MEDICAL MANAGEMENT OF ASPERGILLUS FLAVUS ENDOCARDITIS

An 11-year-old boy underwent a matched unrelated bone marrow transplant for refractory acute myeloid leukemia. He developed invasive aspergillus pneumonia and endocarditis post-transplant. The fungal endocarditis was successfully eradicated with liposomal amphotericin at the dose of 10 mg/kg/day. Surgical intervention was not required and no serious side effects of liposomal amphotericin were observed at this dose.     

Aspergillus endocarditis in chronic granulomatous disease

We report the first case, to our knowledge, of Aspergillus endocarditis in chronic granulomatous disease in a patient who also had an atrial septal defect. A diagnosis was made on culture of the organism from the mass despite extensive prior investigation. The presence of distinctive skin lesions as a diagnostic clue of fungaemia is highlighted. Possible advances in diagnosis by detection of fungal cell wall components and in prophylaxis by use of itraconazole are referred to. We conclude that fungal endocarditis should be considered in this condition, especially in the presence of a structural heart defect.     

Parental knowledge of bacterial endocarditis prophylaxis

Summary The aim of this study was to determine parental knowledge of bacterial endocarditis prophylaxis (BEP).Parents of 135 patients attending a pediatric cardiology clinic in a university center were mailed an eight-question survey pertaining to their knowledge of their child's cardiac disease, medications, and BEP. The patients' cardiac lesions and current medications were verified by a review of clinic and echocardiographic records. Each patient's need for BEP was determined according to American Heart Association (AHA) recommendations [3].Eighty-four (62%) parents returned complete surveys. The patients' mean age was 5 years with a range of 9 weeks to 19 years. Eighty-two (98%) respondents were high school graduates. Fifty-two (62%) respondents correctly defined endocarditis. Eighty-two (98%) parents knew the correct name of their child's cardiac condition and 27/32 (84%) knew the names of their child's current medications. Only 36/64 (56%) parents of at-risk children knew measures to prevent endocarditis.While most parents know the name of their child's heart lesion and current medications, parental knowledge of endocarditis and BEP was limited. Intensified education and awareness programs are needed in order to prevent potential marbidity and mortality for pediatric patients with heart disease.     

WHAT REALLY BOTHERS ONCOLOGY PATIENTS

A 5-month-old boy with X-linked severe combined immunodeficiency (SCID) and aspergillus pneumonia was successfully transplanted. Before and during transplantation, the patient received O 2 administration, systemic amphotericin B, and itraconazole. The transplant was performed with a conditioning regimen of busulfan/cyclophosphamide and 2.9 &;#50 10 6 /kg of CD34 + selected bone marrow cells from his HLA haploidentical mother. Acute grade II graft-versus-host disease (GvHD) was well controlled. Neutrophil counts reached > 0.5 &;#50 10 9 /L by day 15 and platelet counts reached > 50 &;#50 10 9 /L by day 48. The T-cell subset (counts) in peripheral blood increased to 42.2% (0.31 &;#50 10 9 /L) by day 46. The pneumonia improved by day 54. The patient has been doing well with limited chronic GvHD of the gut with a follow-up of longer than 40 months after BMT. Conquest of aspergillus pneumonia in SCID infants could be achieved by CD34 + bone marrow cell transplantation together with appropriate anti-fungal treatment.     

Aspergillus fumigatus endocarditis in a pediatric liver transplant recipient: favorable outcome without cardiac surgery

Abstract:  Transplant recipients are very susceptible to invasive aspergillosis, which increases mortality rate. Disseminated aspergillosis in the liver transplant recipient can affect virtually any organ and endocarditis is often lethal despite cardiac surgery and antifungal therapy. We report the case of a eight-month-old girl who presented with Aspergillus fumigatus endocarditis 18 days after liver transplantation that was successfully treated by a combination of antifungal drugs associated to a low dosage of immunosuppressive therapy.     

