Andrzej Krzysztofiak

Neurological complications of varicella in childhood: case series and a systematic review of the literature.

Although varicella has usually an uncomplicated course in early childhood, several neurological complications may occur. We conducted a study to review the type and the rate of varicella neurological complications in a case series of hospitalized immunologically healthy children over nearly a 8 year period. We also systematically reviewed data from the literature to estimate the rate of varicella neurological complications. In our case reports, the proportion of neurological complications among all those hospitalized for varicella was of 21.7% (CI 17.9-26%). The pooled prevalence of neurological complications resulting from the systematic review of the literature identifies the likelihood of such complications in the range of 13.9-20.4%. Although neurological complications of chickenpox do not frequently result in permanent sequelae, they represent significant determinants of prolonged hospital stay and of other indirect costs. The obtained results may be useful for estimating costs associated with hospitalization from varicella in cost-benefit analysis for immunization.

Use of linezolid in infants and children: a retrospective multicentre study of the Italian Society for Paediatric Infectious Diseases

OBJECTIVES Because of the spread of drug-resistant Gram-positive bacteria, the use of linezolid for treating severe infections is increasing. However, clinical experience in the paediatric population is still limited. We undertook a multicentre study to analyse the use of linezolid in children. METHODS Hospitalized children treated with linezolid for a suspected or proven Gram-positive or mycobacterial infection were analysed retrospectively. Side effects were investigated, focusing on younger children and long-term treatments. RESULTS Seventy-five patients (mean age 6.8 years, range 7 days to 17 years) were studied. Mean ± SD linezolid treatment duration was 26.13 ± 17 days. Clinical cure was achieved in 74.7% of patients. The most frequent adverse events were diarrhoea and vomiting. Two patients had severe anaemia, two neutropenia and one thrombocytopenia. Two cases of grade 3 liver function test elevation and one case of pancreatitis were reported. The overall frequency of adverse events was similar between patients treated for >28 days and those receiving shorter treatments (30.8% versus 28.6%, P = 0.84). Children aged <2 years received linezolid for a shorter duration than older children (21.2 days versus 28.4 days, P = 0.05), whereas the frequency of adverse events was similar in the two age groups. CONCLUSIONS In our paediatric population, linezolid appeared safe and effective for the treatment of selected Gram-positive and mycobacterial infections. The adverse reactions encountered were reversible and appeared comparable to those reported in paediatric clinical trials. Nevertheless, the potential for haematological toxicity of linezolid in children means that careful monitoring is required during treatment.

A 20-Year Retrospective Study of Pediatric Tuberculosis in Two Tertiary Hospitals in Rome

Background: Tuberculosis (TB) is among the top 10 causes of child death worldwide. Nevertheless, childhood disease has been neglected by tuberculosis control programs. Methods: This was a retrospective study of patients < 16 years of age diagnosed with active TB in 2 tertiary hospitals in Rome (Italy), between 1990 and 2009. Results: Two hundred fourteen cases of active tuberculosis were identified (132 definite, 82 probable). Pulmonary involvement was the most common form (75.5%), followed by lymphadenopathy (15.4%) and central nervous system TB (11%). Fever (51.86%) and cough (40%) were the most common presenting symptoms. A total of 23.4% of children were asymptomatic on admission. Sensitivities of the tuberculin skin test and the quantiferon test were 93.4% and 97%, respectively. Both tests performed in 52 children agreed in 49 cases (94%). Sensitivities for culture, Ziehl–Neelsen staining and polymerase chain reaction were 58%, 25% and 66.3%, respectively. The adult source case was identified in 28% of cases. History of contact with a patient with active TB was associated with pulmonary TB (P = 0.0014), whereas negative history of contact was associated with lymph node (P = 0.0064) and central nervous system TB (P = 0.05). Conclusions: Our study emphasizes the difficulty in managing children with suspected TB, because the absence of constitutional symptoms cannot exclude TB, and bacteriologic confirmation is the exception. Immunologic diagnosis can be a valuable tool to identify TB-infected children because the quantiferon test showed high sensitivity in all age groups. This is of primary importance because early identification of children with latent tuberculous infection and appropriate chemoprophylaxis represent, to date, the most important tool to reduce the burden of TB.

