Kazimierz Wardyn

Pseudotumour orbitae as the initial manifestation in Wegener's granulomatosis in a 7-year-old girl

Wegener’s granulomatosis (WG) is a systemic granulomatous vasculitis that typically affects the upper airways, lungs and kidneys. This form of vasculitis is extremely rare in children, the most common form of paediatric systemic vasculitis being Henoch–Schönlein purpura (HSP). Children with systemic vasculitis look ill and have multiple constitutional complaints, often with prolonged fever [1]. As in adults, WG in children is a multisystem disease. There are no precise statistical data concerning ocular involvement in Wegener’s granulomatosis in children. Ocular disease occurs in 50%–60% adult patients with WG and may be an extension of the sinus inflammation or an orbital pseudotumour independent of the sinus disease (15%–50%) [2, 3]; sometimes it presents as an ocular myositis. The most common presenting sign of orbital disease is ptosis and anterior displacement of the eye, pain, blurred vision, eyelid swelling and reduction of eye motility. Here we present the case of a 7-year-old girl with WG whose initial manifestation was pseudotumour orbitae. This patient was negative for an initial c-ANCA test. Biopsy specimens obtained from the lacrimal gland and kidney demonstrated granulomatous vasculitis. Treatment with glucocorticoids and cyclophosphamide led to complete, long-lasting remission.

Influence of Rapid Influenza Test on Clinical Management of Children Younger than Five with Febrile Respiratory Tract Infections

Children are an important vector for spreading influenza and they are at increased risk for complications. The appropriate diagnosis of influenza may help start early antiviral treatment and may optimize the use of antibiotics and additional laboratory tests. The objective of this study was to describe the influence of rapid influenza detection test (RIDT) on clinical management of children with acute febrile respiratory tract infections. The method consisted of a prospective, open, cohort study conducted in three primary care clinics in Warsaw, Poland, during the epidemic influenza seasons of 2009/2010 and 2010/2011. A total number of 256 children of the age 0-5 years with symptoms of febrile respiratory tract infection were enrolled into the study. A 115 of them were tested with RIDT (BD Directigen EZ FluA + B) and another 141 children, who were not tested, constituted a control group. We found that RIDT gave positive results in 35 (30%) out of the 115 tested children. Antibiotics, additional blood tests and urinalysis were administered more often in the control group compared with the rapid test group (16% vs. 7%; 14% vs. 5%, and 47% vs. 32%, respectively). Chest radiograms were made only in six cases of children from the control group. We conclude that in children with symptoms of acute febrile respiratory tract infection, the rapid influenza detection test provides a rational use of antivirals, reduces an inappropriate use of antibiotics, and decreases a number of additional tests conducted.

Cutaneous changes: an initial manifestation of pulmonary Wegener's granulomatosis.

Cutaneous vasculitis can occur as an isolated dermatologic disorder or as manifestation of a potentially life-threatening systemic vasculitis such as Wegeners granulomatosis (WG). The aim of the study was to characterize cutaneous lesions in 66 WG patients (30 female, 36 male) and to assess the viability of skin biopsy the diagnosis of WG. Skin involvement was observed in 21 (32%) WG patients; in 14 (21%) patients as an initial manifestation and in other seven during the diagnosis establishment. Cutaneous lesions included palpable purpura(n=10), subcutaneous nodules(=4), hemorrhagic bullae (n=3), ulcers (n=2), pustules (n=1), pyoderma gangrenosum (n =1). The patient with pulmonary WG can present initially with cutaneous symptoms and positive PR3-ANCA serologic test results. Leukocytoclastic vasculitis (LCV) was the predominant histopathologic pattern.

Epidemiological and immunological reasons for pertussis vaccination in adolescents and adults

The resurgence of pertussis has been the subject of considerable debate. Hypotheses to explain increased reporting in developed countries have focused mainly on three aspects: (1) increased recognition of the disease in adolescents and adults; (2) waning of vaccine-induced immunity and (3) loss of vaccine efficacy due to an antigenic shift of Bordetella pertussis. Waning immunity after vaccination or natural infection combined with the absence of regular boosters either in the form of vaccine boosters or natural exposure to B. pertussis - due to the low circulation of the bacterium in well-immunized populations - has been suggested to explain this shift in the age distribution of pertussis. The highest incidence of the disease is currently reported among adolescents and adults who may additionally serve as the source of infection for susceptible infants. Immunological and epidemiological data indicates the need for a universal booster vaccination against pertussis for adolescents and adults.

