E. Bosdure

Tropheryma whipplei in Children with Gastroenteritis

This bacterium may be an etiologic agent of gastroenteritis.

Outbreak of Corynebacterium pseudodiphtheriticum infection in cystic fibrosis patients, France.

Respiratory tract colonization with these bacteria may be common in this population.

Inquilinus limosus and Cystic Fibrosis

To the Editor: Inquilinus limosus, a new multidrug-resistant species, was reported in 1999 as an unidentified gram-negative bacterium in a lung transplant patient with cystic fibrosis (CF) (1). This species was later characterized by the description of 7 new isolates of I. limosus and 1 isolate of Inquilinus sp (2). Infections and colonizations by I. limosus have been documented mainly in adolescent or adult patients with CF. To date, 8 clinical cases have been described in Germany (3,4), 1 case in the United States (1), 5 cases in France (5), and 1 case in the United Kingdom (6) (Table). Only 1 isolate of Inquilinus sp. has been recovered from blood samples of a patient without CF who had prosthetic valve endocarditis (7). Table Clinical and epidemiologic features of cystic fibrosis (CF) patients with Inquilinus limosus* Because this bacterium is not recorded in all commercial identification system databases currently available, a longitudinal study for I. limosus detection with a new real-time PCR assay with a Taqman probe (Applied Biosystems, Foster City, CA, USA), that targets the 16S rRNA gene, has been developed and compared with the culture isolation. Primers il1d (5′-TAATACGAAGGGGGCAAGCGT-3′) and il1r (5′-CACCCTCTCTTGGATTCAAGC-3′) and probe ilProbe (6FAM-GGTTCGTTGCGTCAGATGTGAAAG-TAMRA), which were used in this study, were designed on the basis of multisequence alignment of all I. limosus 16S rDNA sequences available in the GenBank database. To confirm specificity, the primers and probe were checked by using the BLAST program (www.ncbi.nlm.nih.gov/blast/Blast.cgi) and also by using suspension of several bacteria recovered habitually in patients with CF. For sensitivity of the Taqman PCR assay (Applied Biosystems), the minimal CFU detectable was 2 CFU/PCR. From January 2006 through June 2007, 365 sputum samples recovered from 84 children and 61 adults with CF and 71 sputum samples recovered from 54 patients without CF were screened blindly for I. limosus. By using our real-time PCR, we detected 9 I. limosus-positive samples from 4 patients with CF (Table); 8 of these samples were also culture positive. However, all sputum samples from patients without CF were negative. In 1 patient (Table, case 17), I. limosus was detected by using real-time PCR 3 months before the culture was positive. Retrospectively, the patient’s medical file was rechecked and his clinical respiratory condition worsened briefly at that stage, which indicates an infection by this bacterium. Thus, in our study, the incidence of I. limosus was 2.8% (4.9% for adults with CF and 1.2% for children with CF). The incidence of Burkholderia cepacia complex during the same period and in the same patients was 2.1% (3 adults with CF were positive, data not shown). The genus Inquilinus belongs to the α-Proteobacteria; the genus Azospirillum is the most closely related bacteria (2). This cluster of bacteria contains several strains that are able to grow under saline conditions and in biofilms (8,9). The mucoid phenotype of I. limosus may contribute to its colonization and resistance to many antimicrobial drugs. Recently, the exopolysaccharides (EPS) produced by I. limosus were studied. The authors indicated that I. limosus produces mainly 2 EPSs that exhibit the same charge per sugar residue present in alginate, the EPS produced by Pseudomonas aeruginosa in patients with CF. This similarity may be related to common features of the EPS produced by these 2 opportunistic pathogens that are related to lung infections (10). Transmission of I. limosus between patients with CF is not known, but in the report from Chiron et al., 1 of the 5 patients with I. limosus had a brother who had never been colonized with this bacterium despite living in the same home (5). Schmoldt et al. reported that 3 patients were treated in the same outpatient CF clinic during overlapping time periods and each patient was infected/colonized by an individual I. limosus clone, which suggests that there was no transmission among these patients (4). This bacterium has been recovered mainly from sputum of adolescents (mean age 17 ± 6.47 years, range 8–35), except in our study with a 2-year-old boy, which suggests that this emerging bacterium may be hospital acquired, as recently suggested (7). Because this bacterium is multiresistant to several antimicrobial drugs, particularly colistin, which is widely used for treatment for P. aeruginosa colonization (as was the case for our 4 patients), we hypothesize that this bacterium is selected during the evolution of the disease. We have developed a real-time PCR molecular method that is faster and easier than amplification-sequencing for prompt detection and accurate identification of I. limosus with good specificity and sensitivity. By using this screening assay, we identified 4 additional cases of patients with CF who were also infected with this bacterium, including a 2-year-old child. In addition, by using this technique, we were able to detect I. limosus in a patient with deteriorated respiratory function 3 months before the culture-based isolation, indicating that a low bacterial load, insufficient for being isolated in culture, can be detected by PCR in the lower respiratory tract of patients with CF.

