Value of open lung biopsy in immunocompromised children

OBJECTIVES: To determine the value of open lung biopsy (OLB) in terms of diagnosis, morbidity, mortality, and benefits in immunocompromised children with pulmonary involvement. STUDY DESIGN: We retrospectively reviewed 36 OLBs performed in 32 immunocompromised children between 1985 and 1998. Seventeen biopsies were performed in patients with primary immunodeficiency syndromes and 19 in patients with secondary immunodeficiency syndromes. Twenty-eight biopsies were performed because of a lack of response to ongoing antimicrobial treatments with negative or positive findings on bronchoalveolar lavage (BAL) and a deteriorating clinical or radiologic course, and 8 biopsies were performed because of persistent chest x-ray infiltrates. RESULTS: Diffuse pulmonary infiltrates were observed on chest x-ray in 28 cases, hyperinflation in 3 cases, and nodular infiltrates in 5 cases. A histopathologic diagnosis was possible for all 36 OLBs. Specific diagnosis was obtained in 22 (61%) (12 infectious agents, 6 tumors, 4 bronchiolitis obliterans) and non-specific diagnosis in 14 (39%). Fungi were the main infectious agents (8 of 12). For the diagnosed infections, BAL provided 4 true-positive, 3 false-positive, and 6 false-negative results. Specific treatment was changed in 77% of cases, providing real benefits in 12 (33%) cases. The morbidity and overall mortality rates were 31% and 33%, respectively. The mortality rate was significantly higher in the first 30 days after OLB in patients receiving ventilatory assistance (58%). CONCLUSIONS: OLB in immunocompromised children with deteriorating clinical or radiologic course is a sensitive diagnostic tool.     

An uncommon cause of neonatal respiratory distress

We describe a term infant without any features of congenital infection, who presented with respiratory distress at birth. Respiratory distress persisted despite change of antibiotics, and chest radiography showed bilateral diffuse patchy infiltrates. Congenital infections screening obtained on the 10th day of life was reported positive for syphilis. The infant was started on penicillin G and came off oxygen within five days. Although the presentation of congenital syphilis as pneumonitis in the absence of other clinical signs is unusual, in view of the re-emergence of the disease, syphilitic involvement of the lungs should be considered in any infant presenting with persistent diffuse lung disease of unknown etiology.     

Pulmonary fungal infections after bone marrow transplantation

Of 319 pediatric patients treated with bone marrow transplantation (BMT) during a 10-year period, 27 developed pulmonary fungal infections (PFI). Only 2 patients (7%) survived. Twenty-three patients (85%) had been treated with systemic antifungal therapy immediately before or at the time of diagnosis. Nineteen patients (70%) were neutropenic, and 4 of the 8 patients who were not neutropenic were being treated with systemic steroids for graft vs. host disease (GVHD). Seven patients (26%) died within 7 days of diagnosis. The diagnosis was made ante-mortem in 9 patients (33%). Radiographic abnormalities were variable. At the onset of chest X-ray (CXR) change, the pulmonary infiltrates were unilateral in 14 patients (52%) and, at diagnosis, bilateral in 18 (66%). At diagnosis the infiltrates were interstitial in 3 patients (11%), alveolar in 20 (74%) and mixed in 4 (15%). Six patients (22%) developed cavitary lesions. The infecting agents were Aspergillus in 21 patients (78%), Candida in 7 (26%), Mucormycosis in 3 (11%), and Fusarium in 1 (4%). Five patients (19%) had mixed fungal infections and 7 (26%) had concurrent cytomegalovirus (CMV) pulmonary infections. Although the radiographic changes are often nonspecific in PFI, alveolar or nodular infiltrates in neutropenic patients or in those being treated for GVHD should strongly suggest a fungal etiology.     