HHV6 meningoencephalitis sequelae in previously healthy children

IntroductionHuman herpes virus 6 (HHV6) infection is a self-limiting illness occurring in early childhood. As with other herpes viruses, the encephalopathy associated with HHV6 is often attributable to the reactivation of a virus previously latent in human brain tissue. Previous reports on HHV6 encephalopathy dealt mainly with virus reactivation in immune-depressed older children and, above all, refer to encephalitis and not to meningoencephalitis. Complications are rare in healthy children. Encephalopathy has rarely been associated with HHV6 infection in children not affected by chronic disease.PurposeThe aim of this study was to evaluate sequelae of HHV6 meningoencephalitis in previously healthy children.ResultsWe report three cases of HHV6 meningoencephalitis in previously healthy children followed for a 10-year period. Two of the patients presented invalidating sequelae. In detail, one patient developed speech disturbance and the other persistent hemiplegia and bilateral visual deficit. To our knowledge, this is the first case in which an ocular complication developed in the course of HHV6 meningoencephalitis.ConclusionHHV6 meningoencephalitis can be associated with a wide range of clinical outcomes, from long-term neurological sequelae to a benign post-infectious clinical course.

Linezolid therapy for pediatric thoracic spondylodiscitis due to Staphylococcus aureus sepsis.

We report the case of an immunocompetent child with spondylodiscitis as a result of staphylococcal sepsis, which was successfully treated with linezolid. The patient was admitted with fever and circumferential swelling in the paradorsal region, which was evident only in the flexed back position. A chest X-ray showed a pleural effusion with pneumonitis and dorsal kyphosis. Following the yield of Staphylococcus aureus from blood cultures, the initial therapy of ceftriaxone and amikacin was changed to vancomycin. However, the dorsal swelling increased further and imaging investigations showed destruction of the vertebral bodies D8-D10 and surrounding tissue swelling. Vancomycin was changed to linezolid, and the patient began to improve; a full recovery was made. Our case suggests that even if spondylodiscitis is rare in the pediatric age-group, particularly as a complication of staphylococcal sepsis, early diagnosis and prompt and appropriate therapy are important to prevent severe complications.

Daptomycin for Children in Clinical Practice Experience.

Data on daptomycin use in the pediatric setting are scanty. We conducted a multicenter, retrospective study on 46 children treated with intravenous daptomycin at a mean dosage of 7.0 mg/kg/d, for a median of 14 days. Three children had adverse events possibly related to daptomycin. The drug was overall well tolerated, even with prolonged treatment.

Diagnosis and management of acute mastoiditis in a cohort of Italian children

Objective: The Italian Society for Pediatric Infectious Diseases created a registry to determine the management of pediatric acute mastoiditis (AM) in Italy. Methods: A cross-sectional survey of paediatricians was conducted to evaluate hospitalization due to AM in Italian pediatric wards between 1 January 2002, and 31 December 2013. Results: A total of 913 children (561 males, 61.4%) were included in this study. The annual number of AM cases significantly increased during the study period (30 in 2002 and 98 in 2013) but only among older children (≥4 years old; p = 0.02). AM complications occurred in 69 (7.6%) of the children and sequelae were observed in 13 (1.4%) patients. Conclusion: The annual number of pediatric AM cases admitted to Italian pediatric wards increased in the past few years; this increase was strictly age-related. The risk of severe AM complications appeared relatively low, and most AM cases could be treated conservatively.