THERAPEUTIC APPROACHES TO GASTROINTESTINAL VIRAL INFECTION OF THE PEDIATRIC BONE MARROW TRANSPLANT PATIENT

Viral infection of the gastrointestinal tract following bone marrow transplantation in childhood continues to be an important clinical problem associated with significant morbidity. In addition to acute symptoms, gastrointestinal viral infection may potentially initiate graft-versus-host disease or lead to persistent symptoms related to alterations in gastrointestinal motility. Effective therapeutics for this problem are limited. In this review we consider the potential protective effects of probiotic and passive immune therapy. We also discuss the potential role of novel, anti-inflammatory biologic therapeutics that may decrease symptoms and prevent the onset and perpetuation of graft-versus-host disease.     

感染性心内膜炎诊断标准的评价--附病理证实216例分析

目的 为提高诊断的敏感性,中华医学会儿科学分会心血管学组和中华儿科杂志编委会提出感染性心内膜炎(infective endoearditis,IE)诊断标准(简称试行标准)。本研究评估Duke标准与试行标准对IE的诊断价值。方法 从15所医院收集经尸检或手术证实(有血培养及超声心动图检查资料)的IE193例(A组),≤17岁127例,平均年龄8．5岁,≥18岁66例,平均年龄35．9岁,及临床诊断IE而手术未发现IE征象的23例患儿(B组)(除2例成人,平均年龄4．7岁)的病历资料。以Duke标准及试行标准对216例进行诊断评估,并比较二种诊断标准对比诊断的敏感性及特异性。结果 (1)A组病例中,连续2次血培养阳性并为相同病原菌的有50例(25．9％),1次血培养阳性有36例(18．7％);超声心动图发现心内膜受累征象165例(85．5％),160例(82．9％)为赘生物,其中100例的赘生物呈摆动团块(62．5％)。B组病例中,连续2次血培养阳性并为相同病原菌的有3例(13．0％),1次血培养阳性2例(8．7％),超声心动图检查仅1例(4．3％)伴有三尖瓣赘生物。(2)A组病例中按Duke标准94例(48．7％)被确诊为IE。按试行标准,156／193例(80．8％)被确诊为匹,其中62例(32％)符合心内膜受累超声心动图征象和2项次要指标。B组病例中,按Duke标准均不符合确诊IE条件,而按试行标准有1例符合确诊IE条件。(3)全组216例中,试行标准对IE的诊断敏感性及特异性分别为80．8％及95．7％,而Duke标准分别为48．7％及100％。结论 试行标准中增加心内膜受累超声心动图征象(主要指标)和2项次要指标作为临床确诊条件,对IE的诊断敏感性明显优于Duke标准,而特异性差异无显著性。     

VARICELLA ZOSTER VIRUS INFECTIONS IN THE PEDIATRIC STEM CELL TRANSPLANT PATIENT

Varicella zoster virus (VZV), a member of the human herpesvirus family, causes the clinical syndromes of chickenpox during primary infection and shingles on later reactivation. In immunocompromised patients, including those undergoing hematopoietic stem cell transplantation, VZV can produce life-threatening infections. The most serious forms of VZV infection involve hematogenous dissemination of the virus to vital organs, such as the lung, brain, and liver. Advances in immunoprophylaxis, antiviral chemotherapy, and vaccine development have provided effective tools to limit the morbidity and mortality previously associated with VZV infection in hematopoietic stem cell transplant patients. In this review, we discuss virologic aspects of VZV, pathogenesis of VZV infection, methods of viral diagnosis, clinical manifestations of infection in both normal and immunocompromised patients, and available preventative and therapeutic measures.     

Diphtheritic septicaemia and probable endocarditis: A case report and review of the literature

Corynebacterium diphtheriae usually produces an infection limited to the respiratory tract and the organisms rarely invade the blood stream. We report the case of a 6-year-old girl who, 2 months after an unsuccessful repair of a ventricular septal defect, developed septicaemia with nontoxigenic C. diphtheriae. The organism appeared resistant to penicillin in vitro and failed to respond to a course of trimethoprim-sulfamethoxazole to which it was susceptible in the laboratory. A cure was finally achieved using cephalothin and gentamicin, followed by an additional course of ampicillin and amoxicillin. Twelve previously recorded cases of diphtheritic sepsis and endocarditis are reviewed.Abbreviations VSD ventricular-septal defect - TMS trimethoprim-sulfamethoxazole     

Group C β-hemolytic streptococcal endocarditis: Report of a pediatric case

Summary A 9-year-old boy with a ventricular septal defect and a bicuspid aortic valve developed bacterial endocarditis due to group C streptococci. He responded to an initial antibiotic regimen of nafcillin plus gentamicin and was cured by the use of penicillin G following the isolation of the organism. The unusual nature of this case is discussed and physicians are cautioned to recognize this organism as a potential cause of infectious endocarditis in the pediatric population.     

