Adenovirus 7a: a community-acquired outbreak in a children's hospital

BACKGROUND: Adenoviruses produce many illnesses in children, particularly respiratory and gastrointestinal disease. The most common adenoviral respiratory infections in children are caused by types 1, 2, 3 and 5. Adenoviruses spread rapidly in closed environments often causing epidemic disease. Serotype 7a has been responsible for outbreaks of respiratory disease in children living in close proximity with one another. This report describes a large community-acquired adenovirus 7a epidemic in hospitalized children. METHODS: Evaluation of all patients with cultures positive for adenovirus from a children's hospital-based virology laboratory during a recognized adenovirus outbreak. All such adenovirus isolates were typed, and patients with adenovirus 7a are described by review of medical records. RESULTS: Between March 1 and July 26, 1997, 47 children admitted to the hospital were identified as infected with adenovirus. Of these 47 patients 26 (55%) were infected with adenovirus 7a. Twenty-four (92%) infections were community-acquired. The age range was 11 days to 10 years with a median of 9.5 months. Twenty-two patients (84%) had respiratory symptoms, and 21 (8%) had fever, making these the most common symptoms. The mean durations of fever and hospitalization were 5.5 and 7 days, respectively. One of 26 patients died. CONCLUSIONS: Adenovirus 7a can cause large community epidemics affecting children. The disease produced by adenovirus 7a in children is almost exclusively of the respiratory tract, and in some individuals it may be very severe and possibly fatal.     

Bacteremia in children: etiologic agents, focal sites, and risk factors

A prospective study was carried out on 210 cases of children under 10 years of age with fever. Cases of gastroenteritis, respiratory tract infections, and suspected sepsis in children seen or admitted to the pediatric hospital were studied. Clinical and microbiological data were recorded in a questionnaire or obtained from patient medical records. Most of the children with septicemia (71.3 per cent) were less than 1 year old. Focal source of bacteremia was gastroenteritis (40.4 per cent), pneumonia or bronchopneumonia (20 per cent), meningitis (7.4 per cent), and urinary tract infections (7.4 per cent). The predominant pathogens isolated from blood or stool specimens were gram-positive bacteria (53.3 per cent), mainly Streptococcus pneumoniae and coagulase-negative Staphylococcus spp. The gram-negative bacteria (45.6 per cent) were mainly Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Yersinia spp. One case of Candida albicans (1.1 per cent) was reported. Pasteurella pneumotropica was reported in two cases for the first time. The mortality rate was 4 per cent, mostly from septicemia cases. Long duration of hospitalization (> 10 days) and parenteral feeding were identified as risk factors. Resistance of the isolated pathogens to several commonly used antibiotics was observed. Empirical treatment with antibiotics is recommended only in life-threatening cases.     

Disseminated adenovirus infection with respiratory failure in pediatric liver transplant recipients: impact of intravenous cidofovir and inhaled nitric oxide

Adenoviruses (AdV) are opportunistic pathogens that can lead to severe infections and respiratory failure (acute respiratory distress syndrome, ARDS) with high mortality in immunosuppressed patients. Cidofovir (CDV) has been used in adenoviral disease in bone marrow transplant recipients. Two pediatric liver transplant recipients with disseminated adenoviral disease and ARDS were treated with reduction of immunosuppression, CDV, and inhaled nitric oxide (iNO). CDV 1 mg/kg was given three times per week intravenously with intravenous hydration and oral probenecid. Viral suppression and clinical improvement was achieved. AdV hepatitis did not occur, and graft function was preserved, although acute rejection occurred in both patients. Adverse effects were mild and transient not requiring dose modification. Severe hypoxemia was reversed with iNO 10-20 p.p.m. CDV treatment of AdV infections in organ transplant recipients and other immunocompromised patients should be further investigated in prospective studies.     

Factors predisposing to abnormal pulmonary function after adenovirus type 7 pneumonia.

Adenoviruses are well known causes of respiratory illness in children. Long term sequelae reported with types 3, 7, and 21 include bronchiolitis obliterans, bronchiectasis, and the hyperlucent lung or McLeod syndrome. Twenty children admitted to hospital with adenovirus type 7 pneumonia between 1960 and 1978 were studied and compared with 20 controls admitted during the same period with adenovirus type 7 upper respiratory tract infections. Sixty five per cent of the pneumonia group had developed evidence of airways obstruction compared with 10% of controls. Young age at the time of pneumonia and a ''measles-like'' illness before its onset increase the chance of developing long term pulmonary function abnormalities. Sex and family history of smoking or atopy do not influence outcome.     