Antibiotic Consumption Pattern in the Neonatal Special Care Unit Before and After Implementation of the Hospital’s Antibiotic Policy

Current and detailed knowledge of antibiotic use is essential in order to implement strategies for reducing the overuse of antibiotics. The objective of our study was to determine the effectiveness of the implementation of the hospital antibiotic policy (HAP) by assessing antibiotic consumption in the Special Neonatal Care Unit (SNCU) in Warsaw, Poland, before and after this intervention. Antibiotic use was calculated in daily defined doses (DDDs) per 100 patient-days and DDDs per 100 admissions. The antibiotics were ranked by volume of DDDs and the number of antibiotics, which accounted for 90 % and 100 % of the total volume, respectively: DU90% and DU100% (where DU stands for drug use). Total antibiotic consumption increased slightly after the introduction of the HAP: the total DDDS was 707.87 and 753.12 in 2011 and 2012, while the number of DDDs/100 admissions was 352.17 and 369.12 in 2011 and 2012, respectively. After the introduction of the HAP, an increase in ampicillin and aminoglycoside use was observed, along with a reduction in the DU100% and DU90% rates (15 vs. 9 and 4 vs. 3, respectively). The introduction of the HAP resulted in changes in antibiotic consumption patterns, but the general antibiotic consumption density remained the same.

Nosocomial rotavirus gastroenterocolitis in a large tertiary paediatric hospital in Warsaw, 2006-2010.

Introduction Rotaviruses are the leading cause of community-acquired and nosocomial gastroenterocolitis in children. There are limited data concerning the epidemiology of nosocomial rotavirus gastroenterocolitis (NRVG) in Central European countries, including Poland. The aim of our study was to analyse the epidemiology of NRVG in a large tertiary hospital in Warsaw. Material and methods We analysed retrospectively data of 63 173 patients aged 0-18 years hospitalized in the period 2006-2010. Nosocomial rotavirus gastroenterocolitis was defined as acute gastroenterocolitis (> 3 loose, or looser than normal, stools in 24 h and/or vomiting), confirmed with rapid immunochromatographic test (BioMaxima, Poland), if symptoms developed > 48 h after admission. Results In total 575 cases of NRVG were diagnosed. The cumulative attack rate of NRVG was calculated as 0.91% (95% CI: 0.85-0.98%). The incidence density was 2.05/1000 bed-days (95% CI: 0.19-0.22/1000 bed-days). The mean proportion of NRVG among all rotavirus infections was 24%. The highest rates of NRVG were noted at wards where the mean duration of hospital stay was longer than 5 days (General Paediatrics and Neonatal Pathology). Seventy-one percent of children with NRVG were younger than 2 years. The mean duration of hospital stay of children with NRVG was longer than the average duration of hospitalization (11.6 days vs. 4.6 days, p < 0.01). Conclusions Our study showed a relevant incidence of NRVG, which can prolong the childrens hospital stay. Limiting the number of NRVG is important to improve patients’ safety and to avoid additional costs. Routine vaccination against rotavirus diseases could reduce the number of NRVG.

Cancer Incidence in Pulmonary Vasculitis

Pulmonary vasculitis is a potentially lethal autoimmune disease characterized by granulomatous inflammation of respiratory tract, necrotizing vasculitis affecting small-to medium-size vessels and antineutrophil cytoplasmic antibodies elevation. Typical therapy involves high-dose glucocorticosteroids combined with cyclophosphamide in a dose 1-2 mg/kg/per day. A high relapse rate in pulmonary vasculitis means prolonged courses of cyclophosphamide in some patients. Carcinogenic effects of cyclophosphamide, especially its toxic metabolite acrolein that is excreted into the urine, are responsible for the development of acute myeloid leukemia (AML) and bladder cancer. These and other malignancies are cyclophosphamide dose-depended. The aim of the present study was to assess the incidence of cancer in patients with pulmonary vasculitis in comparison with the incidence of cancer in the general population. Analyses were done according to the cumulative dose of cyclophosphamide, subdivided into low (≤35 g) and high (>35 g). During the observation period 15 cancers occurred. A significantly increased standardized incidence ratio (SIR) was observed for non-melanoma skin cancers (SIR 5.2; 95 % Cl 2.3-8.7), AML (SIR 4.3; 95 % Cl 2.1-11.2), and bladder cancer (SIR 3.4; 95 % Cl 1.6-5.2). Induction remission treatment and relapse treatment with cyclophosphamide involves a substantial risk of late appearing malignances in patients with pulmonary vasculitis. Monitoring and prophylactic management in pulmonary vasculitis after cessation of cyclophosphamide therapy is crucial.