744例儿童发热待查的临床分析

目的 探讨儿童发热待查病因构成、诊断方法和思路。方法 １９９３年１月１日￣１９９８年１２月３１日符合发热待查诊断标准的住院患儿７４４例,按年龄分为〈３岁,３￣７岁、〉７岁三组,进行回顾性分析。结果：（１）〈３岁组９６例,其中感染性疾病５０例（５２％）（呼吸道感染２１例,２２％）;先天性疾病１４例（１５％）;恶性肿瘤９例（９％）。（２）３￣７岁组１９２例,感染性疾病１１５例（５９．９％）（呼吸道感染     

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??Bacterial pneumonia is the main cause of severe pneumonia in children. It is difficult to collect the samples of children’s respiratory tract infection??especially the acquisition of lower respiratory tract specimens is a challenge for the primary pediatricians??and it also affects the etiological diagnosis of children’s respiratory tract infection. Among children under 5??bacterial pathogens include Streptococcus pneumoniae??Staphylococcus aureus and Streptococcus pyogenes. Streptococcus pneumoniae infection is more common in healthy children aged 5 and above. The etiology of bacterial pneumonia in children was reviewed in this paper.     

Open lung biopsy–successful diagnostic tool with therapeutic implication in the critically ill paediatric population

Open lung biopsy (OLB) is an important diagnostic tool in children with immune deficiency and/or chronic lung disease with diffuse pulmonary compromise. These patients require a tailored therapeutic approach owing to their fragile status and the side effects of unnecessary or inadequate treatment. Twenty-six patients of mean age 5.6 y underwent 41 open lung biopsies in our centre between 1991 and 1995. Seventeen (65%) were immunocompromised (including 13 with malignancy) and 9 had other lung diseases. The biopsies were diagnostic in 25 patients (96%), and complete clinical-pathological correlation was found in 11 (42%). A specific infectious aetiology was detected in nine patients (35%), all of them immunocompromised. Therapeutic changes were instituted on the basis of the biopsy findings in 18 patients (69%). Two patients had postoperative complications (prolonged pleural leak). We conclude that OLB is a safe diagnostic procedure even in the critically ill child and should be employed without hesitation when conventional methods fail to provide a definitive diagnosis to help redirect therapy.     

儿童细菌性肺炎的病原学

细菌性肺炎是儿童重症肺炎的主要原因,但儿童呼吸道感染的病原因年龄和感染场所的不同而不同。儿童呼吸道感染标本采集较为困难,尤其是下呼吸道标本的获取更是基层儿科医师面临的挑战,也影响儿童呼吸道感染病原学诊断。在5岁以下的儿童中,细菌病原体包括肺炎链球菌、金黄色葡萄球菌和化脓性链球菌较为重要。在5岁及以上健康儿童中,肺炎链球菌感染较为常见。该文对儿童细菌性肺炎的病原学进行了简述。     

不同类型呼吸衰竭患儿行支气管镜检查灌洗术病例对照观察

目的 评价支气管镜检查灌洗术在不同类型呼吸衰竭(呼衰)患儿中的应用价值。方法 回顾性收集2011年3月至2012年6月于PICU住院并行支气管镜检查灌洗术的呼衰患儿的临床资料。分析患儿行支气管镜灌洗治疗前后血气变化、胸部X线（CT）改变及支气管镜检查镜下表现。结果 60例呼衰患儿进入分析。ARDS组11例和非ARDS组49例;非ARDS组中Ⅰ型呼衰亚组11例、Ⅱ型呼衰亚组17例和单纯高碳酸血症亚组21例。①60例患儿支气管镜下均可见黏膜粗糙、水肿。分泌物增多ARDS组8/11例（72.7%）,非ARDS组19/49例（38.8%）;气管狭窄16例（均为非ARDS组）;通气不良ARDS组2/11例（18.2%）,非ARDS组7/49例（14.3%）;黏膜糜烂ARDS组5/11例（45.4%）,非ARDS组2/49例（4.1%）。②支气管镜检查明确病因诊断43.3%（26/60）,ARDS组和非ARDS组分别为27.3%（3/11)和46.9%(23/49)。③51例行支气管肺泡灌洗治疗术前和术后胸部X线（CT）检查,ARDS组以实变影、磨玻璃影和支气管充气征为主;非ARDS组以实变影、支气管充气征和肺充气不良为主。非ARDS组和ARDS组胸部X线（CT）有效率分别为87.5％（33/40）和0。④58例支气管镜检查及灌洗术后较术前血气分析改善41例,其中ARDS组3/11例（27.3％）,非ARDS组38/47例（80.8％）。⑤ARDS组和非ARDS组总有效率分别为27.3%（3/11）和93.9%(46/49),差异有统计学意义(P=0.000)。Ⅰ型呼衰亚组、Ⅱ型呼衰亚组和单纯高碳酸血症亚组的有效率分别为90.9%（10/11）、94.1%(16/17)和95.2%（20/21）,与ARDS组有效率差异均有统计学意义（P均<0.05）。结论 ①ARDS患儿不宜行支气管镜检查灌洗治疗术。②非机械性梗阻的非ARDS呼衰患儿支气管镜灌洗治疗有效。③呼衰患儿病因不明时可行支气管镜检查协助病因诊断。     

