José Carlos Fernandes

Cervical necrotizing fasciitis in an infant caused by Haemophilus non influenzae

We describe a rare case of cervical necrotizing fasciitis caused by Haemophilus non influenzae in a 5-month-old infant who was concomitantly affected by bacteremia, pneumonia and meningitis. The patient had a satisfactory evolution after treatment with antibiotics, intensive clinical support, and five surgical debridements of the lesion. A previously healthy 5-month-old boy was brought to the Emergency Room with fever and enlargement of the neck associated with vomiting and irritability during the 3 previous days. There was no history of previous trauma nor significant infections. The immunization schedule had not included a vaccine against Haemophilus. The infant was found to be febrile, irritable, pale and dehydrated, with signs of respiratory distress and upper airway obstruction. Examination of the oral cavity revealed the presence of a purulent secretion covering the pharynx. The skin in the cervical region appeared stretched and erythematous, and there were dark purple spots in the right submandibular area. The tissues had a hard consistency without fluctuation points. Lung auscultation showed bilateral rales and inspiratory stridor. X-rays of the cervical area showed a hyperextended cervical lordosis and a diffuse radiolucent area in the retropharyngeai region. Ultrasonographic and computerised tomography (CT) of the neck and skull revealed extensive swelling of the soft cervical tissues. The chest scan disclosed condensations in the lower two thirds of the right lung and in the left pulmonary base, which were barely visible in the X-ray. The infant was admitted to the Intensive Care Unit where laboratory tests conducted showed some abnormal blood results: anaemia, leukopenia withneutrophil ia, increased prothrombin and activated partial thromboplastin time, and analysis of the arterial gases revealed hypoxemia. The cerebrospinal fluid yielded an elevated cellularity mostly of polymorphonuclear cells, as well as high protein and low glucose content. CSF bacterioscopy presented intraand extra-cellular gram-negative pleomorphic bacilli, but the culture was found to be negative. Three blood cultures in brain heart infusion (BHI) medium were performed and subsequently replicated in chocolate agar incubated in carbon dioxide [1]. Samples for culture in tryptic soy broth (TSB) with polianetol sodium sulphonate in anaerobiosis were also collected. The clinical laboratory picture led to a diagnosis of necrotizing fasciitis of the cervical region with meningitis and bilateral bronchopneumonia. Due to his respiratory insufficiency, the infant was submitted to orotracheal intubation and mechanical ventilation. Parenteral antimicrobial therapy was started with clindamycin and ceftriaxone. Surgical intervention was subsequently performed to decompress the airways and remove necrotic tissues. Bacterioscopic examination of the secretion showed the presence of gram-negative coccobacilli which, however, did not grow either in BHI subcultured in chocolate agar under CO 2 or in TSB under anaerobiosis. The patient s initial outcome was unfavourable. Another CT scan disclosed the presence of gas in the soft tissues of the cervical region. The blood cultures allowed the identification of Haemophilus sp. non influenzae, resistant to the antibiotics in use but susceptible to chloramphenicol [2]. After the therapeutic change to chloramphenicol, the infant showed overall improvement. However, the cervical lesion continued to show new necrotic areas and four other debridements were performed. The patient was discharged on day 34 and was followed up by the outpatient clinic team for I year, showing no functional impairment or relevant infections. Immunologic evaluation tests remained normal throughout this period. Our literature review revealed that this is the first documented case of necrotizing fasciitis caused by Haemophilus non influenzae in children, although other previous cases may have not been recognized [3, 4]. There are two reports of necrofizing fasciitis in infants caused by Haemophihts influenzae [5, 6]. The first is similar to the one described here in its pharyngeal onset and cervical involvement: however, three other pathogens including two anaerobic bacteria were also involved [5]. In the other case, the bacteria caused an isolated infection in a 13-month-old infants leg where there might have been a previous trauma [6]. In a recent literature review, only Haemophihts influenzae is mentioned among the various bacteria potentially causing necrotizing fasciitis in children, whereas this aetiology is recognized in adults [7, 8]. The most frequent causal agents of necrotizing fasciitis are group A beta-hemolytic streptococci and Staphylococcus aureus which may act separately, in conjunction with, or associated with other pathogens. For the other aerobic and anaerobic bacteria, a synergistic action is considered essential to the occurrence of necrosis of the fascia and other deep soft tissues, but this was not observed in the present case [5, 10]. In our infant, only Haemophihts sp. was isolated from the blood and observed in the material collected from the cervical lesion and the spinal fluid [111 . The hypothesis of a simultaneous occurrence of infection caused by strictly anaerobic bacteria was considered, given the high fiequency of these agents in deep infections of the neck and the local presence of gas revealed by the CT scan [5]. The fact that these agents were neither observed at the microscopy nor isolated from the specific culture led us to the conclusion that these bacteria are probably not involved. It is possible that the tissue gas was produced by Haemophilus non influenzae which can act as a gas-producing facultative anaerobic bacterium [3]. The occasional pathogenicity of Haemophilus non influenzae in various severe diseases in.children as well as its frequent presence in the upper airways are recognized [3]. The high virulence of~the strain involved in the case reported here could be indirectly inferred through observation of multiple infectious sites caused in this immunocompetent infant. Unfortunately, the loss of viability of the strain in culture did not permit a conclusive identification of the species of this Haernophilus non influenzae. There is, however, indirect evidence of the species involved. The bacterial growth was found to be dependent only on factor X

