and profound neutropenia. Despite aggressive treatment, the outcome is poor without neutrophil recovery. The authors describe two children with acute myelogenous leukemia (AML) with extensive invasive aspergillosis who were successfully treated both for their infection and the underlying malignancy. These patients were treated aggressively for their infections and simultaneously were able to complete treatment of their AML. Currently both patients are alive without evidence of fungal infection or AML. Patients with hematologic malignancies can survive severe, invasive aspergillosis during prolonged periods of neutropenia with a combination of antifungal and growth factor therapies, donor granulocyte infusions, and surgical debridement.     

Acute mediastinitis

Mediastinitis is not a new disease, however, the occurrence was rare especially in children. Focal infection, which considered to be insignificant, can result in diffuse dissemination involving mediastinum leading to fatal condition. This paper reported a case of mediastinitis with very critical condition. Fast and accurate diagnosis as well as adequate antibiotic treatment saved the patient without surgical intervention.     

Urinary tract infection in childhood. Review of guidelines and recommendations

Children with urinary tract infection continue to be an important part of the pediatric practice. New uroradiologic imaging techniques like cortical radionuclide scanning and prenatal ultrasonography improved our understanding of the etiology, effect of treatment and outcome of these patients. Evidently, most kidneys at risk are those which already sustained intrauterine damage by obstruction or vesicoureteral reflux. It is the pediatrician's role to minimize ex-utero damage caused by bacterial infection by early diagnosis and appropriate intervention. The introduction of new potent oral antimicrobials limits the need for hospitalization only to the very young infant and the very seriously ill child. Whereas the roles of routine renal ultrasound and cortical radionuclide scan are debatable, all young children and select older children have to be investigated by cystography for possible vesicoureteral reflux. In children with vesicoureteral reflux, long-term antibiotic prophylaxis is required in most children but in a few surgical correction might be indicated. Young siblings of the propositus with vesicoureteral reflux have to be investigated as well for possible reflux. This review covers these and other guidelines and recommendations of diagnosis and treatment of UTI in children at the beginning of the third millennium.     

Cutaneous mucormycosis in children

Cutaneous mucormycosis is a rare fungal infection in children. It is commonly found in immunocompromised children. Early diagnosis is difficult and requires a very high degree of suspicion. Recommended mainstay of treatment has been amphotericin B and extensive surgical debridement which may at times require amputation if limb is involved. The authors share their experience of two cases of successfully treated cutaneous mucormycosis.     

106例儿童EB病毒感染的临床分析

目的 分析儿童EB病毒感染实验室检查的临床特点.方法 回顾性分析我院2005年1月至2007年11月收治的EB病毒感染患儿106例的实验室检查资料.结果 EB病毒感染WBC及淋巴细胞比例常明显升高,部分有血小板升高及轻度贫血,CRP及血沉常无升高.肝酶及心肌酶升高常见,其中LDH最常见,其次为αHBDH、AST、ALT.外周血异常淋巴细胞未达到10%者也较常见.结论 要重视分析EB病毒的实验检查,以便找到早期诊断EB病毒感染的线索.     

Clinical features of recurrent Kawasaki disease and its risk factors

The clinical features and risk factors for recurrence of Kawasaki disease (KD) remain unclear. In order to summarize clinical features of recurrent KD and identify risk factors associated with recurrence, we conducted a retrospective review of the medical records of consecutive cases of KD from January 2002 to December 2010. Demographic, clinical, laboratory, and echocardiographic data were analyzed. The maximum coronary artery Z score normalized against body surface area was assessed using coronary artery diameters. At the first onset of recurrent KD, children had longer durations of fever before intravenous immunoglobulin (IVIG) treatment and higher levels of alanine aminotransferase, serum aspartate aminotransferase (AST), and lower hemoglobin levels than those with a single episode of KD. Multivariate logistic regression analysis showed that long durations of fever before IVIG treatment, high AST levels, and reduced hemoglobin levels were significantly associated with recurrent KD. Ten of the 22 recurrent KD children had coronary artery complications during the first onset episode, and six (60 %) of these also had coronary artery complications during the recurrence. Children with longer durations of fever, lower hemoglobin levels, and higher AST levels may be at increased risk for KD and coronary artery complications are more likely to occur in children with recurrent KD if they were present during the first episode.