Predictors of Mortality in Hospitalized Children with Pandemic H1N1 Influenza 2009 in Pune, India

Objective

To analyse the factors associated with increased mortality among Indian Children with H1N1.

Methods

Data were abstracted from available hospital records of children less than 12?y of age, who were admitted to Sassoon General Hospital in Pune, India, with confirmed pandemic 2009 H1N1 influenza infection from August 2009 through January 2010. Logistic regression analysis was used to identify clinical characteristics associated with mortality.

Results

Of 775 pediatric cases admitted with Influenza Like Illness (ILI), 92 (11.8%) had confirmed H1N1 influenza infection. The median age of HIN1 cases was 2.5?y; 13 (14%) had an associated co-morbid condition. Median duration of symptoms was 4?d (interquartile range (IQR), 3?C7?d). All 92 H1N1 cases received oseltamivir and empiric antimicrobials on admission. Intensive care unit (ICU) admission was required for 88 (96%) children, and 20 (23%) required mechanical ventilation.Fifteen children (16%) died; mortality was associated with presence of diffuse alveolar infiltrate on admission chest radiography (odds ratio (OR) 45, 95%CI :5.4?C370; p?p?=?0.001), SpO₂ <80% on admission (OR 32.8, 95% CI: 5.8?C185.5; p?p?n?=?4 each, 27%) with gram positive organisms consistent with severe viral and bacterial co-infection.

Conclusions

Hypoxia, ARDS and use of corticosteroids in children with ARDS who were mechanically ventilated were the factors associated with increased odds of mortality. Necropsy also suggested bacterial co-infection as a risk factor.     

Clinical and MRI features of neurological complications after influenza A (H1N1) infection in critically ill children

Background

Influenza A (H1N1) can cause severe neurological complications.

Objective

The purpose of this study was to analyze clinical and MRI features of neurological complications after H1N1 infection in critically ill children.

Materials and methods

We retrospectively analyzed clinical and neuroimaging findings in 17 children who were hospitalized in an intensive care unit with severe neurological complications after H1N1 infection in South China between September 2009 and December 2011. All children underwent pre- and post-contrast-enhanced brain MRI. Postmortem studies were performed in two children.

Results

Six children died, five because of acute necrotizing encephalopathy (ANE) and one because of intracranial fungal infection. Eleven recovered; their manifestations of H1N1 were meningitis (3), encephalitis (1) and influenza encephalopathy (7). MRI features of ANE included multiple symmetrical brain lesions demonstrating prolonged T1 and T2 signal in the thalami, internal capsule, lenticular nucleus and pontine tegmentum. Postmortem MRI in two children with acute necrotizing encephalopathy showed diffuse prolonged T1 and T2 signal in the bilateral thalami, brainstem deformation and tonsillar herniation.

Conclusion

Fatal neurological complications in children after H1N1 infection include ANE and opportunistic fungal infection. MRI is essential for identification of neurological complications and for clinical evaluation.     

Nephrotic Syndrome Following H1N1 Influenza in a 3-Year-Old Boy

Background

The pandemic influenza A/H1N1, spread through the world in 2009, producing a serious epidemic in Italy. Complications are generally limited to patients at the extremes of age (<6 months or >65 years) and those with comorbid medical illness. The most frequent complications of influenza involve the respiratory system.

Case Presentation

A 3-year-old boy with a recent history of upper respiratory tract infection developed a nephrotic syndrome. Together with prednisone, furosemide and albumin bolus, a therapy with oseltamivir was started since the nasopharyngeal swab resulted positive for influenza A/H1N1. Clinical conditions and laboratory findings progressively improved during hospitalization, becoming normal during a 2 month follow up.

Conclusion

The possibility of a renal involvement after influenza A/H1N1 infection should be considered.     

Findings in children severely infected with a novel influenza A virus of swine origin: pulmonary imaging

Background

This article reviews the chest radiography of children with severe infection caused by a novel influenza A (H1N1) virus of swine origin (S-OIV). We analyzed the role of their pulmonary images in predicting the severity and diagnosis of the disease.

Methods

Among 97 patients with confirmed novel H1N1 infection, 42 patients treated with mechanical ventilation formed group 1, and the remaining 55 patients constituted group 2. The initial and subsequent radiograhic findings in groups 1 and 2 were compared with respect to the pattern, distribution, and extent of the abnormality.