Evaluation of the dead space to tidal volume ratio as a predictor of extubation failure.

OBJECTIVE The objective of this study was to evaluate the ratio of dead space to tidal volume (VD/VT) as a predictor of extubation failure of children from mechanical ventilation. METHODS From September 2001 to January 2003 we studied a cohort consisting of all children (1 day-15 years) submitted to mechanical ventilation at a pediatric intensive care unit who were extubated and for whom pre-extubation ventilometry data were available, including the VD/VT ratio. Extubation success was defined as no need for any type of ventilatory support, invasive or otherwise, within 48 hours. Patients who tolerated extubation, with or without noninvasive support, were defined as success-R and compared with those who were reintubated. Statistic analysis was based on a VD/VT cutoff point of 0.65. RESULTS During the study period 250 children received mechanical ventilation at the pediatric intensive care unit. Eighty-six of these children comprised the study sample. Twenty-one children (24.4%) met the criteria for extubation failure, with 11 (12.8%) of these requiring non-invasive support and 10 (11.6%) reintubation. Their mean age was 16.8 (+/-30.1) months (median = 5.5 months). The mean VD/VT ratio for all cases was 0.62 (+/-0.18). Mean VD/VT ratios for patients with successful and failed extubations were 0.62 (+/-0.17) and 0.65 (+/-0.21) (p = 0.472), respectively. Logistic regression failed to reveal any statistically significant correlation between VD/VT ratio and success or failure of extubation (p = 0.8458), even for patients who were reintubated (p = 0.5576). CONCLUSIONS In a pediatric population receiving mechanical ventilation due to a variety of etiologies, the VD/VT ratio was unable to predict the populations at risk of extubation failure or of reintubation.

Avaliação da relação entre espaço morto e volume corrente como índice preditivo de falha de extubação

