Lucila Marquez

A report of three cases and review of intrauterine herpes simplex virus infection.

Background: Intrauterine herpes simplex virus (HSV) infection often is omitted from descriptions of neonatal HSV disease. Previous characterizations of intrauterine HSV infection limit manifestations to the triad of cutaneous, central nervous system (CNS), and ophthalmologic findings. We report 3 cases of intrauterine HSV infection and provide a contemporary literature review of this disease. Methods: Cases published between 1963 and January 2009 were identified. Selected cases fit the clinical description of intrauterine HSV infection, had manifestations present at birth, and had virologic confirmation of infection. Results: This review yielded 64 cases, 3 of which were our own, of intrauterine HSV infection. Less than one-third fit the typical triad. Of the patients with cutaneous findings at birth, 24 (44%) had manifestations other than vesicles or bullae. Confirmation of HSV infection by culture of cutaneous lesions present at birth was delayed beyond 72 hours after birth in 15 patients and occurred at a median of 10 days of age. Nine of these patients had lesions at birth that were neither vesicles nor bullae, and 14 cases were confirmed by culture of new vesicles. Conclusions: More than two-thirds of reported cases do not present with the typical triad. Cutaneous findings are not limited to vesicles or bullae. A high index of suspicion and recognition of varied cutaneous manifestations is necessary to diagnose infants with intrauterine HSV infection.

Zika Virus-Associated Microcephaly and Eye Lesions in the Newborn

On February 1, 2016, Zika virus (ZIKV) was designated as a Public Health Emergency of International Concern by the director of the World Health Organization. Zika virus has spread to numerous countries throughout the Americas, affecting up to an estimated 1.3 million people since the first reports from Brazil in early 2015. Although ZIKV infections are self-limiting, fetal microcephaly and ophthalmic anomalies have been associated with ZIKV infection as a possible result of perinatal transmission. The causal link between maternal ZIKV infection and newborn microcephaly and eye lesions has not been proven beyond doubt and is currently debated. We discuss the possibility of causality by ZIKV using Kochs postulates and the more appropriate Bradford Hill criteria. In this review, we summarize and consolidate the current literature on newborn microcephaly and eye lesions associated with ZIKV infection and discuss current perspectives and controversies.

An Outbreak of Burkholderia cepacia Complex Infections Associated with Contaminated Liquid Docusate

OBJECTIVE To investigate an outbreak of Burkholderia cepacia complex and describe the measures that revealed the source. SETTING A 629-bed, tertiary-care, pediatric hospital in Houston, Texas. PATIENTS Pediatric patients without cystic fibrosis (CF) hospitalized in the pediatric and cardiovascular intensive care units. METHODS We investigated an outbreak of B. cepacia complex from February through July 2016. Isolates were evaluated for molecular relatedness with repetitive extragenic palindromic polymerase chain reaction (rep-PCR); specific species identification and genotyping were performed at an independent laboratory. The investigation included a detailed review of all cases, direct observation of clinical practices, and respiratory surveillance cultures. Environmental and product cultures were performed at an accredited reference environmental microbiology laboratory. RESULTS Overall, 18 respiratory tract cultures, 5 blood cultures, 4 urine cultures, and 3 stool cultures were positive in 24 patients. Among the 24 patients, 17 had symptomatic infections and 7 were colonized. The median age of the patients was 22.5 months (range, 2-148 months). Rep-PCR typing showed that 21 of 24 cases represented the same strain, which was identified as a novel species within the B. cepacia complex. Product cultures of liquid docusate were positive with an identical strain of B. cepacia complex. Local and state health departments, as well as the CDC and FDA, were notified, prompting a multistate investigation. CONCLUSIONS Our investigation revealed an outbreak of a unique strain of B. cepacia complex isolated in clinical specimens from non-CF pediatric patients and from liquid docusate. This resulted in a national alert and voluntary recall by the manufacturer. Infect Control Hosp Epidemiol 2017;38:567-573.

