Antonia Teresinha Tresoldi

Paracoccidioidomycosis in children: clinical presentation, follow-up and outcome

From February, 1981 to May, 2001, 63 children under 15 y old (ages 2 - 15 y, median = 8 y, mean +/- 1 SD = 8 +/- 3 y) presenting 70 episodes of Paracoccidioidomycosis were admitted. The main clinical manifestations and laboratory features observed upon admission were: lymph node enlargement (87.1%), fever (75.7%), weakness (48.6%), pallor (41.4%), hepatomegaly (40%), splenomegaly (35.7%), anemia (90%), hypergammaglobulinemia (88.5%), eosinophilia (75.5%) and hypoalbuminemia (72.5%). Moderate to severe malnutrition was detected in 35.7% of the episodes (Gomezs criterion). Radiographic and technetium studies showed bone lesions in 20 of the episodes, most of them being multiple lytic lesions, involving both long (70%) and plain bones (30%). First line treatment consisted of an association of sulfametoxazole-trimethoprin, which was used, exclusively, in 50 episodes. Follow-up of hemoglobin levels, number of eosinophils in the peripheral blood, albumin and gammaglobulin serum levels revealed significant sequential improvement one and six months after hospital admission, being quite useful to evaluate treatment effectiveness. Six patients died (9.3%) and four developed sequelae (6.3%). In conclusion, the juvenile and disseminated forms can be observed in about 70% of the episodes of PCM occurring in children younger than 15 y old, most of them presenting with a febrile lymphoproliferative syndrome associated to anemia, eosinophilia and hypergammaglobulinemia.

Application of genomic DNA subtyping by pulsed field gel electrophoresis and restriction enzyme analysis of plasmid DNA to characterize methicillin-resistant Staphylococcus aureus from two nosocomial outbreaks

Pulsed-field gel electrophoresis (PFGE) and restriction enzyme analysis of plasmid DNA (REAP) were applied to study the epidemiologic relationship among methicillin-resistant Staphylococcus aureus (MRSA) isolates from outbreaks in two hospitals in São Paulo, Brazil: 82 MRSA isolates, 73 from a university hospital and nine from a general adult intensive care unit of a private hospital, were collected from 62 patients: 95% of the MRSAs were also resistant to gentamicin and ciprofloxacin. REAP subtyping of both collections identified six different subtypes: 55 (72.6%) MRSAs from the university hospital and nine isolates from the private hospital shared the same epidemic REAP subtype. Discrimination by restriction of genomic DNA with Sma I followed by PFGE enabled the identification of 14 DNA subtypes. Based on the combined REAP-genomic DNA subtype, the predominant subtype in the university hospital was A/A (44 isolates) whereas the epidemic subtype in the private hospital was A/M (seven isolates). The application of two typing methods showed better discrimination among MRSAs than did either method alone.

Risk factors for central venous catheter-related infections in pediatric intensive care

OBJECTIVES To identify risk factors for short-term percutaneously inserted central venous catheter-related infections in children and to evaluate the accuracy of a mortality score in predicting the risk of infection. METHOD After reviewing the charts of patients who developed catheter-related infection in a university hospitals pediatric intensive care unit, we conducted a case-controlled study with 51 pairs. Variables related to patients and to catheter insertion and use were analyzed. Risk factors were defined by logistic regression analysis. The accuracy of the Pediatric Risk of Mortality score to discriminate the risk for infection was tested using the Receiver Operating Characteristic curve. RESULTS Infection was associated with respiratory failure, patients length of stay, duration of tracheal intubation, insertion of catheter in the intensive care unit and parenteral nutrition. Insertion site (femoral or internal jugular) was unimportant. Multivariate logistic regression analysis identified the following variables. Risk factors included more than one catheter placement (p=0.014) and duration of catheter use (p=0.0013), and protective factors included concomitant antibiotic use (p=0.0005) and an intermittent infusion regimen followed by heparin filling compared to continuous infusion without heparin (p=0.0002). Pediatric Risk of Mortality did not discriminate the risk of infection. CONCLUSIONS Central parenteral nutrition and central venous catheters should be withdrawn as soon as possible. Femoral vein catheterization carries a risk of infection similar to internal jugular catheterization. The Pediatric Risk of Mortality score should not be used to predict the risk of central catheter-related infections.