OBJETIVO: O objetivo do estudo foi avaliar a relacao entre espaco morto e volume corrente (VD/VT) como preditivo de falha na extubacao de criancas sob ventilacao mecânica. METODOS: Entre setembro de 2001 e janeiro de 2003, realizamos uma coorte, na qual foram incluidas todas as criancas (1 dia-15 anos) submetidas a ventilacao mecânica na unidade de terapia intensiva pediatrica em que foi possivel realizar a extubacao e a ventilometria pre-extubacao com a medida do indice VD/VT. Considerou-se falha na extubacao a necessidade de reinstituicao de algum tipo de assistencia ventilatoria, invasiva ou nao, em um periodo de 48 horas. Para a analise dos pacientes que foram reintubados, definiu-se como sucesso-R a nao reintubacao. Para as analises estatisticas, utilizou-se um corte do VD/VT de 0,65. RESULTADOS: No periodo estudado, 250 criancas receberam ventilacao mecânica na unidade de terapia intensiva pediatrica. Destas, 86 compuseram a amostra estudada. Vinte e uma criancas (24,4%) preencheram o criterio de falha de extubacao, com 11 (12,8%) utilizando suporte nao-invasivo e 10 (11,6%) reintubadas. A idade media foi de 16,8 (±30,1) meses, e a mediana, de 5,5 meses. A media do indice VD/VT de todos os casos foi de 0,62 (±0,18). As medias do indice VD/VT para os pacientes que tiveram a extubacao bem sucedida e para os que falharam foram, respectivamente, 0,62 (±0,17) e 0,65 (±0,21) (p = 0,472). Na regressao logistica, o indice VD/VT nao apresentou correlacao estatisticamente significativa com o sucesso ou nao da extubacao (p = 0,8458), nem para aqueles que foram reintubados (p = 0,5576). CONCLUSOES: Em uma populacao pediatrica submetida a ventilacao mecânica, por etiologias variadas, o indice VD/VT nao possibilitou predizer qual a populacao de risco para falha de extubacao ou reintubacao.

Eficácia e segurança do uso inalatório da adrenalina-L na laringite pós-intubação utilizada em associação com a dexametasona

OBJECTIVE: to assess the efficacy and safety of the use of nebulized L-epinephrine associated with dexamethasone in postintubation laryngitis. METHOD: We carried out a prospective, randomized, double-blind, placebo controlled study with two cohorts of patients with postintubation laryngitis graded 3 to 6 by Downes-Raphaelly score during two years. Our population was divided into two groups: A and B; both groups received intravenous dexamethasone and two doses of nebulized saline; however, only group B received L-epinephrine. The efficacy was assessed by Downes-Raphaelly score. The side effects of L-epinephrine were evaluated according to the occurrence of cardiac arrhythmia, increased blood pressure, and average heart rate of group B in comparison to group A. RESULTS: Twenty-two patients were included in group A (average score = 4.8) and 19 in group B (average score = 5.2). During treatment, 3 patients in group A presented a score of 8 and were reintubated. This group also showed higher mean clinical scores than group B during the first two hours of the protocol; these results were not statistically significant. No side effects were observed due to epinephrine. The gas blood measurements were adequate in both groups, but better in the control group. CONCLUSIONS: We did not observe increased efficacy for the treatment of postintubation laryngitis when nebulized L-epinephrine was used simultaneously with intravenous dexamethasone. Some indicators, however, did present a favorable trend when combined therapy was used and should be submitted to further evaluation.

Ruptura traumática de via aérea em criança: um desafio diagnóstico

OBJETIVO: Relatar um caso de ruptura da via aerea em crianca vitima de trauma toracico decorrente de queda do tanque de lavar roupas. DESCRICAO: Relato de caso descritivo. O paciente pre-escolar de 34 meses, do sexo masculino foi atendido na unidade de terapia intensiva pediatrica de Hospital Universitario. Foram realizados os seguintes procedimentos: radiografia simples e tomografia de torax, endoscopia respiratoria, toracotomia, antibioticoterapia, ventilacao mecânica. A radiografia simples de torax, tomografia computadorizada de torax e endoscopia respiratoria foram necessarias para definir o diagnostico de ruptura traumatica da via aerea associada a contusao pulmonar, pneumotorax, pneumomediastino e enfisema subcutâneo. O paciente foi submetido a toracotomia para reparacao de lesao quase completa de bronquio principal esquerdo. Antibioticoterapia de largo espectro e suporte ventilatorio contribuiram para resolucao do caso sem sequelas a medio prazo. COMENTARIOS: Na vigencia de trauma toracico em crianca, a busca diagnostica por lesoes incomuns, mas potencialmente letais, como a ruptura da via aerea, deve ser incessante, particularmente naqueles pacientes com fortes evidencias clinicas. A complementacao diagnostica deve ser otimizada com a radiografia simples de torax, a tomografia de torax e o exame endoscopico que estabelece o diagnostico definitivo.