Viral aetiology of acute respiratory infections in children in north India

Two hundred and thirty children clinically diagnosed as suffering from acute respiratory infection were tested for four major groups of viral aetiological agents, i.e. influenza para-influenza, respiratory syncytial virus (RSV) and adenoviruses using indirect immunofluorescence technique. At least one of the respiratory viruses was identified in 51 (22 per cent) specimens, which included influenza A in 6 (3 per cent), influenza B in 3 (1 per cent), para-influenza type 1 in 3 (1 per cent), para-influenza type 3 in 13 (6 per cent), RSV in 11 (5 per cent) adenovirus in 12 (5 per cent), and dual virus infections in 3 (1 per cent) cases. Maximum number of virus identification was noted in children below 1 year of age, particularly infection with RSV followed by para-influenza and adenoviruses. Value of rapid diagnosis by indirect immunofluorescence technique is stressed.     

Clinical features of children infected with different strains of influenza B in southern Taiwan

BACKGROUND: This study was designed to determine the clinical characteristics of children infected with different strains of influenza B viruses isolated in southern Taiwan. The clinical features were compared with influenza A infection occurring in the same period. METHODS: All children enrolled in the study had laboratory-confirmed infection with influenza A or B viruses. Influenza B speciation was performed by RNA extraction, cDNA synthesis, and amplification by polymerase chain reaction and sequencing. Demographic data, clinical findings, diagnoses, and outcomes were obtained. RESULTS: During the study period, 163 strains of influenza A and 118 strains of influenza B were isolated. The Yamagata-like strains were most prevalent in 2001. New reassortant strains were identified since 2002 and became predominant in 2005 and 2006. Children with influenza B were more likely than those with influenza A to be diagnosed as upper respiratory tract infection, myositis, and gastroenteritis (P < 0.05). Children infected with Yamagata-like strains were more likely to develop lower respiratory tract infection (P < 0.05) and accounted for all cases of invasive disease. Children infected with the Victoria-like group had the longest hospital stays associated with severe bacterial superinfection. CONCLUSIONS: Currently new reassortant influenza B viruses are the predominant strains circulating in southern Taiwan. There is considerable similarity of clinical features between influenza A and B in children. The Yamagata-like strains were associated with more invasive infections. Continuous influenza virus surveillance is essential particularly in Taiwan where pandemic strains tend to appear earlier than in other countries.     

A randomized controlled study of the impact of dietary zinc supplementation in the management of children with protein-energy malnutrition in Lesotho. I: Mortality and morbidity

Protein-energy malnutrition (PEM) remains one of the common causes of morbidity and mortality among children throughout the world. The supplementation of 10 mg elemental zinc, as zinc sulphate, was evaluated in the management of PEM in a randomized, controlled double-blind clinical trial in 300 children, aged 6-60 months (zinc, n = 150; control, n = 150) admitted to the Queen Elizabeth II Hospital, Maseru, Lesotho. Supplementation and follow-up were done for 3 months post-discharge from the hospital. Mortality during hospitalization was significantly lower in the zinc supplemented group (4.7 per cent), compared with 16.7 per cent in the control group. The prevalence of morbidity was significantly higher in the control group at 1, 2, and 3 month's follow-up. In the zinc supplemented group 58 per cent of the children were above the 80th percentile of expected weight-for-age 3 months after discharge, compared with 27.6 per cent in the control group. Dietary zinc supplementation resulted in a significant reduction in diarrhoeal disease, respiratory morbidity, and episodes of clinical anaemia, skin infections, and fever as well as vomiting in children with PEM. These findings suggest that interventions to improve zinc intake in their management may be of benefit to Basotho children in Lesotho with PEM.     

The health status of rural school children in the Amazon basin of Ecuador

An assessment of the health status among school children of the Naporuna ethnicity was conducted in north-eastern Ecuador. Prevalence of protein-energy malnutrition (PEM), parasitic infections, and pathology was investigated among 511 school children. The overall nutritional status of the school children was found to be good despite a high prevalence of helminthic infections. The prevalence of stunting was 1.4 per cent and of wasting 1.8 per cent. Sixty-four per cent of the children surveyed were found infected with one or more of the soil-transmitted helminths. In the clinical examination high prevalence of pterigium (89.2 per cent) was found. Upper respiratory infections (5.2 per cent), septic skin lesions (4.4 per cent), mycotic otitis (3.8 per cent), tinea (3.4 per cent) and bronchitis (2 per cent) were the main infectious pathology found. Likely explanations of these findings are discussed.     