Influenza Immunization Rates in Children and Teenagers in Polish Cities: Conclusions from the 2009/2010 Season

The aim of this study was to determine influenza vaccine coverage among children aged 0-18 years in inner city practices in Poland in the 2009/2010 season and factors that might have influenced low vaccination coverage. A retrospective review of 11,735 vaccination charts of children aged 0-18 from seven randomly selected general practices in the capital city of Warsaw and one large practice in the city of Wroclaw was performed. We calculated the numbers of children who were vaccinated in the 2009/2010 season and analyzed the age distribution of vaccinated children. We also reviewed the vaccination history in patients who were vaccinated against influenza including: previous influenza vaccinations, modification (widening) of standard immunization scheme, and a proportion of children who completed the recommended two-dose schedule of vaccination. In the calculations, 95% confidence intervals were used. Out of the total of 11,735 children surveyed, 362 (3.1%, CI: 2.8-3.4%) were vaccinated against influenza in the 2009/2010 season. For 115 of these 362 (31.8%, CI: 27.0-36.6%) children it was their first vaccination against influenza. The mean age of a vaccinated child was 6.0 ± 4.3 years. Children aged 2-5 were most commonly vaccinated (153/362, 42.3%, CI: 37.2-47.4%), while infants (aged 6-12 months) were vaccinated rarely (15/362, 4.4%, CI: 2.2-6.2%). In the group of children younger than 8 years (86/362 children) who were vaccinated for the first time in their life only 29/86 (33.7%, CI: 23.7-43.7%) completed the recommended two-dose schedule. In conclusion, the importance of vaccinating children against influenza is hugely understated in Poland. General physicians should actively recommend annual influenza immunization of children. Recommendations of National Immunization Program concerning influenza vaccine should be clearer, simpler, and easier to implement.

Clinical Features and Outcomes of Influenza A and B Infections in Children

The aim of the study was to describe the course of influenza among children aged 0-59 months. A total of 150 children with influenza-like symptoms (ILI): cough, fever >37.8 °C, and sore throat was included into the observation. All children were tested with both rapid influenza detection test (RIDT) BD Directigen™ EZ Flu A+B® and RT-PCR. Sixty four cases of influenza were diagnosed (incidence rate 40 %): 19 (30 %) cases of influenza caused by type B virus and 45 (70 %) cases caused by type A virus. Children with influenza required more often follow up visits (p < 0.05, OR 1.99, 95 % CI 1.03-3.85) and less often were administrated antibiotic therapy (p < 0.05, OR 0.25, 95 % CI 0.04-0.97). The logistic regression analysis revealed that only positive result of rapid influenza detection test, not any of clinical symptoms, could be found as an independent predictor of influenza (OR 4.37, 95 % CI 2.03-9.43). Patients with influenza type A more often reported muscle ache (p < 0.05) and complications (p < 0.05; OR 6.06, 95 % CI 1.20-60.38). Otitis media occurred more often among patients with than without influenza (p < 0.01; OR 15.50, 95 % CI 2.10-688.5). We conclude that although influenza infections among children younger than 59 months were generally mild and self-limited, pediatric burden of the disease was significant.

Accuracy of Rapid Influenza Detection Test in Diagnosis of Influenza A and B Viruses in Children Less Than 59 Months Old

Influenza burden among children is underestimated. Rapid influenza diagnostic tests (RIDTs) may be helpful in the early diagnosis of the disease, but their results should be interpreted cautiously. The aim of our study was to estimate the accuracy of the rapid influenza detection test BD Directigen™ EZ Flu A+B (Becton, Dickinson and Company, Sparks, MD) used among children with influenza-like illness (ILI) consulted in the ambulatory care clinics. A total number of 150 patients were enrolled into the study. The inclusion criteria were: age of the child less than 59 months, presentation of ILI according to CDC definition (fever >37.8 °C, cough, and/or sore throat in the absence of another known cause of illness), and duration of symptoms shorter than 96 h. In all patients two nasal and one pharyngeal swab were obtained and tested by RIDT, RT-PCR, and real time RT-PCR. For or influenza A(H1N1)pdm09, virus sensitivity of RIDT was 62.2 % (95 %CI 53.4-66.5 %), specificity 97.1 % (95 %CI 93.4-99 %), positive predictive value (PPV) 90.3 % (95 %CI 77.5-96.5 %), and negative predictive value (NPV) 85.7 % (95 %CI 82.4-87.3 %). For influenza B, virus sensitivity was 36.8 % (95 %CI 23.3-41.1 %), specificity 99.2 % (95 %CI 97.3-99.9 %), PPV 87.5 % (95 %CI 55.4-97.7 %), and NPV 91.5 % (95 % CI 89.7-92.1 %). We conclude that the RIDT immunoassay is a specific, but moderately sensitive, method in the diagnosis of influenza type A and is of low sensitivity in the diagnosis of influenza B infections in infants and children.