Barbara Andreola

Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department.

Objective: To assess the value of procalcitonin (PCT) and C-reactive protein (CRP), compared with that of total white-blood cell count (WBC) and absolute neutrophil count (ANC), in predicting severe bacterial infections (SBIs) in febrile children admitted to Emergency Department. Methods: A prospective study was conducted in 408 children aged 7-days to 36-months, admitted with fever without source, at a tertiary care Pediatric Emergency Department. PCT, CRP, WBC, and ANC were determined upon admission and compared. Specificity, sensitivity, multilevel likelihood ratios, receiver operating characteristic (ROC) analysis, and multivariate stepwise logistic regression were carried out. Results: SBI was diagnosed in 94 children (23.1%). PCT, CRP, WBC, and ANC were significantly higher in this group than in non-SBI patients. The area under the ROC (AUC) obtained was 0.82 (95% CI: 0.78–0.86) for PCT, 0.85 (95% CI: 0.81–0.88) for CRP (P = 0.358), 0.71 (95% CI: 0.66–0.75) for WBC, and 0.74 (95% CI: 0.70–0.78) for ANC. Only PCT (OR: 1.32; 95% CI: 1.11–1.57; P < 0.001) and CRP (OR: 1.02; 95% CI: 1.01–1.03; P < 0.001) were retained as significant predictors of SBI in a multiple regression model. For infants with fever <8 hours (n = 45), AUC for PCT and CRP were 0.92 (95% CI: 0.80–0.98) and 0.75 (95% CI: 0.60–0.87), respectively (P = 0.056). Conclusion: Both PCT and CRP are valuable markers in predicting SBI in children with fever without source and they perform better than WBC and ANC. PCT appears more accurate at the beginning of infections, but overall CRP may be the most convenient marker for its better sensitivity and feasibility.

Validation of a laboratory risk index score for the identification of severe bacterial infection in children with fever without source

Objective The identification of severe bacterial infection (SBI)in children with fever without source (FWS) remains a diagnostic problem. The authors previously developed in their Swiss population a risk index score, called the Lab-score, associating three independent predictors of SBI, namely C reactive protein (CRP), procalcitonin (PCT) and urinary dipstick. The objective of this study was to validate the Lab-score in a population of children with FWS different from the derivation model. Methods A prospective study, conducted in Padova, on 408 children aged 7 days to 36 months with FWS was recently published. PCT, CRP, white blood cell count (WBC) and urinary dipstick were determined in all children. The Lab-score was applied to this population and the diagnostic characteristics for the detection of SBI were calculated for the Lab-score and for any single variable used in the Italian study. Results For the identification of SBI, the sensitivity of a score ≥3 was 86% (95% CI 77% to 92%) and the specificity 83% (95% CI 79% to 87%). The area under the receiver operating characteristic curve for the Lab-score (0.91) was significantly superior to that of any single variable: 0.71 for WBC, 0.86 for CRP and 0.84 for PCT. The Lab-score performed better than other laboratory markers, even when applied to children of different age groups (<3 months, 3–12 months and >12 months). The results obtained in this validation set population were comparable with those of the derivation set population. Conclusions This study validated the Lab-score as a valuable tool to identify SBI in children with FWS.

Predicting severe bacterial infections in well-appearing febrile neonates: laboratory markers accuracy and duration of fever.

Objectives: To assess the diagnostic accuracy of white blood cell count (WBC), absolute neutrophil count (ANC), and C-reactive protein (CRP) in detecting severe bacterial infections (SBI) in well-appearing neonates with early onset fever without source (FWS) and in relation to fever duration. Methods: An observational study was conducted on previously healthy neonates 7 to 28 days of age, consecutively hospitalized for FWS from less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period. Laboratory markers were obtained upon admission in all patients and repeated 6 to 12 hours from admission in those with normal values on initial determination. Sensitivity, specificity, positive and negative likelihood ratios, and receiver operating characteristic analysis were carried out for primary and repeated laboratory examinations. Results: Ninety-nine patients were finally studied. SBI was documented in 25 (25.3%) neonates. Areas under receiver operating characteristic curves were 0.78 (95% CI, 0.69–0.86) for CRP, 0.77 (95% CI, 0.67–0.85) for ANC and 0.59 (95% CI, 0.49–0.69) for WBC. Sixty-two patients presented normal laboratory markers on initial determination. Of these, 58 successfully underwent repeated blood examination at >12 hours from fever onset. Five of them had an SBI. The area under curve calculated for repeated laboratory tests showed better values, respectively of 0.99 (95% CI, 0.92–1) for CRP, 0.85 (95% CI, 0.73–0.93) for ANC and 0.79 (95% CI, 0.66–0.88) for WBC. Conclusions: In well-appearing neonates with early onset FWS, laboratory markers are more accurate and reliable predictors of SBI when performed after >12 hours of fever duration. ANC and especially CRP resulted better markers than the traditionally recommended WBC.