Zika virus epidemic: an update

ABSTRACT Introduction: Zika Virus (ZIKV), previously the cause of only rare and sporadic human infections, is now considered a Public Health Emergency of International Concern. Over the past two years, ZIKV has become a pandemic encompassing much of the Americas. ZIKV is now proven to cause microcephaly and ophthalmic anomalies in the newborn. Hydrops fetalis, developmental delay, and other anomalies are increasingly being attributed to ZIKV infection in fetuses and neonates. Sequelae of congenital infection and rapid spread of ZIKV throughout the Americas has catapulted Zika virus concerns to the forefront of the medical community. Areas covered: This review seeks to consolidate ZIKV epidemiology, diagnostic testing methods, CDC screening recommendations, and preventive strategies including potential vaccines. Expert commentary: Many unknowns still exist regarding ZIKV infections and its long-term effects in neonates. In addition, further studies need to evaluate if genomic differences that have occurred from the African to the Asian lineage of the virus have led to increased virulence of the virus. The authors believe that all pregnant women with fetuses showing microcephaly and/or intracranial calcifications should be tested for ZIKV infection if they cannot recall their sexual partner travel history. This change from the current CDCs recommendations could increase substantially the number of pregnant women and neonates, screened for ZIKV.

Pediatric tuberculosis: the litmus test for tuberculosis control.

Background: The epidemiology of pediatric tuberculosis (TB) from 1995 to 2000 in Harris County, TX, has been previously reported. This study was conducted to evaluate the continued trends of Mycobacterium tuberculosis clustering and the role of genotyping in pediatric TB. Methods: Data came from the Houston Tuberculosis Initiative, a prospective population-based active surveillance and molecular epidemiology project. The study population consisted of TB patients ⩽18 years of age diagnosed in Harris County, TX, from 2000 to 2004. Available Mycobacterium tuberculosis isolates were characterized by insertion sequence 6110 restriction fragment length polymorphism and spoligotyping. Results: One hundred three pediatric TB cases were enrolled in the Houston Tuberculosis Initiative study from 2000 to 2004. Sixty-one (59%) patients had potential source cases. Mycobacterium tuberculosis isolates were available and genotyped for 36 pediatric cases; 27 (75%) were clustered into 22 different genotypes. Of the 20 genotyped patients with a potential source case, 16 (80%) were clustered. Genotypes matched the potential source case in 12 cases. Eleven of the 16 (69%) genotyped patients without a potential source case were clustered. Conclusions: Compared with pediatric cases between 1995 and 2000, there was a significant increase in the number of patients with unknown potential source cases that were clustered within the Houston Tuberculosis Initiative database. Because genotypic clustering is associated with recent transmission, there appears to be a failure in the identification of potential source cases through contact tracing. Reduced funding of public health departments forces more limited TB control activities and therefore could pose a threat to TB control.

Diagnosis and management of TB in children: an update.

In recent years, several notable modifications have occurred in the management of TB infection and disease in children. First, we review new data related to infection, including alternative regimens for the treatment of latent TB, management of drug-resistant infection and preventive therapy in the context of HIV infection. Next, we summarize updated WHO guidelines for the treatment of TB in children, explore issues specific to the management of disease in HIV-infected children, and retreatment of TB, and review pediatric recommendations for the management of drug-resistant TB. Finally, we conclude with a discussion of adjunctive therapy and new drugs in development.

Newly Recognized Pediatric Cases of Typhus Group Rickettsiosis, Houston, Texas, USA

An increase in typhus group rickettsiosis and an expanding geographic range occurred in Texas, USA, over a decade. Because this illness commonly affects children, we retrospectively examined medical records from 2008–2016 at a large Houston-area pediatric hospital and identified 36 cases. The earliest known cases were diagnosed in 2011.

Complications of Sinusitis

Complications of sinusitis arise mostly as a result of the sinuses being separated from key organ structures only by relatively thin pieces of bone. As a result, there is always the potential for the disease to spread from the sinuses into the orbital space, and intracranially.