Results

In group 1, 24 patients presented with three or more lung zone diseases, whereas only 5 patients in group 2 demonstrated these findings (P<0.001). A pneumomediastinum or pneumothorax was observed in 24/42 patients in group 1 and in 18/55 patients in group 2 (P=0.019). Twelve patients in group 1 and 5 in group 2 developed a ground-glass opacity cyst with a honeycomb appearance (P=0.007).

Conclusions

The most common radiographic and computed tomography findings in children who were severely infected with S-OIV included unilateral or bilateral ground-glass opacities with or without associated focal or multifocal areas of consolidation. Children with bilateral involvement or with greater opacity on the chest radiographs were more likely to worsen and require the mechanical ventilation.     

CT Findings in Pediatric Novel Influenza A (H1N1)-Associated Pneumonia

Objective

To explore CT findings in pediatric novel influenza A (H1N1)-associated pneumonia

Methods

We examined the CT findings in a series of six children with influenza H1N1-associated pneumonia.

Findings

In this series of cases, the predominant CT patterns were consolidations surrounded by ground glass opacities (GGOs) as well as isolated GGOs in all patients. Atelectasis was present in the right upper lobe (n=2) in three cases and pneumomediastinum in two.

Conclusion

In this series of cases, there may be no imaging differences between pediatric and reported adult influenza H1N1 cases and other viral pneumonia cases even with CT. Pneumomediastinum and atelectasis, especially in the right upper lobe, may frequently present in influenza H1N1-associated pneumonia as well as in other pediatric respiratory diseases.     

Influenza?A/H1N1-2009 bei Kindern und Jugendlichen in Hamburg

Background

No reports have yet been published about the disease characteristics of Influenza?A/H1N1-2009 infections in children and adolescents in Germany.

Study

We reviewed the charts of 95 pediatric patients hospitalized at our clinic between August 2009 and March 2010 for Influenza?A (H1N1) infections. 60% of the patients were under 5 years of age. The majority presented with respiratory symptoms and temperatures above 39°C. Two thirds of our patients exhibited gastrointestinal symptoms and 23% developed neurological complications. Inflammatory parameters were only slightly elevated. Infants showed a longer course of the disease than children older than 1 year. Patients with underlying pulmonary conditions did not suffer a more prolonged illness than previously healthy patients. The mean duration of the disease with oseltamivir treatment was 25% shorter than without antiviral treatment. All patients survived.

Conclusion

Infants and toddlers are more seriously affected than older children. In contrast to seasonal influenza, pre-existing pulmonary condition did not prolong the duration of symptoms. Oseltamivir can shorten the course of disease.     

Furosemide infusion in children with dengue fever and hypoxemia

Objectives

To study the role of furosemide infusion in the management of Acute respiratory distress syndrome (ARDS) associated with dengue fever.

Methods

Children between the ages of 1 month to 18 years, who fulfilled the WHO clinical criteria for dengue infection and American European Consensus Criteria criteria for ARDS with Dengue IgM positivity, were evaluated. Patients were studied as group D (receiving diuretic therapy alone) and group B (both ventilation and diuretics), and compared to a historical control group V (ventilation alone). Furosemide infusion was administered at 0.05–0.1 mg/kg/hour for 48 hours, maintaining a urine output of 2–4 mL/kg/hour.

Results

There was a significant difference in survival in the three groups. Significant difference was noted between pre- and postintervention arterial blood gases with respect to PCO₂ (P=0.02), pO₂ (P=0.003), PaO₂/FaO₂ ratio (P<0.001) and alveolar-arteriolar oxygen gradient (P=0.002).

Conclusion

Diuretic infusion improves outcome in dengue with ARDS.     

Corpus callosum agenesis and rehabilitative treatment

Background

To investigate the rates of pneumococcal and influenza vaccinations and their determinants in children with chronic medical conditions.

Patients and Methods

Children with HIV infection, cystic fibrosis, liver transplantation and diabetes mellitus were enrolled. Physicians of regional Reference Centres for each condition, primary care paediatricians and caregivers of children provided information through specific questionnaires. For diabetes, 3 Reference Centres were included.