儿童感染性心内膜炎临床特点变化及病原学变迁

目的分析儿童感染性心内膜炎临床特点变化及病原菌的变迁，为临床诊治提供进一步指导。方法回顾分析10年中我院73例14岁以下儿童感染性心内膜炎患儿外科手术的临床资料。并将1995年1月-1999年12月的32例（Ⅰ组）与2000年1月-2004年12月的41例（Ⅱ组）做统计学分析对比，比较两组病例临床特点的变化及病原菌的变迁。结果73例患儿占同期同年龄组住院患儿总数的7．3％（73／998），Ⅱ组的比例（41／671，6．1％）低于Ⅰ组（32／327，9．8％，P〈0．05）。66例有基础心脏病，其中室间隔缺损（VSD）47例，动脉导管未闭（PDA）15例，其他4例。心脏赘生物的检出率，Ⅱ组的比例（27／41，65．9％）高于Ⅰ组（15／32，46．9％，P〈0．01）。59例血细菌培养阳性，14例血细菌培养阴性。总的细菌培养阳性率为73．9％（54／73），Ⅰ组为96．88％（31／32），Ⅱ组为68．29％（28／41）。心脏赘生物的检出率增高，由Ⅰ组的46．9％（15／32）增高为Ⅱ组为65．9％（27／41）。儿童IE的病原菌菌谱发生明显变化，革兰阳性球菌的阳性检出率明显减少，而革兰阴性杆菌的检出率明显增加。结论外科治疗的儿童感染性心内膜炎临床特点发生一定变化，血培养的阳性率降低，而心脏赘生物的检出率增高。儿童IE的病原菌菌谱中革兰阴性杆菌所占比例有明显的增高。     

小儿感染性心内膜炎4种诊断标准诊断价值的比较

目的 比较Duke标准、St Thomas标准、Duke修改标准及国内制定的“小儿感染性心内膜炎诊断标准建议”(简称国内标准)对小儿感染性心内膜炎(IE)的诊断结果,以评估国内标准的诊断价值.方法 对临床诊断IE的45例患儿,以手术、病理或尸检资料为金标准,按Duke标准、St Thomas标准、Duke修改标准及国内标准分别行诊断分组,并行诊断价值评估,比较4种标准的敏感性、特异性和准确性.结果 45例临床诊断IE的患儿,32例经手术、病理或尸检证实为IE,13例排除.Duke标准、Duke修改标准及国内标准对45例临床诊断IE和26例血培养阴性患儿的诊断特异性均为100％,而St Thomas标准的特异性为92.3％.对于45例临床诊断IE者,国内标准的敏感性及准确性分别为90.6％和93.3％,Duke标准及Duke修改标准均为62.5％和73.3％,St Thomas标准分别为87.5％和88.9％;对于26例血培养阴性者,国内标准的敏感性及准确性分别为76.9％和88.5％,Duke标准及Duke修改标准均为7.7％和53.8％,St Thomas标准分别为69.2％和80.8％.对于45例临床诊断IE者,Duke标准、Duke修改标准和St Thomas标准与国内标准的Youden指数比较差异无统计学意义(P＞0.05),但对于26例血培养阴性患儿,Duke标准、Duke修改标准与国内标准的Youden指数比较差异有统计学意义(P＜0.01),而St Thomas标准与国内标准的Youden指数比较差异无统计学意义(P＞0.05).结论 与Duke标准、Duke修改标准和St Thomas标准相比较,国内标准增加了心内膜受累超声心动图征象和2项次要指标作为临床确诊条件及增加了相关的临床次要指标,明显提高了小儿IE临床诊断的敏感性和准确性,更适合于我国小儿IE的诊断.     