Antibiotic use in community-based pediatric outpatients in southern region of Brazil

The irrational use of antibiotics is incriminated for the escalating antimicrobial resistance problem worldwide. This cross-sectional survey was conducted to describe patterns of antibiotic use in community-based pediatric outpatients in the southern region of Brazil. A sample of children (29 days to 18 years of age) was selected from each community-based outpatient clinic. Information related to antibiotic use in the child was obtained by interview with their parents using a structured questionnaire. Of 489 children, 201 (41.1 per cent) had received at least one antimicrobial course in the previous 2 months. The most commonly prescribed antibiotic was amoxicillin (54.0 per cent) and broad-spectrum agents were used in 15.3 per cent of antimirobial courses. Acute respiratory infections were the most frequent diagnosis for antibiotic prescribing (91.2 per cent), but at least 39.5 per cent were conditions of presumed viral etiology. Antibiotic use in the previous 2 months was more likely in children younger than 2 years (PR 1.36, 95 per cent CI 1.10-1.69); with chronic diseases (PR 1.38, 95 per cent CI 1.10-1.75); with higher paternal education level (PR 1.38, 95 per cent CI 1.11-1.72); with parents' pressure on physician for antibiotics (PR 1.66, 95 per cent CI 1.05-2.64) and with parental self-prescribing habit (PR 1.47, 95 per cent CI 1.06-2.04). Antibiotic use in children increased with mother's age (p=0.03 for linear trend). In conclusion, antibiotic prescribing is very common in community-based pediatric outpatients in the southern region of Brazil and inappropriate use is frequent. The independent risk factors for antibiotic use are child's age under 2 years, the presence of chronic diseases in the child, older mother, higher paternal education level, parents' pressure on physician and parental self-prescribing habit.     

The causes of hospital admission and death among children in Bamako, Mali

The health burden and mortality caused by infections during childhood remain large in sub-Saharan Africa. We performed a review of the causes of hospitalization and death among children admitted to a pediatric teaching hospital in Bamako, Mali. Medical records of children admitted throughout 2000 were systematically sampled and abstracted for demographics, diagnosis, hospital course, and disposition. A sample of 1644 charts, from 5001 admitted children, were abstracted. The median age was 8 months. Half of the children had a febrile illness. All diagnoses were made clinically. The annual incidence per 100,000 and case fatality rates of the four most common serious infections, excluding malaria, were as follows: pneumonia, 165 (12 per cent); sepsis, 75 (37 per cent); meningitis, 71 (20 per cent); and enteric fever, 14 (12 per cent). An estimated 1300 children were admitted with thick-smear confirmed malaria; at least 64 per cent met World Health Organization criteria for severe malaria and 11 per cent died. Seventy-one per cent of admissions were due to infections. Overall 21 per cent of children admitted died in the hospital, most within the first 3 days of admission. Infectious diseases remain the primary cause of hospitalization among Malian children and frequently lead to death. A substantial proportion of this morbidity and mortality is probably attributable to vaccine-preventable diseases, such as Haemophilus influenzae type B, Streptococcus pneumoniae, and Neisseria meningitidis. Prospective surveillance using microbiological data is needed to delineate the organism-specific burdens.     

Health status of rural school children in Western Orissa

A clinical survey of 916 school children in a rural area in Western Orissa was carried out. Immunization coverage for primary small-pox was 100 per cent while that for B.C.G. was 69.5 per cent. Anthropometric measurements revealed that the height of these children was more than the ICMR standard while weight was lower than the ICMR standard. Chest circumference was more or less similar to the ICMR standard. Common causes of morbidity were vitamin B complex deficiency (42.9 per cent), vitamin A deficiency (28.6 per cent), anemia (25.7 per cent), upper respiratory tract infections (22.1 per cent), gastro-intestinal tract disorders (8.7 per cent), scabies (16 per cent) and dental diseases (8.5 per cent).     