Respiratory virus infections in children with cancer or HIV infection

Most studies focusing on respiratory infections in immunocompromised children have been addressed to bacterial etiology. However, respiratory virus infections in this population can also lead to severe disease. The objective of this study is to evaluate the clinical significance of respiratory virus infections in children with cancer or human immunodeficiency virus (HIV) infection.Retrospective study conducted in a teaching hospital in Madrid. Medical records from children 相似文献   

Isolated pulmonary Langerhans cell histiocytosis in a 17-year-old male

We report a case of a previously healthy 17-year-old male with a history of cigarette smoking, who presented with acute development of respiratory distress. Computed tomography demonstrated cystic pulmonary changes. A lung biopsy confirmed Langerhans cell histiocytosis (LCH). The definitive diagnosis was isolated pulmonary LCH, a disorder that is infrequently found in adults, and rarely in children. We know of only one other case of a previously healthy adolescent cigarette smoker who developed isolated pulmonary LCH. The etiology of pulmonary LCH is unknown, but smoking has been considered as a risk factor.     

Pulmonary carcinomatous lymphangitis and renal adenocarcinoma

The case of a 7 year-old who presented with lymphangitic carcinomatosis revealed by lung biopsy and secondary to renal adenocarcinoma is described. This biopsy was performed because of radiologic and clinical signs associating bilateral interstitial infiltrates, mediastinal adenopathy and gradually increasing respiratory distress. Despite treatment, the child died two weeks later.     

儿童反复咯血的病因及临床诊治分析

目的 分析儿童反复咯血的病因、临床特点、治疗方法及预后,以提高儿科医师对小儿反复咯血的病因诊断及治疗水平。方法 收集1996 年1 月至2013 年2 月39 例反复咯血患儿的临床、实验室及影像学资料,对其起病年龄、病因、咯血量、影像学改变、治疗方法及随访转归等进行回顾性分析。结果 39 例反复咯血患儿中,特发性肺含铁血黄素沉着症16 例（41%）,肺血管畸形8 例（21%）,肺动静脉瘘7 例（18%）,支气管扩张症3 例（8%）,肺结核和肺囊性纤维化各2 例（5%）,肺肿瘤1 例（3%）。肺部增强CT 扫描和肺动脉-支气管动脉造影发现35 例患儿肺部有不同程度的影像学改变。反复咯血患儿以Ⅰ度（51%）和Ⅱ度（28%）咯血为主,Ⅲ度（21%）咯血少见。39 例患儿根据不同病因经相应的治疗后咯血均得到有效控制,随访0.5~5 年,除3 例特发性肺含铁血黄素沉着症患儿失访外,其余患儿均未再次发生咯血。结论 反复咯血患儿的病因以特发性肺含铁血黄素沉着症为主,肺部增强CT 扫描和肺动脉-支气管动脉造影检查是诊断反复咯血患儿病因的重要方法,应根据患儿不同的病因选择不同的治疗方法。     

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??Diffuse panbronchiolitis??DPB????an idiopathic inflammatory disease??is characterized by chronic respiratory bronchioles of the bilateral lung. The etiology and pathogenesis of DPB is unknown. The main etiology is now believed to be related to gene and infection. Pathological examination is the gold standard for DPB diagnosis. Low-dose and long-term treatment with macrolides has been shown to significantly improve the prognosis of DPB patients.     

Acute respiratory illness in children with acute lymphoblastic leukemia

Ten of 70 children (14%) with acute lymphoblastic leukemia developed severe interstitial pneumonitis within three weeks after induction of central nervous system prophylactic therapy. The clinical picture was characterized by fever, cough, progressive dyspnea, and hypoxemia with complete resolution in one to three weeks, except in one patient who died during the acute illness from respiratory failure. P. carinii organisms were found in the lung tissue of only one patient. The etiology of the pneumonitis in the other nine children was probably viral, acquired or activated during a period of lymphopenia and immunosuppression. The morbidity and potential mortality from the pneumonitis warrants early recognition by open lung biopsy and intensive supportive therapy.     

