M. Le Bourgeois

Value of bronchoalveolar lavage in the management of severe acute pneumonia and interstitial pneumonitis in the immunocompromised child.

The diagnostic value of 73 bronchoalveolar lavages was assessed in 67 immunocompromised children (aged 3 months to 16 years) with pulmonary infiltrates. Thirty one children had primary and 19 secondary immune deficiency, 14 acquired immunodeficiency syndrome (AIDS), and three AIDS related complex. Bronchoalveolar lavage was performed during fibreoptic bronchoscopy, under local anaesthesia in all but two. One or more infective agents was found in eight of 11 patients with severe acute pneumonia and in 26 of 62 patients with interstitial pneumonitis. In interstitial pneumonitis, the most frequently encountered agents were Pneumocystis carinii (12), cytomegalovirus (8), and Aspergillus fumigatus (3). The yield was related to the severity of interstitial pneumonitis. The mean cellular count and cytological profile in lavage returns from patients with varying infective agents or underlying pathological conditions showed no significant difference, except in those children with AIDS and AIDS related complex who had appreciable lymphocytosis (mean percentage of lymphocytes 28 (SD 17]. In children with AIDS and chronic interstitial pneumonitis lymphocytosis without pneumocystis infection was observed in eight of nine bronchoalveolar lavage returns and was suggestive of pulmonary lymphoid hyperplasia. Finally, bronchoalveolar lavage produced a specific diagnosis from the microbiological or cytological findings in 44 instances (60%). Transient exacerbation of tachypnoea was observed in the most severely ill children but there was no case of respiratory decompensation attributable to the bronchoscopy. Bronchoalveolar lavage is a safe and rapid examination for the investigation of pulmonary infiltrates in immunocompromised children. It should be performed as a first line investigation and should reduce the use of open lung biopsy techniques.

Lung clearance index: Evidence for use in clinical trials in cystic fibrosis

The ECFS-CTN Standardisation Committee has undertaken this review of lung clearance index as part of the groups work on evaluation of clinical endpoints with regard to their use in multicentre clinical trials in CF. The aims were 1) to review the literature on reliability, validity and responsiveness of LCI in patients with CF, 2) to gain consensus of the group on feasibility of LCI and 3) to gain consensus on answers to key questions regarding the promotion of LCI to surrogate endpoint status. It was concluded that LCI has an attractive feasibility and clinimetric properties profile and is particularly indicated for multicentre trials in young children with CF and patients with early or mild CF lung disease. This is the first article to collate the literature in this manner and support the use of LCI in clinical trials in CF.

Bronchoalveolar lavage in HIV infected patients with interstitial pneumonitis.

The value of taking microbiological and cytological specimens by flexible bronchoscopy and bronchoalveolar lavage under local anaesthesia was assessed on 43 occasions in 35 HIV infected children, aged 3 months to 16 years, with interstitial pneumonitis. In acute interstitial pneumonitis (n = 22, 26 specimens from bronchoalveolar lavages) the microbiological yield was 73%, Pneumocystis carinii being the commonest infective agent (n = 14). P carinii pneumonia was found only in children with deficient antigen induced lymphocyte proliferative responses who had not been treated with long term prophylactic co-trimoxazole. In contrast, in 13 children with chronic interstitial pneumonitis that was consistent with a diagnosis of pulmonary lymphoid hyperplasia who underwent bronchoalveolar lavage on 17 occasions, there were two isolates of cytomegalovirus and one of adenovirus, but P carinii was not found. Ten of the 13 children had normal antigen induced lymphocyte proliferative responses. Useful cytological data were also gleaned from bronchoalveolar lavage specimens. Lymphocytosis was significantly higher in pulmonary lymphoid hyperplasia (36(SD 11)%) than in P carinii pneumonia (24(19)%) whereas the percentage of polymorphonuclear neutrophils was significantly lower (3(2)% compared with 12(13)%). Flexible bronchoscopy with bronchoalveolar lavage is safe even in young infants and should reduce the necessity for open lung biopsy in the management of HIV infected children with interstitial pneumonitis.