Anticipatory postural adjustments in a bimanual load-lifting task in children with Duchenne muscular dystrophy

We investigated the consequences of a progressive damage to the muscular system on the organization of anticipatory postural adjustments (APA) in children with Duchenne muscular dystrophy (DMD). We used a bimanual load-lifting task requiring the stabilization of the forearm position despite its voluntary or imposed unloading. Eight children with DMD from 4 to 11 years of age were compared to eight typically developing (TD) children. Elbow angle and multiple surface EMGs were recorded and assessed the use of APA. The muscle weakness did not impair (1) the proprioceptive afference and the motor efference constituting the unloading reflex; and (2) the use of an anticipatory function in children with DMD. However, APA used for the forearm stabilization were less efficient in the group of children with DMD. We conclude that in DMD the muscular weakness could be a restraint to the efficiency of APA with respect to TD children.

Endocardite infectieuse sur cœur sain chez l’enfant : étude rétrospective de 11 cas

The aim of our study was to determine the different characteristics of infective endocarditis in children without underlying heart disease. This was a descriptive, retrospective study including all cases of infective endocarditis without underlying heart disease occurring in children under 18 years of age, hospitalized at the Timone Childrens Hospital in Marseille, France, between 1997 and 2008. The clinical, microbiological, and echocardiography data; treatment; and outcome were reviewed for each case. Over an 11-year period, 26 children were hospitalized with infective endocarditis. Eleven children (7 boys) had no underlying heart disease (42 %). Their mean age was 8 years and 3 months. Underlying conditions including neoplasm, preterm birth, and central venous catheter were found in 6 cases. A heart murmur was observed in 82 % of the children. A microorganism was isolated in 10 children (91 %). Staphylococcus aureus was the most common agent (45 %), followed by fungi (18 %). Echocardiography detected cardiac complications in 7 cases (64 %). Ninety-one percent of the children received intravenous antibiotics for a mean duration of 45 days. Eighty-two percent of our patients required surgical intervention. In our series, 91 % of the patients met the modified Duke criteria defining infective endocarditis. In-hospital mortality was 11 %. Embolic complications were seen in 5 cases (45 %), patients whose cultures yielded S. aureus or fungal organisms were more likely to present complications. Infective endocarditis without heart disease has particular features that differ from those of congenital heart disease. This diagnosis must be considered when predisposing factors are present.

Syndrome de choc toxinique streptococcique ou syndrome de Kawasaki ? À propos de 2 cas cliniques d’enfants présentant une pleuropneumopathie à streptocoque bêta hémolytique du groupe A

We report 2 cases of children with group A streptococcus pyogenes pleuropneumonia, in one child associated with Kawasaki disease and in the other with streptococcal toxic shock syndrome. These 2 features, with theoretically well-defined clinical and biological criteria, are difficult to differentiate in clinical practice, however, likely due to their pathophysiological links. In case of clinical doubt, an echocardiography needs to be performed to search for coronary involvement and treatment including intravenous immunoglobulins, and an antibiotic with an anti-toxin effect such as clindamycin has to be started early.

Évolution inhabituelle d’une bronchiolite aiguë à virus respiratoire syncitial chez un nourrisson

We report the case of a 10-month-old girl hospitalized with RSV acute bronchiolitis who developed necrotizing pneumonia with pyopneumothorax due to Panton-Valentine leukocidin-secreting Staphylococcus aureus. The outcome was fortunately favorable with antibiotics and pleural drainage.