儿童感染性心内膜炎36年的临床变迁

目的为了解儿童感染性心内膜炎(IE)临床变迁的趋势,为早期诊断和治疗提供参考.方法将1964～1983年我院确诊的IE患儿34例(A组)与1984～1999年的38例(B组)进行临床对比分析.临床资料包括基础疾病、临床表现、血培养致病菌的种类、超声心动图(UCG)检查的情况、治愈率和病死率.结果72例IE患儿的基础疾病包括先天性心脏病40例,后天性心脏病16例,其他疾病16例.B组风湿性心脏病的比例为13%,较A组的27%有所下降;而B组无基础心脏病者(29%)较A组(15%)增加,两组基础疾病的构成差异无显著性(x2=3.685,P＞0.05).B组瘀点(斑)、脾肿大、动脉栓塞的发生率较A组虽有所下降,但差异无显著性(x2分别为3.34、2.18、0.37,P＞0.05),而心力衰竭的发生率则较A组明显上升,两组比较差异有显著性(x2=9.34,P＜0.01).B组金黄色葡萄球菌的发生率(14%)低于A组(55%)(经Fisher精确计算,P=0.081).而其他革兰阳性球菌包括四联球菌、腐生葡萄球菌、表皮葡萄球菌的发生率(64%)明显高于A组(0)(经Fisher精确计算,P=0.001).结论IE发生于先天性心脏病者仍居首位,近16年风湿性心脏病作为引起IE的基础疾病的比例有所下降,而无基础心脏病者增加;致病菌中金黄色葡萄球菌减少,而条件致病菌明显增加;临床表现心力衰竭明显增加.强调UCG在诊断IE中有重要价值,合理治疗可改善预后.     

Duke标准在小儿感染性心内膜炎诊断中的价值

目的：探讨Duke标准对小儿感染性收内膜炎诊断的价值。方法：应用Duke标准对50例临床诊断为感染 心内膜炎并经超声心动图检查的患儿及其中经手术证实为IE的患儿进行分组分析。结果：连续2次或2次以上血培养阳性并为相同致病菌的有15例（30％）,1次血培养阳性10例（205）,39例（78％）超声心动图检出赘生物,其中26例的螯生物呈摆动状态。有1例伴瓣膜穿孔,1例伴室间隔缺损补片脱落,按Duke标准,50例患儿中21例（42％）被确诊为IE。其中12例符合2项主要指标。9例符合1项主要和≥3项次要指标。1例被排除IE。在13例经手术证实的IE必中按Duke标准诊IE5例（385）,8例为可能IE,其中6例符合1项主要和2项次要指标,2例符合1项主要和1项次要指标。手术证实为IE的13例患儿中,10例血培养阴性,2例赘生物不摆动。结论应用超声心动图检出赘生物对IE诊断有重要意义,在儿科病例中螯生物的确定不必限于摆动的团块。曾用抗生素治疗,有典型心内膜受累的超心动图表现,另具备Duke标准中2项临床次要指标的可确诊为IE,这样将会进一步提高Duke标准诊断IE的敏感性。     

儿童感染性心内膜炎外科治疗时机

目的 探讨儿童感染性心内膜炎(IE)外科治疗时机。方法 收集儿童IE病例43例。其中合并基础心脏病38例，予手术治疗28例，药物治疗10例；无基础心脏病5例，予手术治疗3例，药物治疗2例。结果 行手术治疗IE者31例，全部治愈；药物治疗12例，近期死亡2例。手术治疗患儿随访27例，无死亡及心内膜炎复发等并发症，生活质量明显提高。结论 儿童感染IE的临床特征和超声心动图的表现与成人患者心内膜炎表现相似，外科手术是治疗IE的有效手段，掌握手术时机是治愈本病的关键。急症手术治疗指征为：心力衰竭恶化，心腔赘生物或瓣膜赘生物大于10mm者，经药物治疗难以控制的感染。儿童感染IE大多数有心脏结构异常，先天性心脏畸形，患儿应早期治疗，以减少IE的发生。     