Nasal lavage leukotrienes in infants with RSV bronchiolitis

Respiratory syncytial virus (RSV) bronchiolitis is a very common infection in infants and, after the acute phase, a number of patients develop a reactive airway disease that lasts for years. Although the pathogenesis of the lung damage after RSV bronchiolitis is still largely unknown, previous studies suggest that leukotrienes may play an active part in it. The aim of this study was to measure leukotriene levels in the nasal lavage fluid (NLF) collected in infants during RSV bronchiolitis and 1 month later. Cysteinyl leukotrienes (Cys‐LTs) and leukotriene B4 (LTB4) were measured in the NLF of 22 infants with their first episode of RSV bronchiolitis and 16 healthy infants. A second NLF sample was collected to measure leukotriene levels 1 month after the acute disease. NLF Cys‐LT levels were significantly higher in infants with RSV bronchiolitis than in healthy controls [950 pg/ml (285.5–2155.9) vs. 110.5 pg/ml (66.5–451.3), p = 0.01], and they remained so a month after the acute infection (p = 0.02). A subanalysis showed no difference in Cys‐LTs concentrations, either between bronchiolitis infants with and without a family history of atopy, or between those with and without passive exposure to cigarette smoke. No significant difference was found between the LTB4 levels measured in the bronchiolitis cases and the control children. Cys‐LTs are significantly increased in the NLF of infants with acute RSV bronchiolitis, and remain so at 1‐month follow‐up, suggesting a possible role of these eicosanoids in the pathogenesis of the disease.

Exhaled leukotriene B4 in children with community acquired pneumonia.

The infiltrate in pneumonia is characterized by a large number of activated neutrophils, for which leukotriene B4 (LTB4) is a strong chemotactic agent. Exhaled breath condensate (EBC) is a non‐invasive technique for studying the lower airways. The present study was conducted to measure EBC LTB4 as a potential non‐invasive marker of inflammatory response in community acquired pneumonia (CAP).

Unilateral mydriasis due to Angel's Trumpet

Introduction. There are many causes of bilateral and unilateral mydriasis. Common garden plants, such as Brugmansia (Angels trumpet), contain tropane alkaloids. Case Report. An 11–year-old girl was brought to the Emergency Department because of discomfort and difficulty with near vision in the left eye, accompanied by unilateral mydriasis (pupil approximately 8 mm, unresponsive to both papillary light reflex and accommodation reflex). The consensual papillary light reflex of the right eye, the anterior chambers, the fundi, and the extraocular movements were intact. The history revealed that she had been playing in the garden and had just touched “a nice pink flower, similar to a trumpet.” Treatment was symptomatic and supportive, and the anisocoria resolved 48 hours after exposure. Morphological and chemical investigations showed high amounts of parasympatholytic tropane alkaloids in a corolla area rich in Dargendorff-positive glandular hairs. Discussion. Simple topical exposure to the flowers of Angels trumpet, without instillation of plant sap into the eye, can produce self-limited unilateral mydriasis. Conclusions. This case adds to the differential diagnosis of acute anisocoria in otherwise healthy children. An accurate and detailed history will avoid unnecessary and expensive diagnostic tests. It is important for parents and garden suppliers have information about the potential adverse effects after handling Angels trumpet plants.

Implementation of a Febrile Seizure Guideline in Two Pediatric Emergency Departments

Despite the typically benign nature of febrile seizures, a large number of children with simple febrile seizures are overinvestigated and overtreated, according to the personal clinical experience of the treating doctors. The study objective was to analyze the effect of implementing an evidence-based medicine guideline on the management of febrile seizures in two European pediatric emergency departments. After introduction of a selected guideline, we analyzed the change in hospitalization rate and in the rate of execution of blood exams in children presenting with febrile seizures. Included in the study were 483 children. Clinical characteristics of seizures were similar both before and after implementation. Clinical management was modified after guideline introduction, because the hospitalization rate significantly decreased (respectively, from 57.3% to 20.5%, and from 16.9% to 3.2%), without any concomitant increase in readmission rate. Readmission cases were never due to severe bacterial infections. The proportion of patients who received blood examinations decreased significantly. We conclude that in both of the Emergency Departments studied, introduction of a guideline on febrile seizure positively modified clinical management. The availability of a guideline contributed to accelerating the process of improving welfare and positively influenced the quality of care.