轻症COVID-19患儿流行病学和临床特征分析

目的 探讨轻症2019-冠状病毒病(coronavirus disease 2019,COVID-19)患儿的流行病学和临床特征.方法 以2020年2月5日至3月10日武汉市武昌方舱医院确诊的轻症COVID-19儿童患者为研究对象,收集患儿住院期间和隔离期随访的临床、实验室、肺部影像学资料.该研究为回顾性、单中心系列病...     

Utility of bronchoscopy in immunocompromised paediatric patients: Systematic review

PurposeThe objective of this study was to describe the diagnostic yield and safety of bronchoalveolar lavage (BAL) in the evaluation of pulmonary lesions in immunocompromised children.MethodsWe conducted a systematic review of literature published during the past 20 years, searching Medline, Medline EPub, EMBASE, and Scopus. Studies included involved paediatric patients (<18 years) on treatment for an oncological diagnosis or other immune compromise who underwent BAL for evaluation of pulmonary lesions. Only English language publications were included.ResultsIn all, 272 studies were screened and 19 included. All were observational studies with moderate (11/19) or serious (8/19) risk of bias. BAL yielded a potential pathogen in 43% of cases (496/1156). Two papers reported improved diagnostic yield with early BAL (less than 3 days of presentation). A change in patient management after BAL was reported in 53% of cases (275/519). Adverse events were reported in 19% of cases following BAL (193/993) but were generally mild with no procedure-related mortality reported.ConclusionBAL appears to be useful for evaluation of pulmonary lesions in immunocompromised children with generally acceptable safety, though included studies had at least moderate risk of bias. Future prospective studies may provide more definitive estimates of benefit, timing and risk of BAL in this population.     

Severe RSV bronchiolitis in an immunocompromised child

A 9-year-old with immunodeficiency developed a severe, diffuse respiratory illness that necessitated mechanical ventilation. Open lung biopsy revealed Respiratory Syncytial Virus (RSV) as the sole pathogen. RSV detection should be included in the differential diagnosis of diffuse lung disease in an immunocompromised child.     

Childhood encephalitis in Sweden: Etiology, clinical presentation and outcome

Acute encephalitis is a relatively uncommon but potentially harmful CNS inflammation usually caused by infection. The diagnosis is difficult to establish and the etiology often remains unclear. Furthermore, the long-term prognosis of acute encephalitis in children is poorly described. In this study, we characterize childhood encephalitis from a Swedish perspective in regard to etiology, clinical presentation and sequele. We retrospectively studied all children (n=93) who were admitted for acute encephalitis at Karolinska University Hospital in Stockholm during 2000-2004. A confirmed etiological agent was identified in eight cases and a probable one in 37; in 48 cases no etiological agent could be found. Tick-borne encephalitis virus, enterovirus, respiratory syncytial virus, varicella zoster virus and influenza virus predominated and represented 67% of all the confirmed or probable etiologies. Encephalopathy was present in 80% of the children, 81% had fever, 44% had focal neurological findings, and seizures occurred in 40%. EEG abnormalities were seen in 90% and abnormal neuroimaging was present in 30%. The cerebrospinal fluid showed pleocytosis in 55%. There was no mortality, but 60% of the children had persisting symptoms at the time of discharge, 41% of which were moderate to severe. We conclude that the etiology of encephalitis among Swedish children is at large the same as in other European countries with similar vaccination programs. Fever and encephalopathy were seen in a majority of children and the most sensitive tool for making the diagnosis was EEG examination. Furthermore, many children display persisting sequele at discharge for which the strongest predictive factor was focal neurological findings at presentation.     

Pulmonary radiological changes in kerosene poisoning in the Asir region of Saudi Arabia.

A prospective study of pulmonary radiological changes following accidental kerosene poisoning in 67 children is presented. Abnormalities were seen in 41 patients (61.2%), and these were categorized according to nine patterns. These included varying degrees of perihilar and lung infiltration, pulmonary cystic changes, pleural effusion, empyema, pneumomediastinum and surgical emphysema. The two most common were bilateral perihilar infiltrates with clear lung bases and bilateral perihilar with basal infiltrates. In the majority of cases, these radiological changes resolved completely within 10-12 days with only two needing surgical intervention.