Contribuição da biópsia pulmonar a céu aberto na avaliação de pneumopatias difusas e agudas em unidade de terapia intensiva pediátrica

Introducao:: Os dados clinico-laboratoriais convencionais raramente fornecem o diagnostico empneumopatias difusas. O objetivo deste estudo foi avaliar o papel da biopsia pulmonar a ceu aberto noque se refere ao seu potencial diagnostico, ao impacto dos resultados sobre a conduta clinica e aincidencia de complicacoes do procedimento. Material e metodos: Material e metodos: No periodo de janeiro/1987 ajaneiro/1997, 29 biopsias pulmonares foram realizadas em criancas com pneumopatias difusas, eminsuficiencia respiratoria aguda, sem etiologia e sem resposta a terapeutica empirica previa. Foramexcluidos os recem-nascidos, criancas com pneumopatias cronicas previas e criancas comcoagulopatia ou choque intrataveis. Todas as biopsias foram realizadas atraves de microtoracotomia nopulmao mais acometido ao exame radiologico. O fragmento de tecido pulmonar foi analisado pormeio de culturas e de exames de microscopia otica, eletronica e imunofluorescencia. Resultados: Resultados: Oprocessamento do material da biopsia forneceu pelo menos um diagnostico histopatologico em todasas criancas estudadas (100%) e em 20 (68,9%) obteve-se um diagnostico etiologico. Os principaisdiagnosticos histopatologicos foram: pneumonite intersticial nao especifica com fibrose variavel em 18casos; bronquiolite em oito casos e hipertensao pulmonar em tres casos. Nos diagnosticos etiologicos,os principais agentes foram: citomegalovirus em seis criancas; Pneumocystis carinii em tres;adenovirus em tres e infeccao pelo virus respiratorio sincicial em tres casos. Os resultados gerarammudancas no tratamento em 20 casos (68,9%). As principais alteracoes de conduta foram aintroducao de corticoterapia em 14 pacientes e a revisao da antibioticoterapia em seis. Sete casos(24,1%) apresentaram complicacoes, que foram resolvidas, e nenhum obito foi relacionado aoprocedimento. Conclusao:Conclusao: Conclui-se que a biopsia pulmonar a ceu aberto e um procedimento que,mesmo invasivo, deve ser considerado na avaliacao de criancas com pneumopatias difusas graves, semetiologia definida, sem resposta a terapeutica previamente instituida e em insuficiencia respiratoria.

Therapeutic of septic children with purpuric presentation with two antibiotic schedules

OBJECTIVE: The authors evaluate the therapeutic efficacy of two antibiotic schedules, ceftriaxone alone and the combined use of ampicillin and chloramphenicol, in the treatment of septic children with purpuric presentation.METHODS: A randomized open clinical trial was conducted including septic children with purpuric presentation treated at a pediatric intensive care unit from April 1988 to June 1992. All cases with systemic purpura standing for less than a week were included in one of two groups, except for those recently hospitalized or with previous hemorrhagic disturbs. Patients in group A received ampicillin and chloramphenicol and those in group B were given ceftriaxone. Quantitative parameters were adopted to compare the efficacy of the two antibiotic schedules: sensitivity of bacteria isolated at blood and liquor cultures, complications, therapeutic procedures, period of hospitalization, and sequelae.RESULTS: 19 cases were included in the group A and 16 in group B, both homogenous on clinical-laboratorial aspects. The parameters evaluated did not show different efficacy between the two antimicrobial schedules tested, except for the number of complications observed during hospitalization, which was higher among the children that received ampicillin and chloramphenicol. The overall mortality for the patients treated was 13.8%, excluded the undernourished. CONCLUSIONS: The authors verify similar clinical therapeutic efficacy with the combined use of ampicillin and chloramphenicol or ceftriaxone, as observed previously. It must be pointed that the number of complications detected during hospitalization were higher in the group that received the combined antibiotic schedule. Low mortality in the present study may be attributed to the early diagnosis and therapeutic measures adopted at the pediatric intensive care unit.