Results

Less than 25% of children in each group received pneumococcal vaccination. Vaccination rates against influenza were 73% in patients with HIV-infection, 90% in patients with cystic fibrosis, 76% in patients with liver transplantation, and ranged from 21% to 61% in patients with diabetes mellitus. Reference Centres rather than primary care paediatricians had a major role in promoting vaccinations. Lack of information was the main reason for missing vaccination. Awareness of the severity of pneumococcus infection by key informants of at-risk children was associated with higher vaccination rate.

Conclusions

Vaccination rates in children with chronic conditions were poor for pneumococcus and slightly better for influenza. Barriers to vaccination include lack of awareness, health care and organization problems.     

Clinical characteristics of adenovirus associated lower respiratory tract infection in children

Background

Acute lower respiratory tract infection (ALRI) due to adenovirus infection is a low frequency event but often causes severe outcome. This study was undertaken to uncover the clinical and epidemiological features of adenovirus infection in children.

Methods

Hospitalized children with ALRI were analyzed through continuous monitoring from 2006 to 2012. Nasopharyngeal aspirates were examined by direct immunofluorescence to detect respiratory agents including respiratory syncytial virus, adenovirus, influenza virus types A/B, parainfluenza virus types 1/2/3. Chlamydia pneumonia, Mycoplasma pneumonia and Chlamydia trachomatis were determined by real-time PCR. A retrospective analysis was made of 479 patients with positive infection of adenovirus.

Results

The positive detection rate of adenovirus was 0.63% in patients with ALRI. The incidence rate of adenovirus-associated acute lower respiratory tract infection peaked at the second six months of life. The morbidity was much higher in winter, spring and summer than in autumn. Patients with pneumonia accounted for 73.90% of the patients. More than one-third of the patients developed severe pneumonia, whereas no death was found. Features of severe adenovirus-associated lower respiratory tract infection included persistent high fever with serious infective symptoms, and hepatic dysfunction was one of the most common complications. Mixed infection of atypical pathogens was common (18.58%) in this study.

Conclusions

Adenovirus is a critical pathogen that can cause severe respiratory infections even in immunocompetent children. Coinfection of adenovirus with atypical pathogens is common. Antibiotic treatment with azithromycin or erythromycin is necessary in patients with mixed infection of atypical pathogens.     

Impfungen zum Schutz vor Atemwegsinfektionen bei Risikogruppen

Background

S. pneumoniae and influenza are the most common pathogens in the airways that are preventable by vaccination.

Objectives

The German Committee for Vaccinations (STIKO) also recommends vaccinations against pneumoccocci and influenza virus for subjects who are at risk. Using a literature search, we assessed which vaccines may be considered for which conditions.

Results

The STIKO gives an almost general recommendation for both pneumococcus and influenza vaccination. Children and adolescents with any condition considered a health risk may benefit from these immunisations. Namely, but not exclusively, patients with immunodeficiencies or airway diseases should be considered for vaccination. Pneumococcal conjugate vaccines appear more beneficial than the pneumococcal polysaccharide vaccine, also beyond the age of 5 years. A live attenuated influenza vaccine is more efficient than the trivalent inactivated influenza vaccine in children.

Conclusion

Vaccinations against pneumococci and influenza would greatly reduce morbidity caused by these pathogens in children and adolescents with chronic conditions.     

Extracorporeal membrane oxygenation with prone position ventilation successfully rescues infantile pertussis: a case report and literature review

Background

Bordetella pertussis can cause fatal illness with severe acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT).

Case presentation

A 6-month-old non-vaccinated boy with B. pertussis infection who developed ARDS was treated by extracorporeal membrane oxygenation (ECMO). During his ECMO support stage, sudden occurred decreasing of ECMO flow implied increasing intrathoracic pressure. The airway spasm followed caused sudden drop of ventilator tidal volume as well as poor lung compliance. Prone position ventilation and bundle care were conducted as lung protection ventilator strategy. After 297-h of ECMO support, the patient was weaned off ECMO, and extubated one week later.

Conclusions

In this patient with severe ARDS caused by Bordetella pertussis, ECMO was performed for cardiopulmonary support and rescued the infant with severe pertussis. During ECMO support period, prone position ventilation and care bundle nursing strategy contributed to the relief of continuous airway spasm.

     

Fatty liver disease and hypertransaminasemia hiding the association of clinically silent Duchenne muscular dystrophy and hereditary fructose intolerance

Background

Vaccination coverage rates against pandemic flu were far below those required by Italian Public Health Authorities. The aim of this retrospective study was to assess how the management of vaccination against pandemic flu in the Health District of Piacenza (Northern Italy) had conditioned the adherence of patients at risk to the H1N1flu immunization program.