Multicentre trial evaluating alveolar NO fraction as a marker of asthma control and severity.

To cite this article: Mahut B, Trinquart L, Le Bourgeois M, Becquemin M‐H, Beydon N, Aubourg F, Jala M, Bidaud‐Chevalier B, Dinh‐Xuan A‐T, Randrianarivelo O, Denjean A, de Blic J, Delclaux C. Multicentre trial evaluating alveolar NO fraction as a marker of asthma control and severity. Allergy 2010; 65: 636–644.

Hypersensitivity reactions to paracetamol in children: a study of 25 cases

Background:  Allergic‐like reactions to paracetamol (acetaminophen) are rare. Paracetamol allergic and nonallergic hypersensitivity (HS) has been diagnosed in a few patients with skin and/or respiratory symptoms, immediate and accelerated urticaria, and angioedema especially. Most patients with HS to paracetamol were also hypersensitive to anti‐inflammatory drugs (i.e. acetylsalicylic acid, ASA), suggesting that their reactions resulted from a nonallergic HS. However, anaphylactic reactions, and potentially harmful toxidermias, such as acute generalized exanthematic pustulosis and toxic epidermal necrolysis, have been related to specific paracetamol allergic HS, with tolerance to anti‐inflammatory drugs.

The role of inflammation in childhood asthma

The role of inflammation in adult asthma is well known, involving a cascade of immunological stimulation in which mast cells and eosinophils play pivotal roles. However, the assessment of airway inflammation in children is more difficult as the invasive methods used in adults cannot ethically be used for this purpose alone. Nevertheless, limited data from studies using invasive methodology, and studies using novel non-invasive techniques such as sputum induction and nitrous oxide exhalation, are improving knowledge. The immunopathology in childhood asthma appears to mirror that in adult sufferers. The inflammatory processes are evident at an early age in wheezing infants who later develop asthma, and there are different “wheezing phenotypes” in children with atopic asthma or viral associated wheeze. The mechanisms underlying childhood asthma are dependent not only on increased numbers of inflammatory cells in the airways, but also increased activation of these cells. In vitro data have shown that corticosteroids can inhibit the secretion of proinflammatory compounds from alveolar macrophages, suggesting a potential important role for these agents in halting the development of asthma. Techniques for measuring inflammation in infants need to be refined, in order to provide increased knowledge and accurate monitoring of the disease. It is hoped that this will enable the development of early interventions to minimise the impact of asthma in infants who are identified as being susceptible.

Correlation between activity of beta-lactam agents in vitro and bacteriological outcome in acute pulmonary exacerbations of cystic fibrosis

A study was conducted to determine whether a direct relationship exists between β-lactam and/or aminoglycoside activity measured in vitro and bacteriological outcome in acute pulmonary exacerbations of cystic fibrosis. Twenty-seven patients, aged between 6 months and 24 years (mean age 10 1/2 years), were included in the study and received 41 i.v. courses of a β-lactam agent combined with an aminoglycoside. A total of 63Pseudomonas aeruginosa strains were found in sputum taken on admission at densities exceeding 106 cfu/g of sputum. For each episode, the serum inhibitory quotient (SIQ) and the serum bactericidal quotient (SBQ) of the β-lactam agent and of the aminoglycoside administered were determined for thePseudomonas aeruginosa isolate(s). The SIQs and SBQs were calculated by dividing the average peak serum levels achievable in the patients by the minimal inhibitory concentrations and minimal bactericidal concentrations, respectively. The SIQs and SBQs were compared to bacteriological outcome. Bacteriological success was defined as a decrease of 2 log10 counts or more in thePseudomonas aeruginosa density in sputum between days 0 and 7 of therapy. The SIQ and SBQ of β-lactam agents were good predictors of bacteriological outcome: SIQs of < 1:16 were 100 % predictive of failure (χ2 28; p<0.001) and of ≥ 1:64 were 92.9 % predictive of success (χ2 35.68; p<0.001); SBQs of < 1:8 were 100 % predictive of failure (χ2 42.78; p<0.001) and of ≥ 1:32 were 95.8 % predictive of success (χ2 31.5; p<0.001). Aminoglycoside SIQs and SBQs were not predictive of outcome.

