Catarina Gouveia

Community-Associated Methicillin-Resistant Staphylococcus aureus Lacking PVL, as a Cause of Severe Invasive Infection Treated with Linezolid

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging public health problem worldwide. Severe invasive infections have been described, mostly associated with the presence of Panton-Valentine leukocidin (PVL). In Portugal limited information exists regarding CA-MRSA infections. In this study we describe the case of a previously healthy 12-year-old female, sport athlete, who presented to the hospital with acetabulofemoral septic arthritis, myositis, fasciitis, acetabulum osteomyelitis, and pneumonia. The MRSA isolated from blood and synovial fluid was PVL negative and staphylococcal enterotoxin type P (SEP) and type L (SEL) positive, with a vancomycin MIC of 1.0 mg/L and resistant to clindamycin and ciprofloxacin. The patient was submitted to multiple surgical drainages and started on vancomycin, rifampicin, and gentamycin. Due to persistence of fever and no microbiological clearance, linezolid was started with improvement. This is one of the few reported cases of severe invasive infection caused by CA-MRSA in Portugal, which was successfully treated with linezolid. In spite of the severity of infection, the MRSA isolate did not produce PVL.

Linezolid in the treatment of multidrug-resistant/extensively drug-resistant tuberculosis in paediatric patients: experience of a paediatric infectious diseases unit.

Abstract Linezolid has been used in the treatment of multidrug-resistant/extensively drug-resistant tuberculosis in adults with encouraging results, however experience in children is scarce. We describe our experience with the use of linezolid as part of a multidrug regimen in the treatment of 4 patients who had persistent positive cultures, despite prolonged combined therapy.

Early “Relapse” After Herpetic Encephalitis: Extensive White Matter Lesions in an Infant With Interferon Production Deficit

Acute secondary neurological deterioration after herpes simplex encephalitis has been reported. An immune-mediated process is thought to be responsible for some cases. The authors report the case of an infant who presented with fever, irritability, and orofacial involuntary movements, 15 days after herpes encephalitis onset. Polymerase chain reaction for herpes simplex virus was negative, and the magnetic resonance imaging revealed extensive white matter lesions. Chorea appeared only 11 days later. Raised immunoglobulin G index with oligoclonal bands and spreading of white matter lesions corroborated an immune-mediated etiology. An interferon production deficit was also detected. This case alerts that this form of ‘‘relapse’’ appears earlier than previously reported. A high level of suspicion is needed in the presence of atypical neurological deterioration and early white matter lesions should be considered as a warning sign. This case is also relevant because it associates, for the first time, an immune-mediated ‘‘relapse’’ to an interferon production deficit.

Pantoea Species Bacteremia in a Child With Sickle Cell Disease: Looking for a Culprit

Pantoea agglomerans has been classically associated with cellulitis or synovitis secondary to penetrating trauma by vegetation. It is an infrequent cause of systemic infections. We describe the case of a 5-year-old girl with sickle cell disease with P. agglomerans bacteremia and review its potential causes.

Severe Israeli spotted fever with multiorgan failure in a child.

An increased risk of severe and fatal Israeli spotted fever (ISF) has been observed in adults, mostly associated with ISF strain. Here, we report a case of severe ISF with multiorgan failure in a Portuguese child.

Severe Stevens-Johnson syndrome/toxic epidermal necrolysis overlap syndrome-beyond skin involvement

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but serious dermatologic diseases with many potential multisystem complications. We describe the case of an 8‐year‐old girl who developed severe SJS/TEN overlap syndrome (25% of her body surface area was affected) complicated by pancreatitis and bronchiolitis obliterans. These rare complications emphasize the need for careful, intensive monitoring of possible complications and an interdisciplinary team approach to provide optimal treatment and follow‐up.

Arthritis in Kawasaki disease: A poorly recognised manifestation: Arthritis in Kawasaki disease

To determine the prevalence of arthritis in Kawasaki disease (KD) and the clinical characteristics of children with KD and arthritis.