Methods

From a population of 27.018 children aged between 6?months and 16?years, 2361 pediatric patients considered at risk according to the guidelines of the Ministry of Health were enrolled to receive pandemic flu vaccination. Children enrolled in the immunization program were vaccinated with one of the following three options:

1. by their pediatrician in his office after contacting him directly or by phone
2. by their pediatrician in his office or in a public Health District office with the assistance of a nurse after an appointment had been booked by patient??s parents using a dedicated free of charge phone number
3. by a doctor of the public Health District after an appointment had been booked as for option B

Results

The best outcomes of population vaccination coverage for pandemic flu were achieved when patients were vaccinated with option B (44.2%). For options A and C rates coverage results were 22.8% (OR 2,69) and 24.9% (OR 2, 39) respectively.

Conclusion

The results of this study may be taken into account by the public health Authorities when planning the management of future immunization campaigns out of the usual vaccination schedule or in an emergency event.     

Alpha 1 antitrypsin deficiency in children with chronic liver disease in North India

Objective

We attempted to determine the role of alpha-1-antitrypsin (AAT) deficient variants as an etiologic factor for chronic liver disease in North Indian children.

Design

This study investigated 1700 children (682 retrospectively and 1018 prospectively) (840 CLD, 410 neonatal cholestasis and 450 without liver disease) for AAT deficiency.

Setting

Tertiary referral center, All India Institute of Medical Sciences, New Delhi.

Patients

Of 1250 liver disease patients, 98 (7.8%) were suspected to be AAT deficient on the basis of screening tests (low serum AAT levels and/or absent/faint alpha-1-globulin band on serum agarose electrophoresis and/or diastase resistant PAS positive granules on liver biopsy).

Main outcome measures

AAT deficient Z or S allele in suspected patients.

Results

Z or S allele was not observed on phenotyping (1700 subjects), or with PCR-RFLP, SSCP and sequencing done in 50 of 98 suspected AAT deficient patients. A novel mutation G-to-A at position 333 in exon V was found in two siblings having positive immunohistochemistry for AAT on liver biopsy, both of whom had significant liver disease with portal hypertension.

Conclusion

In conclusion, AAT deficiency as an etiologic factor for chronic liver disease in childhood appeared to be uncommon in North India     

Analysis of Fatal Cases of Pandemic Influenza A (H1N1) Virus Infections in Pediatric Patients with Leukemia

Background: Pandemic influenza A/H1N1/2009 virus usually causes mild illness in healthy children. Chronic medical conditions are recognized as increasing the risk for complications of influenza virus infection. Although most studies including children with acute leukemia and H1N1 virus have reported no deaths, some anectodal reports with low patient numbers have reported mortality rates as high as 28.5%. Here, we report patients with leukemia and H1N1 virus and review the literature. Methods: Medical records of all children with leukemia and H1N1 virus in our institution were reviewed for demographic, clinical, and laboratory data. We also carried out a systematic review of the English-language literature. Among the 24 articles found, only patients with leukemia and pandemic H1N1 infections were reviewed by two independent reviewers. Results: Eight of 98 children who received chemotherapy for leukemia were diagnosed with pandemic H1N1 infection. One developed pneumonia and acute respiratory distress syndrome (ARDS) and died. Another one developed hemophagocytic lymphohistiocytosis (HLH) and died due to secondary infection during the 6th week of treatment for HLH. In our study, 2 of 8 patients had a fatal course (25%), compared with an overall mortality of 2.5% in the studies retrieved from PubMed (6/232). Conclusion: Pandemic H1N1 influenza virus caused mortality in patients with ARDS or HLH; an unexpected finding for pandemic H1N1 (2009) influenza virus. Thus, for children with leukemia and infected with H1N1 virus, short- and long-term complications should be kept in mind during evaluation.     

Healthcare-associated infections in a neonatal intensive care unit in Turkey

Objective

To determine the incidence, risk factors, mortality rate, antibiotic susceptibility and causative agents of healthcare-associated infections (HAIs) in the Neonatal Intensive Care Unit.

Design

Prospective, cohort.

Setting

A 38-bed, teaching, referral, neonatal intensive-care unit.