Paradoxical reaction to treatment in 2 patients with severe acute paracoccidioidomycosis: a previously unreported complication and its management with corticosteroids.

Paradoxical reactions have never been described in patients with paracoccidioidomycosis or other deep endemic mycoses out of the context of human immunodeficiency virus infection. We describe 2 patients with an acute form of paracoccidioidomycosis who presented with a worsening of their clinical manifestations while on appropriate antifungal treatment. These manifestations were severe and required adjunct corticosteroid therapy.

Risk factors associated with the acquisition of multiresistant bacteria in a pediatric nursery

OBJECTIVE: To identify the risk factors in patients who had a multiresistant bacteria during their staying in a Pediatric Intensive Care Unit and in a pediatric nursery of a tertiary teaching hospital.METHODS: Chart review of the patients who stayed in the units from January, 1995 to July, 1997 and had a multiresistant microorganism isolated (both infection and colonization). A case-control study was done using McNemar test for group comparison and using stepwise logistic regression to select independent risk factors. The following risk factors were tested: prior hospital staying, underlying disease, intensive care unit admission, surgical procedure, urinary catheter, central venous line, ventilator, prior antibiotic therapy and skin lesion.RESULTS: Among 52 patients, 66 multiresistant bacteria were identified (among them, 33 were gram-negative bacilli and 33 were methicillin-resistant S. aureus). The logistic regression analysis of the case-control study identified 2 risk factors: prior antibiotic therapy and skin lesion. A single risk factor was indicated for patients with gram-negative bacilli. Nevertheless, for patients with methicillin-resistant S. aureus, central venous lines and skin lesion were significant.CONCLUSION: Prior antibiotic therapy and skin lesion were the factors associated with the acquisition of multiresistant bacteria. Besides skin lesion, for oxacilin-resistant S. aureus colonized patients, central venous catheter use was a risk factor. The strategies employed to limit the spread of those bacteria in the hospital should consider these three factors.

Dapsone hypersensitivity syndrome in an adolescent during treatment during of leprosy

A 12 y old girl was admitted 24 days after start a WHO multidrug therapy scheme for multibacillary leprosy (dapsone, clofazimine and rifampicin) with intense jaundice, generalized lymphadenopathy, hepatoesplenomegaly, oral erosions, conjunctivitis, morbiliform rash and edema of face, ankles and hands. The main laboratory data on admission included: hemoglobin, 8.4 g/dL; WBC, 15,710 cells/mm3; platelet count, 100,000 cells/mm3; INR = 1.49; increased serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transpeptidase, alkaline phosphatase, direct and indirect bilirubin. Following, the clinical conditions had deteriorated, developing exfoliative dermatitis, shock, generalized edema, acute renal and hepatic failure, pancytopenia, intestinal bleeding, pneumonia, urinary tract infection and bacteremia, needing adrenergic drugs, replacement of fluids and blood product components, and antibiotics. Ten days after admission she started to improve, and was discharged to home at day 39th, after start new supervised treatment for leprosy with clofazimine and rifampicin, without adverse effects. This presentation fulfils the criteria for the diagnosis of dapsone hypersensitivity syndrome (fever, generalized lymphadenopathy, exfoliative rash, anemia and liver involvement with mixed hepatocellular and cholestatic features). Physicians, mainly in geographical areas with high prevalence rates of leprosy, should be aware to this severe, and probably not so rare, hypersensitivity reaction to dapsone.

Nasal MRSA colonization of AIDS patients cared for in a Brazilian university hospital

Weekly culture surveillance was conducted over a 2-year period to determine the incidence of methicillin-resistant Staphylococcus aureus nasal colonization among acquired immunodeficiency syndrome patients cared for in a day-care unit and in an infectious diseases unit. Analysis of genomic DNA profiles showed a predominant pattern in both units.