Infections fongiques au cours de la mucoviscidose

Resume Au cours de la mucoviscidose, la colonisation fongique est frequente et dominee par Aspergillus fumigatus ( A. fumigatus ). Des analyses mycologiques sur milieux selectifs ont mis en evidence d’autres especes filamenteuses Scedosporium, Geosmithia argillacea . Des etudes prospectives sont necessaires pour apprecier leur prevalence et leur caractere pathogene. A. fumigatus est le plus souvent responsable d’une aspergillose broncho-pulmonaire allergique (ABPA). L’infection invasive est exceptionnelle dans ce contexte. Un diagnostic precoce d’ABPA est important pour eviter la deterioration bronchique cependant, il est difficile malgre des recommandations internationales. De nouveaux marqueurs biologiques plus specifiques sont en cours d’evaluation. Le traitement repose sur la corticotherapie orale dont les effets indesirables sont plus frequents au cours de la mucoviscidose. L’association a des antifongiques permet une epargne corticoide. De nouvelles strategies therapeutiques sont en cours d’etude en cas de cortico-dependance ou en cas de resistance fongique.

Allergie au latex chez les enfants asthmatiques

Resume Les enfants multi-operes et les atopiques constituent les groupes a risque d’allergie au latex. Rien ne permet d’etablir une relation entre l’asthme et l’allergie au latex. L’objectif de notre travail a ete de comparer les caracteristiques cliniques, biologiques et fonctionnelles des enfants asthmatiques allergiques au latex et non allergiques au latex. Patients et methodes. – Deux groupes d’enfants asthmatiques allergiques et non allergiques au latex ont ete compares vis-a-vis des antecedents personnels et familiaux, des sensibilisations et de la fonction respiratoire en consultation d’allergologie a l’hopital Necker–Enfants-malades. Resultats. – Cent soixante-sept enfants asthmatiques non allergiques au latex ont ete compares a 15 asthmatiques allergiques au latex. Nous avons trouve une association forte entre l’allergie au latex et la polysensibilisation (OR = 40,3 ; IC 95 % 5,1–316,1), les antecedents maternels d’eczema (OR = 4,7 ; IC 95 % 1,3–16,4), les antecedents personnels de chirurgie (OR = 14,8 ; IC 95 % 3,9–56,1), d’eczema (OR = 12,2 ; IC 95 % 3,9–45,7), de conjonctivite (OR = 20,0 ; IC 95 % 5,6–70,9), d’urticaire (OR = 11,4 ; IC 95 % 3,0–42,5), de rhinite (OR = 3,3 ; IC 95 % 1,1–10,4), l’augmentation des IgE totales et l’âge relativement plus eleve des enfants ( p Conclusion. – Ces resultats suggerent que l’atopie familiale soit un facteur predisposant a la survenue d’une allergie au latex chez l’enfant asthmatique. Le role des hospitalisations repetees et/ou des interventions chirurgicales est important. L’allergie au latex n’est pas un facteur aggravant de l’asthme. L’eviction du latex est la seule mesure efficace.

Atteinte respiratoire de la mucoviscidose de l’enfance à l’âge adulte

The respiratory disease of cystic fibrosis, which is secondary to bronchial inflammation and infection, appears from the youngest age and its evolution is made of exacerbations due to acute respiratory infections. In adulthood, complications such as hemoptysis and pneumothorax are more frequent and respiratory insufficiency is more severe, conditioning prognosis. Care is mainly based on physiotherapy and adapted antibiotics.