L’enfant et l’avion : résultats d’une enquête nationale

Airplanes are widely used by families and their children and pediatricians are increasingly asked to answer questions on this subject. The main purpose of this study was to evaluate the knowledge of pediatricians in this field except for medical transportation. Pediatricians belonging to the AFPA, the SFP, the SNPEH, or the SP2A were emailed a questionnaire on the physiological particularities of airborne transportation, contraindications to flight related to diseases (infections, diabetes, sickle-cell anemia, respiratory diseases, etc.) and the possible medication intake on board. Among the 232 responders, 82.3% had an exclusive hospital practice and 65% were specialized in more than one area of medicine. Regarding contraindications to flying, the rate of correct answers varied from 14 to 84% with divided opinions regarding respiratory and hematological pathologies. However, contraindications related to infections were well known. Items related to oxygen therapy raised questions as 35-68% of pediatricians stated that they could not answer. On the whole, this work demonstrated very fragmented knowledge on this topic.

Early Halt of a Randomized Controlled Study with 3% Hypertonic Saline in Acute Bronchiolitis

Background: Albeit not recommended because of contradictory results, nebulized 3% hypertonic saline is widely used for treating acute viral bronchiolitis. Whether clinical differences may be attributed to the type of nebulizer used has never been studied. Objectives: By modifying the amount of salt deposited into the airways, the nebulizer characteristics might influence clinical response. Methods: A prospective, randomized, controlled trial included infants hospitalized in a French university hospital for a first episode of bronchiolitis. Each child received 6 nebulizations of 3% hypertonic saline during 48 h delivered with 1 of the 3 following nebulizers: 2 jet nebulizers delivering large or small particles, with a low aerosol output, and 1 mesh nebulizer delivering small particles, with a high aerosol output. The primary endpoint was the difference in the Wang score at 48 h. Results: Only 61 children of 168 were recruited before stopping this study because of severe adverse events (n = 4) or parental requests for discontinuation due to discomfort to their child during nebulization (n = 2). One minor adverse event was noted in 91.8% (n = 56/61) of children. A high aerosol output induced 75% of the severe adverse events; it was significantly associated with the nebulization-induced cough between 24 and 48 h (p = 0.036). Decreases in Wang scores were not significantly different between the groups at 48 h, 9 recoveries out of 10 being obtained with small particles. Conclusion: No beneficial effects and possibly severe adverse events are observed with 3% hypertonic saline in the treatment of bronchiolitis.

Intérêt de l’identification en routine des agents pathogènes respiratoires chez les enfants hospitalisés pour une exacerbation d’asthme

BACKGROUND Asthma is the most common chronic disease in childhood. With its high economic burden, it is considered a disease of major public health importance by the World Health Organization. The link between respiratory tract infections and acute exacerbation has been recognized for a long time. The aim of this retrospective study in routine care was to evaluate our practices concerning microbiological prescriptions in children hospitalized for asthma exacerbation. STUDY DESIGN All children aged from 2 to 15 years hospitalized for asthma exacerbation between January 2010 and December 2011 in our unit were included in the study. Microbiological prescriptions, their indications, their results, and their cost were studied. RESULTS One hundred ninety-seven children were included in the study. A potential causative agent was sought in 79.7% of the children (n=157) by immunofluorescence assay (IFA) and/or polymerase chain reaction (PCR). The main indications were upper airway infections, hypoxemia, and pneumonia. Viruses were detected in 23.8% of them (30/126). Mycoplasma pneumoniae was detected by PCR in only 3.2% of these patients (4/125). No other bacterial agent was identified. There was no correlation between the severity of asthma exacerbation and the microbiological diagnosis of infection. The results did not influence the therapy given. These prescriptions represented a substantial cost for each child. CONCLUSION These analyses do not seem to have a real advantage for the patient except for epidemiology. It would be important to conduct a new study analyzing the role of rhinovirus, and of other viruses such as coronavirus, bocavirus, and enterovirus, not routinely investigated in our hospital, and to question the value of these costly microbiological tests.