Débora Morais Cardoso

Rotavirus Gastroenteritis in Children in 4 Regions in Brazil: A Hospital-Based Surveillance Study

BACKGROUND Rotavirus is a major cause of gastroenteritis in children. Knowledge of rotavirus genotypes is important for vaccination strategies. METHODS During 2005-2006, rotavirus surveillance studies were conducted in São Paulo, Salvador, Goiânia, and Porto Alegre, Brazil. Stool samples were collected from children <5 years of age who had diarrhea and were screened by the Rotaclone Enzyme Immunoassay for the presence of rotavirus. Confirmed rotavirus-positive samples were characterized for P and G genotypes by reverse-transcriptase polymerase chain reaction. RESULTS A total of 510 stool samples were collected. Of these, 221 (43.3%) were positive for rotavirus. Overall, G9 was the predominant G type, followed by G2, and G1; P[4] and P[8] were the predominant P types. The most frequent G/P genotype combination detected was G2P[4], followed by G9P[8], G9P[4], and G1P[8]. G2P[4] was the predominant type in Goiânia and Salvador; G9P[8] and G1P[8] were predominant in São Paulo and Porto Alegre, respectively. CONCLUSIONS The prevalence, seasonality, and genotype distribution of rotavirus infection varied in different regions in Brazil. With immunization programs, continuous monitoring of rotavirus types is important to detect novel and emerging strains.

Fever without source: evaluation of a guideline

OBJECTIVE To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 degrees C. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Impacto do uso da prova rápida para estreptococo beta-hemolítico do grupo A no diagnóstico e tratamento da faringotonsilite aguda em pronto-socorro de Pediatria

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Febre sem sinais localizatórios: avaliação de um protocolo de atendimento

OBJECTIVE: To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS: Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS: We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 oC. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION: The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a pediatric emergency room.

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Dengue fever as a cause of hemophagocytic lymphohistiocytosis

Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropod-borne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome.

Acute Hemorrhagic Edema of Infancy: an unusual diagnosis for the general pediatrician

Acute Hemorrhagic Edema of Infancy (AHEI) is a rare leukocytoclastic vasculitis, clinically characterized by the classical triad: palpable purpuric skin lesions, edema and fever, and is commonly misdiagnosed as Henoch-Schönlein purpura. In addition to its sudden onset, AHEI is also characterized by its self-limited course with complete and spontaneous recovery occurring between 1 and 3 weeks. Because of the scarcity of studies on therapy with corticosteroids, the conservative approach is usually recommended. The authors report an unusual case of an one-year-old boy who presented with typical cutaneous rash of AHEI and orchitis, the latter showing complete resolution after less than 24 hours of prednisolone therapy. The authors call attention to this entity mainly as a differential diagnosis of Henoch-Schönlein purpura and to the importance of new studies to establish the benefits of corticosteroid therapy for AHEI.

Otomastoiditis caused by Sphingomonas paucimobilis: case report and literature review

Sphingomonas paucimobilis is an aerobic Gram-negative bacillus that, although rare in humans, most commonly infects immunocompromised and hospitalized patients. Among the 59 pediatric cases of S. paucimobilis infection reported in the literature, the most common diagnosis involves isolated bacteremia. These cases are related to sporadic or epidemic infections. Death related to this infection occurred in only one case. The authors report a case of an 11-year-old boy with the diagnosis of Sphingomonas paucimobilis otomastoiditis and a thorough review of the literature on this infection in pediatrics. The patient presented a 20-day history of fever, otalgia, otorrhea, and progressive retroauricular swelling with protrusion of the left ear; despite 15 days of amoxicillin regimen. His past medical history included chronic bilateral otitis media, but no cause of immunosuppression was found. A brain computed tomography scan showed left otomastoiditis associated with a large circumscribed fluid collection with deep involvement of the soft tissues of the temporal region, including the subperiosteal space. Blood tests showed neutrophilia and elevated C-reactive protein. Surgical manipulation of the cited collection drained a large amount of a fetid purulent secretion. Ceftazidime and clindamycin were empirically initiated. The outcome was favorable, with fever defervescence and resolution of the scalp deformation. Culture of the drained secretion was positive for S. paucimobilis. Ciprofloxacin was scheduled for a further 10 days after discharge. The follow-up showed complete recovery. As far as we know, this is the first case of S. paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. The authors call attention to the increasing number of reports on S. paucimobilis infection over the years, and therefore to the importance of this pathogen, which was previously underestimated.

PO-0200 Sphingomonas Paucimobilis: A Cause Of Otomastoiditis Complicated With Subperiosteal Abscess In An Immunocompetent Child

We present the first case of Sphingomonas paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. Case Report A 11-year-old boy with previous diagnosis of chronic bilateral otitis media presented with 20 days of fever, otalgia, otorrhea, progressive retroauricular swelling with protrusion of the left ear and worsening of the symptoms despite 15 days of Amoxicilin. A CT scan was performed (Figure 1). Blood tests showed WBC 22,4 × 109 (neutrophils 81,2%) and CRP of 142. Surgical drainage of the abscess found a large amount of purulent foetid secretion. We empirically initiated Ceftazidime and Clindamycin. He remained well, with defervescence and resolution of the scalp deformation. Control test showed WBC 7,4 × 109 (neutrophils 58,7%) and CRP of 6. Culture of the abscess grew Sphingomonas paucimobilis. The patient was discharged with Cyprofloxacin and returned after 1 month in our clinic recovered. Discussion S. paucimobilis is an aerobic gram-negative bacillus that rarely infects humans, most commonly immunocompromised and hospitalised patients. We searched the literature for S. Paucimobilis infections in children and found 47 reported cases (Table 1). The most common diagnosis is isolated bacteremia and there are no previous report of otomastoiditis. It is related to sporadic or epidemic infections, leading to just one published case of death in children. S. paucimobilis infection has been increasingly reported over the years and it’s a more important pathogen than previously thought. Abstract PO-0200 Figure 1 CT scan showing left otomastoiditis (yellow arrow) associated with a large collection exterior to the temporal bone (red arrow) Abstract PO-0200 Table 1 Clinical characteristics of paediatric cases of Sphingomonas paucimobilis infection in our literature review

Impacto del uso de la prueba rápida para estreptococos beta-hemolíticos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis en emergencia de Pediatría

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.