Correlation between serum interleukin 6 and C-reactive protein concentrations in patients with adenoviral respiratory infection

OBJECTIVE: To characterize adenoviral respiratory infection, we evaluated clinical features, laboratory findings and serum cytokine concentrations in patients with adenoviral infection and compared them with those in patients with influenza virus and respiratory syncytial virus (RSV) infections. METHODS: We enrolled 106 patients who had been diagnosed with acute viral respiratory infection caused by adeno-, influenza and respiratory syncytial viruses from January, 1995, through December, 1998. Forty-nine patients had adenovirus infection, 19 patients had influenza virus infection and 38 patients had RSV infection. Etiologic diagnosis was made based on the antigen detection by enzyme immunoassay (influenza virus, RSV), and viral isolation was done by tissue culture (adenovirus, influenza virus) from nasopharyngeal specimens. We evaluated clinical manifestations, laboratory findings (white blood cell count, C-reactive protein, erythrocyte sedimentation rate) and serum cytokine [interleukin (IL)-1-beta, IL-6, IL-8, interferon gamma and tumor necrosis factor alpha] concentrations. RESULTS: We observed prolonged fever, strong inflammatory response such as leukocytosis with neutrophilia and high C-reactive protein values in patients with adenoviral respiratory infection compared with those in patients with influenza virus and RSV infections. Serum IL-6 concentrations in patients with adenoviral respiratory infection were higher than those in patients with influenza virus and RSV infections. Other cytokine (IL-1-beta, IL-2, interferon gamma and tumor necrosis factor alpha) values did not differ among adenovirus, influenza virus and RSV infections. CONCLUSIONS: Patients with adenoviral respiratory infection have high grade and prolonged fever, strong inflammatory response and higher serum IL-6 than in influenza and RSV infection.     

Morbidity pattern among children below 5 years in an urban Sindhi community

Summary A morbidity study was carried out in 350 children below 5 years. Sindhi Colony, Raja Park on the eastern outskirts of Jaipur city was selected for study. The minimum number of children (14.3 per cent) was in the age group 48·60 months. 62.9 per cent of the children had one or more behavioural disorders. The leading problem was pico (47.1 per cent). Anajovity (78.0 pevrecehty of the children suffered from one or the other communicable disease. Acute respiratory infections (48.9 per cent). diarrhoea ond dvsentery (18.3 per cent), pneumoning (7.6 per cent) and worm infestation (6.2 per cent) were the leading causes of illness during the preceding twelve months. 27.1 per cent of children were found sick at the time of examination. From the S.M.S. Medical College, Jaipur-302004.     

Persistent diarrhoea: associated infection and response to a low lactose diet

Children aged 4-23 months with persistent diarrhoea received a low lactose diet, multivitamins, minerals and antibiotics for infection. Sixty-one (57 per cent) children improved with low lactose diet while 46 (43 per cent) failed. Children who failed were younger (8.9 +/- 3.5 vs. 11.3 +/- 4.4 months), had higher initial purging rate (146 +/- 102 vs. 109 +/- 102 g/kg/day) and consumed more ORS (138 +/- 77 vs. 95 +/- 79 g/kg/day). A higher proportion of children in the failure group needed unscheduled intravenous fluid (48 vs. 20 per cent) and lost body weight (24 vs. 0 per cent). Single and multiple stool pathogen were isolated from 44 and 45 per cent cases, respectively. Diarrhoeagenic Escherichia coli (66 per cent) was the most common pathogen isolated. Half of all pathogens including Campylobacter, rotavirus, cholera and non-typhoidal Salmonella were nosocomially acquired. Sixty four per cent of children had extraintestinal infections including acute lower respiratory infection (50 per cent), urinary tract infection (29 per cent) and septicaemia (11 per cent). The presence of extraintestinal infections were significantly associated with failure. Overall, 91 per cent of children had either intestinal and/or extraintestinal infections.     

The impact of HIV infection and trimethoprim-sulphamethoxazole prophylaxis on bacterial isolates from children with community-acquired pneumonia in South Africa