Fatores associados às complicações em crianças pré-escolares com pneumonia adquirida na comunidade

OBJECTIVE: To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). METHODS: This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. RESULTS: Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). CONCLUSIONS: Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.OBJECTIVE To identify socioeconomic factors and clinical factors associated with the development of complications in preschool children hospitalized with community-acquired pneumonia (CAP). METHODS This was a prospective longitudinal study involving children (12-59 months of age) diagnosed with CAP and admitted to the pediatric wards of two hospitals in the metropolitan area of Campinas, Brazil. Children with cystic fibrosis, heart disease, pulmonary malformations, neurological disorders, or genetic diseases were excluded. The diagnosis of CAP was based on clinical and radiological findings. Data were collected from the medical records and with a semi-structured questionnaire. The subjects were divided into two groups (complicated and uncomplicated CAP). Socioeconomic and clinical variables were compared, and multivariate logistic regression analysis was performed. RESULTS Of the 63 children included, 29 and 34, respectively, presented with uncomplicated and complicated CAP. No statistically significant differences were found between the groups regarding age at admission, gestational age, birth weight, gender, or socioeconomic variables. Significant differences were found between the groups regarding history of pneumonia (p = 0.03), previous antibiotic therapy (p = 0.004), time elapsed since the onset of CAP (p = 0.01), duration of fever prior to admission (p < 0.001), duration of antibiotic therapy (p < 0.001), and length of hospital stay (p < 0.001). In the multivariate analysis, only duration of fever prior to admission remained in the model (OR = 1.97; 95% CI: 1.36-2.84; p < 0.001). CONCLUSIONS Biological variables, especially duration of fever prior to admission, appear to be associated with the development of complications in children with CAP.

Fatores associados ao óbito em lactentes após eventos com aparente risco de morte (apparent life-threatening event, ALTE)

OBJECTIVE To detect factors associated with greater risk of death in infants after an apparent life-threatening event (ALTE). METHODS This cross-sectional, retrospective, descriptive and analytic study evaluated infants younger than 12 months who had a sudden event of cyanosis, pallor, hypotonia or apnea and were seen in the emergency department of a tertiary university hospital. Forward stepwise logistic regression (Wald) was used to calculate and adjust odds ratios to evaluate associations. RESULTS Mean age of the 145 patients included in the study was 105 days (median = 65 days). Eleven (7.6%) died, and their mean age was 189 days (median = 218 days). Mean age of survivors was 98 days (median = 62 days) (p = 0.003). Activity before the event, prematurity and number of events were not associated with death. A significant association was found with pallor. Of the 11 infants, 3 had spontaneous resolution of ALTE, whereas 8 patients [27.6%; p < 0.001; OR = 14.3 (95%CI 3.51-58.3)] did not. The associations with respiratory or cardiovascular disease were also significant. In multivariate analysis, immediate spontaneous resolution [p = 0.015; OR = 6.06 (95%CI 1.02-35.94)] and diagnosis of cardiovascular disease [p = 0.047; OR = 164.27 (95%CI 7.34-3.673.78)] remained statistically significant. CONCLUSION Infants who experienced an ALTE had a higher risk of subsequent death when their age was greater than 6 months and the event had a long duration, particularly when ALTE was associated with cardiovascular disease.OBJECTIVE: To detect factors associated with greater risk of death in infants after an apparent life-threatening event (ALTE). METHODS: This cross-sectional, retrospective, descriptive and analytic study evaluated infants younger than 12 months who had a sudden event of cyanosis, pallor, hypotonia or apnea and were seen in the emergency department of a tertiary university hospital. Forward stepwise logistic regression (Wald) was used to calculate and adjust odds ratios to evaluate associations. RESULTS: Mean age of the 145 patients included in the study was 105 days (median = 65 days). Eleven (7.6%) died, and their mean age was 189 days (median = 218 days). Mean age of survivors was 98 days (median = 62 days) (p = 0.003). Activity before the event, prematurity and number of events were not associated with death. A significant association was found with pallor. Of the 11 infants, 3 had spontaneous resolution of ALTE, whereas 8 patients [27.6%; p < 0.001; OR = 14.3 (95%CI 3.51-58.3)] did not. The associations with respiratory or cardiovascular disease were also significant. In multivariate analysis, immediate spontaneous resolution [p = 0.015; OR = 6.06 (95%CI 1.02-35.94)] and diagnosis of cardiovascular disease [p = 0.047; OR = 164.27 (95%CI 7.34-3.673.78)] remained statistically significant. CONCLUSION: Infants who experienced an ALTE had a higher risk of subsequent death when their age was greater than 6 months and the event had a long duration, particularly when ALTE was associated with cardiovascular disease.