Prospective Study of the Burden of Acute Gastroenteritis and Rotavirus Gastroenteritis in Children Less Than 5 Years of Age, in Padova, Italy

Background:Data on the burden of rotavirus gastroenteritis in Europe are needed to help understand the potential impact of introducing new rotavirus vaccines.Materials and Methods:As part of prospective observational study (Rotavirus gastroenteritis Epidemiology and Viral types in Europe Accounting for Losses in Public Health and Society Study, REVEAL) conducted in 2004–2005 in seven European countries, we studied, the characteristics of acute gastroenteritis and rotavirus gastroenteritis in children less than 5 years in primary care, emergency room and hospital settings (Padova, Italy).Results:A total of 757 children with acute gastroenteritis were included and enzyme-linked immunoabsorbent assay (ELISA) results were available for 725 cases. The overall estimated annual incidence for rotavirus gastroenteritis was 4.7%. Overall, rotavirus gastroenteritis was estimated to account for 43.6% of acute gastroenteritis cases. Among children with acute gastroenteritis (AGE) aged 6–23 months, 61.2% were rotavirus positive. Rotavirus gastroenteritis (RVGE) was responsible for 68.8% of hospitalizations, 61% of emergency consultations, and 33% of primary care consultations. The most prevalent serotype was G9 (84.4%) followed by G1 (11.8%). The relative risk for rotavirus gastroenteritis of being referred to hospital after an initial consultation in primary care was 3.37 (95% CI: 1.77–6.43) and 3.38 (95% CI: 2.28–5.01) for emergency room referral. Children with rotavirus gastroenteritis generally had more severe disease than children with rotavirus-negative gastroenteritis.Conclusion:Rotavirus accounts for a significant proportion of acute gastroenteritis cases in children less than 5 years in Italy, many of whom require frequent primary care consultations, or care in emergency room or hospital settings.

Severe Mycoplasma pneumoniae-associated mucositis treated with immunoglobulins

Mycoplasma pneumoniae‐associated mucositis (MPAM), previously labelled as atypical Stevens–Johnson syndrome (SJS), SJS with minimal or no skin manifestations, is a rare non‐respiratory manifestation of Mycoplasma pneumoniae infection. The nineteen cases described so far in children and young adults were characterized by a high male gender prevalence (16/19) and a good response to appropriate antibiotic treatment and supportive care in the majority of patients. We describe a case of MPAM in a previously healthy girl, who improved after a 0.5 g/kg daily dose of intravenous immunoglobulins (IVIG) for four consecutive days, after traditional therapy had failed.

Costi della gastroenterite da rotavirus acquisita in comunità in età pediatrica a Padova in Italia

SummaryBackgroundRotavirus gastroenteritis (RVGE) has a major impact in terms of morbidity in Italy. Comprehensive data on the economic impact are needed in order to evaluate the cost-effectiveness of a Rotavirus (RV) vaccination program.MethodsAs part of a prospective observational study (REVEAL) conducted in 2004–2005 in seven European countries, we calculated the average costs per case with confirmed RVGE in primary care (PC), emergency room (ER), and hospital (H) settings, from both the national health care service and societal perspectives.ResultsA total of 336 children <5 years with RVGE were included in the cost analysis. The total societal cost per child was € 292 in PC, € 600 in ER, and € 1,901 in the H setting. Overall total cost of community-acquired RVGE in the Veneto Region was estimated to be around 7 million €. Extrapolating the observed data to the whole Italian country, the total cost was estimated between 67.1–80 million € according to the estimates used. About 61% of the total costs were direct non-medical and indirect costs, mostly related to loss of productivity due to work days lost by parents and other caregivers.ConclusionsRVGE in Italy causes considerable costs in all healthcare settings for the national health care payer and families. An effective childhood vaccination program would have considerable direct and indirect benefits for the Italian society.