Perioperative management of the pediatric transplant patient

With advances in surgical techniques, an increasing number of children are becoming transplant candidates. Pediatric critical care physicians may need to manage both transplant donors and recipients in the pediatric intensive care unit. Care of such patients needs to be performed aggressively with complete attention to details in order to obtain successful transplant outcomes. The postoperative management of the transplant recipient includes the basic intensive care monitoring and management of postoperative patients who are critically ill. Besides this, there are some unique features among these patients which may complicate the postoperative stay in the pediatric intensive care unit and these are discussed here. It is important to remember that the successful management of a transplant patient includes the pediatric critical care physician’s abilities of not only taking care of acute issues but also of coordinating care between subspecialists. The pediatric critical care physician must always continue to provide support to families of these transplant patients during their intensive care unit stay.     

小儿先心病并感染性心内膜炎手术治疗中的体外循环技术

目的总结2002年1月至2011年4月作者收治的15例先天性心脏病合并感染性心内膜炎（infective endocarditis,IE）患儿手术治疗中的体外循环经验（cardiopulmonary bypass,CPB）。方法15例患儿均采用浅低温（28℃～30℃）、较高流量[2．4～3．2L／（min·m2）]灌注。手术方式为畸形矫治（ASD／VSD修补、右室流出道重建）、赘生物摘除、瓣膜整形或置换术。心肌保护采用4℃冷含血晶体保护液顺行灌注。结果15例患儿CPB总时间85～180min,主动脉阻断时间40～120min,均顺利脱离CPB。均获痊愈。1例术后2年死于肺部感染及心功能衰竭。结论CPB中HCT及胶体渗透压的良好控制、采用平衡超滤结合改良超滤、肝素化后监测ACT、CPB中加入敏感抗生素等对患儿术后恢复至关重要。     

Therapeutic monitoring of busulfan in pediatric bone marrow transplantation

The aim of this study was to describe busulfan disposition in a pediatric population who underwent bone marrow transplantation (BMT). Busulfan administered dose was 1 mg/kg every 6 h for 4 days. Plasma determinations were performed after the first dosing at 0, 15, 30, 60, 90, 120, 180, 240, 300, and 360 min. A noncompartment analysis model for extra vascular absorption was used for the pharmacokinetic analysis. To obtain the area under the concentration-timecurve (AUC) within the therapeutic window of 1000-1200 μM ×minutes a busulfan dose adjustment was performed at the fourth dose. Forty-five busulfan pharmacokinetic analyses were performed in 34 children. Eleven children had their dose adjusted \[1.19 ( ±0.14) mg/kg] at the fourth dose and the AUC was monitored at the fifth one. The mean AUC ±SD after the fifth dose (998.1 ±189.2 μM ×min) was different (p = .006) from that after the first dose (1 mg/kg) (687.63 ±166.43 μM ×min). Six children had their first AUC into the therapeutic window, 17 children had their dose adjusted \[1.2 ( ±0.22) mg/kg], but the adjusted AUC was not available. These data suggest that it may be reasonable to recommend a busulfan dose of 1.2 mg/kg to achieve the accepted therapeutic target in children undergoing BMT.     

Prognostic value of day 14 blast percentage and the absolute blast index in bone marrow of children with acute lymphoblastic leukemia

The product of the percentage blasts on the bone marrow aspirate (BMA) and the biopsy cellularity has been termed the "absolute blast index aspirate" (ABI-aspirate) and is used to measure disease response on day 7 of induction therapy. The authors compared the event-free survival (EFS) in high-risk and standard-risk patients as identified by the ABI-aspirate and the BMA percentage blasts on day 14 of induction therapy. Both indices identified high-risk cases. EFS of patients categorized as high-risk by these 2 methods and the high-risk criteria used by the authors' service (WCC of > 20 x 10(9)/L, age < 2 and > 8 years and a peripheral blood blast count of > 1.0 x 10(9)/L on day 8 of induction) did not differ. There was concordance between patients identified as high risk by all 3 methods. The results confirmed the prognostic value of the ABI-aspirate and the BMA percentage blasts on day 14 of induction therapy, but these methods were not superior to the high-risk criteria currently in use.