Reversible Teeth Discoloration in Children A Linezolid Therapy Side Effect

To the Editor: A 9-year-old girl was admitted with surgical-site infection after triple pelvic osteotomy. Superficial wound exudate culture yielded methicillin-resistant Staphylococcus aureus (MRSA). Ultrasound revealed a soft tissue heterogeneous collection with subcutaneous fistulization. She completed 14 days of intravenous vancomycin and gentamicin with clinical and laboratory improvement. After discharge, a subcutaneous fistula with MRSA identification developed and persisted after debridement. Concomitant osteomyelitis was admitted and a 6-week course of oral linezolid (30 mg/kg/d every 8 hours) prescribed and osteotomy screws removed, with good clinical response. Linear brownish enamel discoloration on both her upper and lower anterior teeth (Figure 1) appeared four weeks after initiating linezolid therapy, and resolved with dental cleaning 4 weeks after discontinuation. Apart from reversible teeth discoloration, linezolid therapy was well tolerated. Intravenous or oral linezolid is believed to be well tolerated and superior to vancomycin in treating MRSA-infected surgical-site infections. However, mildto-moderate adverse effects have been reported, such as gastrointestinal (children’s most frequent adverse effect), myelosuppression, skin eruptions, and elevated liver enzymes. Reversible teeth and tongue discoloration have rarely been described, with only 5 cases published in children. Ma described an 8-year-old child with teeth and tongue brownish discoloration after 1 week of oral linezolid. Matson and Miller reported an 11-year-old girl with tooth discoloration after a 28-day course of linezolid orally. Petropoulou et al reported 3 patients with this side effect during intravenous administration. Studies are still needed to establish the discoloration mechanism. With oral administration, it was hypothesized that teeth and tongue direct exposure to the drug is responsible for this phenomenon. With intravenous administration, an affinity of linezolid to dental structures may be postulated. Other authors suggest that it might be related to a change in normal flora of the mouth. It would be essential to advertise patients and their parents of this potential side effect of linezolid therapy.

Hemophagocytic lymphohistiocytosis secondary to Falciparum malaria in a 5 year-old boy.

Dear Editor, A previously healthy 5-year-old Portuguese boy presented to our Emergency Department (ED) with a history of 4 days of high fever and painful abdomen. He had been living in Mozambique (Matola) for the last year and didn’t held malaria prophylaxis. At the time of admission, he was febrile and jaundiced, and a splenomegaly was noticed on physical examination. Initial laboratory data showed leucopenia, thrombocytopenia, high liver enzymes, direct hyperbilirubinemia, and elevated C-reactive protein. The diagnosis of malaria was confirmed by the presence of Plasmodium falciparum trophozoites in thin and thick blood films and by positive Plasmodium antigenemia. Despite a parasitemia of <1 %, he was admitted and treated with IV quinine and clindamycin with diagnosis of severe malaria according to WHO criteria (Table 1). On the following days, his clinical condition deteriorated, presenting with high fever, hypotension, mucosal bleeding, pleural effusion, and ascites. Laboratory workout revealed disseminated intravascular coagulation, pancytopenia, cholestatic hepatitis, hypoalbuminemia, as well as elevated ferritin (5,890 ng/mL) and soluble CD25 (sIL2R =4,352 U/mL). Other co-infections were excluded (Table 1). Despite the diagnosis of Falciparum malaria-associated hemophagocytic lymphohistiocytosis (HLH), he did not receive HLH-directed therapy and was treated with antimalaric drugs and supportive measures: packed red cells, platelets, fresh frozen plasma, cryoprecipitate, purified concentrate of fibrinogen, as well as inotropic support with dopamine (day 2 4). His clinical and laboratory condition slowly improved (Table 1). He was discharged home 12 days after being hospitalized. A hereditary cause for HLH was not investigated due the prompt improvement without HLH-targeted therapy. HLH is a potentially fatal hyperinflammatory condition caused by a highly stimulated but ineffective immune response [1]. It has been described as a familial disorder (due to defects in Nk citotoxicity) and as a sporadic one [2]. The latter has been associated with infections, malignancies, or rheumatologic disorders [3]. Infection-associated HLH can be triggered by virus, bacteria, fungi, or protozoa [1–4], but P. falciparum has rarely been reported as a cause of HLH [5–7], especially in children [10]. A deranged immune response is the cause of HLH, and the associated cytokine storm is responsible for the majority of the clinical and laboratory abnormalities [1–4]. The clinical diagnosis is established fulfilling five of the eight HLH-2004 criteria [1]. Noteworthy are the facts that hemophagocytosis is not required for establishing the diagnosis, that ferritin levels above 10,000 ng/mL are highly specific for HLH and that very high levels of sIL2Rα are almost never seen outside HLH [3]. J. A. Santos (*) : P. Venâncio Pediatric Department, Hospital Dona Estefânia, Centro Hospitalar Lisboa Central, EPE Rua Jacinta Marto, 1169-045 Lisbon, Portugal e-mail: joanaasantos@gmail.com

New Trends in the Management of Osteo-articular Infections in Children

Although many concepts regarding the aetiology, diagnosis and treatment of osteo-articular infection in children and adolescents have remained constant in the last three decades, recently we have seen some changes in the behaviour of the infectious agents, diagnostic tools and therapeutic attitudes that make it fundamental for the young surgeon to be familiar with these new concepts, as they can be used to guide evaluation and improve treatment.