Hipercalcemia e lesões osteolíticas múltiplas em criança com paracoccidioidomicose disseminada e tuberculose pulmonar

Abstract Objective: To describe the case of a child with paracoccidioido-mycosis who presented hypercalcemia with multipleosteolytic lesions.Description: A 6-year-old boy was admitted with a one-month history of fever and hepatosplenomegaly. Onadmission, he looked sick, pale, and had disseminated lymphadenopathy and hepatosplenomegaly. The laboratoryfindings included anemia (hemoglobin = 6.8 g/dl), eosinophilia (1,222/mm 3 ), thrombocytopenia (102,000/mm ), andhypoalbuminemia (serum albumin = 2.2 g/dl). Paracoccidioides brasiliensis was identified in bone marrow examination.In the second week after admission, the patient presented joint pain, poor activity and difficulty in walking. He presentedhypercalcemia (maximum value = 14.9 mg%) and reduction in renal function, which lasted for two weeks. On the 42ndday after admission, his chest X-ray showed lytic lesions in clavicle, scapula, ribs, and humerus, with bilateral slippedcapital humeral epiphysis. The patient presented nephrocalcinosis and nephrolithiasis, reduction in creatinine clearanceand evidence of tubular lesions. At the end of the second month after admission, Mycobacterium tuberculosis was isolatedin gastric lavage. The child received treatment for paracoccidioidomycosis and tuberculosis and has not had any sequelaefor 3 years.Comments: The development of symptomatic hypercalcemia leading to renal lesion, associated with multipleosteolytic lesions, had never been described in paracoccidioidomycosis. Although pulmonary tuberculosis was diagnosedand could be related to hypercalcemia, the sudden onset of hypercalcemia and its normalization without specific treatmentfor tuberculosis suggests that bone lysis was the most important factor in the genesis of hypercalcemia.J Pediatr (Rio J). 2005;81(4):349-52: Paracoccidioidomycosis, tuberculosis, hypercalcemia, osteolytic lesions,children.OBJETIVO: Descrever o caso de uma crianca com paracoccidioidomicose, que apresentou hipercalcemia associada a multiplas lesoes osteoliticas. DESCRICAO: Menino de 6 anos, internado com historia de febre e hepatoesplenomegalia ha 1 mes. A internacao, apresentava-se em regular estado geral, descorado, com linfonodomegalia generalizada e hepatoesplenomegalia. Os exames laboratoriais identificaram anemia (hemoglobina = 6,8 g/dl), eosinofilia (1.222/mm3), plaquetopenia (102.000/mm3) e hipoalbuminemia (albumina = 2,2 g/dl). Paracoccidioides brasiliensis foi identificado no mielograma. A partir da segunda semana de internacao, apresentou artralgia, hipoatividade e dificuldade a deambulacao, sendo constatada hipercalcemia (dosagem maxima de 14,9 mg%) e reducao da funcao renal, que duraram pouco mais de 2 semanas. No 42o dia de internacao, foram vistas, na radiografia de torax, multiplas lesoes liticas em claviculas, escapulas, costelas e umeros, com escorregamento epifisario de umero bilateral. Apresentou nefrocalcinose e nefrolitiase, com reducao no clearance de creatinina e evidencias de lesao tubular. No final do segundo mes de internacao, na cultura do lavado gastrico, foi identificado Mycobacterium tuberculosis. Recebeu tratamento para paracoccidioidomicose e tuberculose e esta ha mais de 3 anos em acompanhamento, sem nenhuma sequela. COMENTARIOS: O desenvolvimento da hipercalcemia sintomatica, levando a lesao renal e associada a lesoes osseas multiplas e disseminadas, nunca foi descrito em paracoccidioidomicose. Embora tenha sido diagnosticada tuberculose pulmonar, que pode estar relacionada a hipercalcemia, a forma abrupta como se instalou e como se normalizou sem o tratamento especifico para tuberculose sugere que a lise ossea foi o fator mais importante na genese da hipercalcemia.