The aim of this study was to compare the type and antimicrobial resistance patterns of bacteria cultured from blood or respiratory tract secretions by HIV status and the use of trimethoprim-sulphamethoxazole (TMP-SMX) prophylaxis in children hospitalized with community-acquired pneumonia. During a 1-year prospective study in Cape Town, South Africa, 250 children [median aged 6 (3-16) months] hospitalized with pneumonia were enrolled; 151 (60.4 per cent) were HIV-infected. The incidence of bacteremia [35 of 244 cultures (14.3 per cent)] did not differ by HIV status. Bacteria were cultured in 17 of 32 (53 per cent) bronchoalveolar lavage specimens (BAL), 128 of 210 (61 per cent) induced sputa and 166 of 231 (71 per cent) nasopharyngeal specimens (NPAs). The type and number of bacteria in respiratory secretions did not differ by HIV status, except for a higher rate of Staphylococcus aureus in sputum or BAL [22 of 146 (15 per cent) vs. 3 of 96 (3 per cent), p = 0.003] and NPAs [41 of 135 (30 per cent) vs. 9 of 96 (9 per cent), p < 0.001] of HIV-positive children. The use of TMP-SMX prophylaxis in HIV-infected children was associated with an increased nasopharyngeal carriage of S. aureus [22 of 51 (43 per cent) vs. 17 of 79 (22 per cent), p = 0.009]. The rising prevalence of HIV infection and the use of TMP-SMX prophylaxis may alter the spectrum of colonizing and pathogenic bacteria in children in developing countries.     

Pancytopenia in children: etiological profile

Pancytopenia is a common occurrence in pediatric patients. Though acute leukemias and bone marrow failure syndromes are usual causes of pancytopenia, etiologies such as infections and megaloblastic anemia also contribute. The aim of this study was to evaluate the clinico-hematological profile of varying degrees of childhood cytopenias with special reference to the non-malignant presentations. This is a retrospective study carried out in a tertiary care children's hospital. We retrospectively analyzed 109 pediatric patients who presented with pancytopenia for different etiologies. Acute leukemia (including ALL, AML and myelodysplastic syndrome) and aplastic anemia accounted for 21 per cent and 20 per cent cases respectively. Megaloblastic anemia was found in 31 (28.4 per cent) patients and was single most common etiological factor. Severe thrombocytopenia (platelet < or = 20 x 10(9)/l) occurred in 25.2 per cent of these patients. Various skin and mucosal bleeding occurred in 45.1 per cent of patients with megaloblastic anemia. Infections accounted for 23 (21 per cent) patients who presented with pancytopenia. Amongst infections, enteric fever occurred in 30 per cent patients. Malaria, kala-azar and bacterial infections were other causes of pancytopenia at presentation. The study focuses on identifying easily treatable causes such as megaloblastic anemia and infections presenting with pancytopenia. These conditions though look ominous but respond rapidly to effective therapy.     

An epidemic of measles in Burkina Faso: 714 cases hospitalized in the hospital at Bobo-Dioulasso. A study of risk factors

From January 1986 through June 1987, 714 children with measles were admitted to the Pediatric Department of the Sanou Souro Hospital in Bobo-Dioulasso, Burkina-Faso. Eighty-four per cent of cases occurred during the first semester of 1987. Sixty per cent of patients were 9 to 35 months of age. The case-fatality rate was 29.1% (31.5% during the first semester of 1987, 12% in 1986). Fifty-five per cent of deaths occurred within 24 hours of admission. The most common clinical features upon admission included dehydration (91% of patients), diarrhea (64%), conjunctivitis (56%), fever in excess of 39.5 degrees C (50%), respiratory infection (46%), and cardiovascular collapse (34.5%). Factors associated with a fatal outcome included dehydration and cardiovascular collapse, poor nutritional status, and occurrence of the disease during the dry season (March, April, May). In most cases, immunization status of affected children was unknown. The high mortality rate can be ascribed to the significant delay with which medical care was provided, due in part to the inadequacy of primary health care facilities. This outbreak denotes the inadequacy of immunization against this disease that is included in the Extended Immunization Program.     

The 1985 influenza epidemic in a pediatric practice

Because it is not possible to distinguish clinically influenza from other respiratory infections, virological methods have to be used to establish the influenza etiology. Nasopharyngeal swabs from 202 children with respiratory symptoms were taken. Influenza A virus (H3N2) was isolated from 44 children, influenza A virus (H1N1) from 61 children and influenza B virus from 13 children. The maximal activity of the two influenza A virus subtypes was different. The following features permitted the classification of 3 groups; monophasic fever greater than or equal to 38.5 degrees C (81.35%), biphasic fever (14.41%), and pseudocroup (4.24%). 16.1% of the children with fever also had gastrointestinal symptoms. No relation between influenza type/subtype and type of manifestation could be established.     

Adenovirus meningoencephalitis.

Central nervous system manifestations in association with adenovirus infections have rarely been documented. In this report, four children, ages 4, 5, 6, and 10 years, with adenoviral meningoencephalitis are described. Adenoviruses were recovered from CSF specimens in all four patients.