Re-emergence of measles in young infants

To the Editors: The World Health Organization goal of eliminating measles in Europe will not be met by the targeted year 2010. In Italy measles incidence declined since vaccine introduction in 1998. Childhood vaccination coverage at 24 months has increased from 56% in 1998 to 90% in 2008. Although public health authorities have made extraordinary efforts, measles is still spreading throughout Europe. After sporadic cases or clusters nationwide during the previous years, we recently observed a local resurgence of measles. At Bambino Gesù Hospital, in Rome, we had no hospitalizations associated with measles from January 2009 to February 2010, whereas we admitted into hospital 26 laboratory confirmed cases from March to September 2010. The median age was of 6 years (range from 1 month to 17 years). The observed complications were dehydration in 13 cases, pneumonia in 11 cases, and otitis in 2 cases. None of them died or had disabling sequelae after discharge. Measles circulation is likely a result of suboptimal vaccination coverage, even if vaccine is offered free-of-charge in a 2-dose routine immunization program, at 12 to 15 months and at 5 to 6 years of age. Vaccine coverage depends strongly on the acceptance of vaccination by parents, as well as on recommendations by pediatricians. Parents are free to decide on their child’s vaccinations and measles immunization is not mandatory for school admission. Parents may consider the potential profit for the community—due to herd immunity effects and a reduced economical burden—as less important than the individual risk from potential vaccination side-effects. Among our hospitalized children, 7 were too young to be vaccinated. Four children were 3 months or younger and 3 were less than 12 months of age. Only one of the mothers of these children was immunized. Four mothers developed the disease 1 week before their children and they were the likely source of infection. In 1 case, the older sister experienced measles 10 days before and probably transmitted the disease to the infant. As for the other infants, parents were not able to identify the source of infection. Immunization was delayed or not consented by the parents of the older 19 children, who then likely had been infected in the household or at school. Among the reasons for not getting vaccinated were: (a) fear of injections or of side effects; (b) perception of measles as a benign disease; (c) no need of vaccination as the child seemed to be healthy; (d) perception of measles as an eliminated disease from Europe and consequently vaccination as unnecessary. Finally, we should consider the important role of the not yet vaccinated infants who may not be protected by passive immunity or who can experience waning immunity. In fact, measles immunity transmitted by mothers may wane shortly after birth. In conclusion, to prevent perspective outbreaks and interrupt measles circulation, strong efforts should be made to achieve and maintain routine coverage over 95%, to adhere to the immunization schedule, to immunize susceptible adults, and to consider offering the vaccine at 9 months of age. Elena Bozzola, MD Anna Quondamcarlo, MD Andrzej Krzysztofiak, MD Laura Lancella, MD Infection Unit Ospedale Pediatrico Bambino Gesù

Risk factors of complicated H1N1 influenza in hospitalized Italian children

We explored complications and risk factors for severe disease in 78 children with swine influenza admitted to Bambino Gesu Children Hospital. The majority of our children experienced respiratory complications (55%). Previously healthy children developed a chest consolidation more frequently than chronic diseases affected patients (p = 0.04). Apparently, the incidence of respiratory complications was slightly higher in the neutropenic group than in those with a normal value of neutrophilis (respectively 94.1% and 80%).

Infective Endocarditis in Children in Italy from 2000 to 2015.

ABSTRACT Objective: The Italian Society for Pediatric Infectious Diseases created a registry on children with infective endocarditis (IE) hospitalized in Italy. Methods: A cross-sectional survey was conducted on patients hospitalized due to IE in Italian paediatric wards between January 1, 2000, and June 30, 2015. Results: Over the 15-year study period, 47 IE episodes were observed (19 males; age range, 2-17 years). Viridans Streptococci were the most common pathogens among patients with predisposing cardiac conditions and Staphylococcus aureus among those without (37.9% vs. 5.5%, p = 0.018, and 6.9% vs. 27.8%, p = 0.089, respectively). Six of the 7 (85.7%) S. aureus strains were methicillin-resistant. The majority of patients with and without predisposing cardiac conditions recovered without any complications. Conclusion: In Italy, paediatric IE develops without any previous predisposing factors in a number of children, methicillin-resistant S. aureus has emerged as a common causative agent and the therapeutic approach is extremely variable.