Participants

All patients in the neonatal intensive care unit who did not have any sign of infection at admission and remained hospitalized for at least 48 hours.

Methods

The study was conducted between January 2009 and January 2011. Healthcare-associated infection was diagnosed according to the criteria of CDC. Risk factors for HAI were analyzed with univariate and multivariate regression analysis.

Results

The incidence of HAI was found to be 16.2%. Blood stream infection was observed as the most common form of HAI (73.2%). The mortality rate was 17.3%. Antenatal steroid use, cesarean section, male gender, low birth weight, parenteral nutrition, percutaneous and umbilical catheter insertion, mechanical ventilation and low Apgar scores were found to be related with HAI (P<0.05). A 10% reduction in infection rate as a consequence of the application of a new total parenteral nutrition guideline was observed. Coagulase negative staphylococci (44. 4%) and Klebsiella pneumoniae (25.9%) were the most common etiologic agents isolated from cultures. Methicillin resistance of coagulase-negative staphylococci and ESBL resistance of Klebsiella pneumoniae were 72% and 44%, respectively.

Conclusions

Antenatal steroid was found to be associated with HAI. Newly applied total parenteral nutrition guidelines reduced the attack rate of infection. Efforts should be focused on developing more effective prevention strategies to achieve better outcomes.     

Serotype Determination of Adenoviruses in Children with Respiratory Infection

Objective

To determine adenovirus serotypes among children with acute respiratory infection (ARI) in Khoozestan province, Iran during years 2010–2011.

Methods

One hundred sixty three nasopharyngeal swabs were collected from children between 1 and 15 y who were hospitalized for the acute respiratory infection. The viral DNA was extracted from the nasopharyngeal swabs and adenoviruses were detected by Nested PCR. Positive PCR samples were sequenced in order to confirm the adenovirus serotypes.

Results

Out of 163 samples, 30 (18.4 %) were positive for adenoviruses by nested PCR. Twenty two PCR products were sequenced and recognized as Ad5 and Ad2 serotypes including 19 (86.3 %) Ad5 and 3 (13.7 %) Ad2.

Conclusions

This study reveals that adenoviruses with Ad5 predominance are important cause of respiratory tract infection in children.     

Reverse vertical transmission of hepatitis-B from transfusion-infected children to biological mothers

Background

Perinatal and horizontal are the common modes of transmission of hepatitis-B virus in children.

Case characteristics

Two mother-child pairs with children having received multiple blood transfusions in past.

Observation

Both the mothers developed acute hepatitis-B infection whereas children were demonstrated to be having chronic infection with hepatitis-B.

Outcome

One mother cleared her hepatitis-B in fection whereas it persisted in the other. Both children required anti-viral treatment.

Message

Hepatitis-B virus may rarely get transmitted from infected children to their mothers causing acute infection.     

Effect of long-term <Emphasis Type="Italic">Helicobacter pylori</Emphasis> infection on growth of children: a cohort study

Background

The effects of Helicobacter pylori (H. pylori) infection on growth are a controversial issue. We investigated the effects of long-term H. pylori infection on height and weight in children.

Methods

A total of 200 children of 7-18 years old suffering from dyspeptic complaints were classified into two groups: H. pylori positive and negative groups, respectively. Whether the infection was impoved was followed up while performing urea breath test, and according to exposure time to the infection, the children were further divided into group 1 (≤1.5 months), group 2 (>1.5-≤6 months) and group 3 (>6 months). Antropometric measurements were obtained and repeated every six months.

Results

Mean growth velocity scores in the H. pylori positive and negative groups were 0.49±3.85 [95% confidence interval (CI): -0.21-1.18] and 1.98±4.42 (95% CI: 1-2.96), respectively. The difference between both groups was statistically significant (P=0.012). Mean growth velocity scores in groups 1, 2 and 3 were 0.96±3.84, 0.16±4.51 and -0.85±3.09, respectively. Mean growth velocity scores of group 3 were significantly lower than those of groups 0 and 1 (P=0.005 and P=0.041). The mean weight scores in group 3 were similar to those in group 2, but the scores in group 3 were significantly lower than those in group 1 (-1.75±1.05, -1.21±1.37 and -0.88±1.49, respectively).

Conclusion

As the duration of exposure is prolonged in children with H. pylori infection, the negative effect of the infection on both height and weight is evident.