Antibiotic Treatment for Febrile Urinary Tract Infection: The Clock Is Ticking

In this issue of JAMA Pediatrics, Shaikh et al1 report that early antibiotic treatment was associated with decreased risk of renal scarring in children with a first or second febrile urinary tract infection (UTI). The authors found that in children with renal scarring, the median duration of fever prior to starting antibiotics was 72 hours vs 48 hours in those without scarring. Delay in treatment remained significantly associated with scarring even after adjusting for confounders such as age, race/ethnicity, and interim UTIs. These findings complement several published studies2-4 that stress the importance of timely antibiotic administration for UTI. So who were the patients included in this study, and what do the findings mean for physicians evaluating children for UTI? The investigators included 482 children aged 2 months to 72 months with an established UTI from 2 large longitudinal studies: the Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation studies.5,6 At the time of enrollment, parents were asked about the duration of their child’s fever prior to the initiation of antimicrobial therapy. Children had a technetium Tc 99m dimercaptosuccinic acid renal scan at baseline and either at a 12to 24-month follow-up visit or 2 to 3 months after recurrence of UTI in those who withdrew from the study. Although a mean of 2 months elapsed between UTI and parental query about duration of fever prior to treatment, this information was gathered prior to determining the dimercaptosuccinic acid scan outcome results, so imprecision in data would likely be similar between groups with and without scarring. The overall incidence of renal scarring in the study was low (7%), but the authors provide compelling data to suggest that a delay in antibiotic therapy is associated with increased risk. The severity of scarring, as measured by the number of renal segments involved, was not associated with duration of fever, and long-term sequelae of minimal scarring were not assessed. Although not a focus of their investigation, a critical issue for clinicians is determining the probability of whether a patient has a UTI in the first place. The American Academy of Pediatrics recommends diagnostic testing for UTI in febrile infants and young children who warrant immediate antimicrobial therapy.7 If the health care professional judges that based on clinical features and risk factors a UTI is possible, then urine should be assessed. If urinalysis is concerning for UTI, antibiotics should be prescribed and modified according to culture results. Furthermore, clinicians must be aware of local susceptibility patterns, especially with regard to the most common pathogen, Escherichia coli, to prescribe the appropriate empirical treatment. While this study provides further evidence for timely treatment of suspected UTI, the reality is that practitioners will continue to be challenged by the need to discern which patients are at risk and who warrants testing. So, who is at risk? In older children, UTI often presents with fever, dysuria, urinary frequency, incontinence, and abdominal or flank pain, so earlier recognition of disease may be possible. Additional risk factors include bowel and bladder dysfunction, vesicoureteral reflux, and a history of UTI. In younger children, symptoms may be nonspecific, and fever can be the only presenting sign. In white female infants younger than 2 years and uncircumcised male infants younger than 3 months, UTI can be the source of fever in nearly 20% of patients, suggesting that evaluation should always occur promptly in these patients.8,9 A meta-analysis found that fever greater than 39°C and lasting more than 24 hours was of some help in identifying children younger than 2 years with UTI.10 Additionally, clinical prediction rules commonly use duration of fever as a risk factor for UTI.7,11,12 However, clinical prediction rules that include duration of fever seem at odds with the need to provide timely treatment. The authors found that approximately 5%, 8%, and 14% of children with fever duration of 1 to 2 days, 2 to 3 days, and greater than 3 days prior to initiating antibiotic therapy, respectively, developed renal scarring. In a prediction rule for febrile infant girls, fever for 2 days or more was a risk factor for UTI along with white race, age younger than 12 months, temperature of at least 39°C, and absence of another source of infection.12 In the context of the Shaikh et al study,1 these findings suggest that using duration of fever as a criterion for assessing risk of UTI could result in an increased probability of renal scarring. Whether duration of fever is an appropriate risk factor criterion warrants further discussion, and current guidelines and algorithms indicate that many febrile children can meet the criteria for evaluation before having 48 hours of fever.7,10 The findings of the Shaikh et al study1 have implications for clinicians providing guidance to caregivers of children with possible or confirmed UTI. As stressed in the American Academy of Pediatrics Guidelines and by the authors, caregivers of children with a history of UTI or significant risk factors should receive anticipatory guidance related to the importance of timely evaluation of a febrile illness. The reality is that children do not always present on the first or even second day of fever for evaluation. In fact, the investigators reported that Related article Opinion