Maria de Fátima B. Pombo March

Penicillin resistant pneumococcus and risk of treatment failure in pneumonia

Objective: To determine whether the presence of in vitro penicillin-resistant Streptococcus pneumoniae increases the risk of clinical failure in children hospitalised with severe pneumonia and treated with penicillin/ampicillin. Design: Multicentre, prospective, observational study. Setting: 12 tertiary-care centres in three countries in Latin America. Patients: 240 children aged 3–59 months, hospitalised with severe pneumonia and known in vitro susceptibility of S pneumoniae. Intervention: Patients were treated with intravenous penicillin/ampicillin after collection of blood and, when possible, pleural fluid for culture. The minimal inhibitory concentration (MIC) test was used to determine penicillin susceptibility of the pneumococcal strains isolated. Children were continuously monitored until discharge. Main outcome measures: The primary outcome was treatment failure (using clinical criteria). Results: Overall treatment failure was 21%. After allowing for different potential confounders, there was no evidence of association between treatment failure and in vitro resistance of S pneumoniae to penicillin according to the Clinical Laboratory Standards Institute (CLSI)/National Committee for Clinical Laboratory Standards (NCCLS) interpretative standards (adjRR = 1.03; 95%CI: 0.49–1.90 for resistant S pneumoniae). Conclusions: Intravenous penicillin/ampicillin remains the drug of choice for treating penicillin-resistant pneumococcal pneumonia in areas where the MIC does not exceed 2 μg/ml.

A retrospective evaluation of a score system adopted by the Ministry of Health, Brazil in the diagnosis of pulmonary tuberculosis in childhood: a case control study

Based on a retrospective case-control study we evaluated the score system adopted by the Ministry of Health of Brazil (Ministério da Saúde - MS), to diagnose pulmonary tuberculosis (PTB) in childhood. This system is independent of bacteriological or histopathological data to define a very likely (> or = 40 points), possible (30-35 points) or unlikely (< or = 25 points) diagnosis of tuberculosis. Records of hospitalized non-infected HIV children at the Instituto de Puericultura e Pediatria Martagão Gesteira of Federal University of Rio de Janeiro (IPPMG-UFRJ), were reviewed. Patients were adjusted for age and divided in two different groups: 45 subjects in the case group (culture-positive) [mean of age = 10.64 mo; SD 9.66]; and 96 in the control group (culture-negative and clinic criteria that dismissed the disease) [mean of age = 11.79 mo.; SD 11.31]. Among the variables analyzed, the radiological status had the greater impact into the diagnosis (OR = 25.39), followed by exposure to adult with tuberculosis (OR = 10.67), tuberculin skin test >10mm (OR = 8.23). The best cut-off point to the diagnosis of PTB was 30 points, where the score system was more accurate, with sensitivity of 88.9% and specificity of 86.5%.

Characteristics of children hospitalized with dengue fever in an outbreak in Rio de Janeiro, Brazil

During a dengue epidemic in Rio de Janeiro in 2007-2008 the Instituto de Puericultura e Pediatria Martagão Gesteira Hospital was a reference for admitted children. The World Health Organization (WHO) considered several manifestations as warning signs of severe dengue This is a retrospective cohort study of all children admitted with dengue fever. Clinical variables considered warning signs by WHO were evaluated in the multivariate analysis, to investigate if they were independently associated with severe dengue. One hundred and eighty one children were admitted, aged from 4 months to 15 years; 30 were classified as severe dengue. Abdominal pain (OR=2.63, 95% CI 1.06-6.53) and lethargy (OR=3.40, 95% CI 1.45-7.99) were independently associated with severe dengue.

Quality of life in children and teenagers with atopic dermatitis

FUNDAMENTOS: A dermatite atopica e uma doenca cuja prevalencia vem aumentando nos ultimos anos apesar do conhecimento crescente sobre a mesma. OBJETIVO: Avaliar a qualidade de vida das criancas e adolescentes com dermatite atopica e de suas familias. METODO: Estudo transversal descritivo com coleta prospectiva de dados de 50 criancas e adolescentes de 5 a 16 anos, com diagnostico de DA e 50 pais ou responsaveis dos mesmos atraves da utilizacao de dois questionarios de qualidade de vida, o Qualidade de Vida na Dermatologia Infantil e o Impacto da Dermatite Atopica na Familia. As variaveis socio-demograficas e clinicas foram avaliadas por uma ficha clinica elaborada especificamente para a pesquisa, os aspectos socioeconomicos, pelo questionario padronizado da Associacao Brasileira de Empresas de Pesquisa, que avalia bens adquiridos e o grau de instrucao do chefe da familia. RESULTADOS: Havia 35/50 (70%) pacientes do sexo feminino; 28(56%) da classe social C. Atraves do questionario Qualidade de Vida na Dermatologia Infantil observou-se que: 19 (38%) pacientes ficaram na faixa de 7 a 12 pontos (impacto moderado da dermatite atopica) e 17 (34%), na faixa de 13 a 30 pontos (impacto elevado da dermatite atopica). Pelo questionario Impacto da Dermatite Atopica na Familia observou-se: 15 (30%) familias apresentaram escores entre 7 e 12 pontos e 22 (44%) entre 13 e 30 pontos. CONCLUSAO: Os resultados mostram que a repercussao da doenca na vida dos pacientes com dermatite atopica e de suas familias e alta, o que nos faz sugerir que seria importante inserir o estudo da qualidade de vida na avaliacao clinica dos mesmos.BACKGROUND Atopic Dermatitis is a disease which has increased during the past years despite our improved understanding of it. OBJECTIVE To assess the impact of Atopic Dermatitis in the quality of life of children and teenagers and their family. METHOD A descriptive cross-sectional method with prospective data collection of 50 children and teenagers diagnosed with Atopic Dermatitis ranging in age from 5-16 years. Fifty parents and/or guardians answered the quality of life questionnaires The Childrens Dermatology Life Quality Index and Family Dermatitis Impact Questionnaire. The socio-demographic and clinical variables were evaluated by a clinical record chart designed specifically for the research and socioeconomic standardized questionnaire by the Brazilian Association of Research Enterprises, which evaluates assets acquired and the educational level of the head of the household. RESULTS Thirty-five out of the 50 patients were female (70%), and 28 (56%) of them were from social class C. The Questionnaire Childrens Dermatology Life Quality Index showed that 19 (38%) patients ranged from 7 to 12 points (moderate impact of atopic dermatitis) and 17 patients (34%) ranged from 13 to 30 points (high impact of atopic dermatitis). The Family Dermatitis Impact Questionnaire revealed that 15 (30%) families had scores between 7 and 12 points and 22 families (44%) scored between 13 and 30 points. CONCLUSION The results show that there is a very high impact on the QoL for atopic dermatitis patients and their families. This makes us suggest the importance of including the quality of life study in clinical evaluations.

Efficacy of the scoring system, recommended by the Brazilian National Ministry of Health, for the diagnosis of pulmonary tuberculosis in children and adolescents, regardless of their HIV status

OBJECTIVE To determine the efficacy of the scoring system, recommended by the Brazilian National Ministry of Health (NMH), for the diagnosis of pulmonary tuberculosis (TB) in children and adolescents, regardless of their HIV status. METHODS This was a cross-sectional analytical study carried out between January of 2002 and December of 2006, involving 239 individuals less than 15 years of age. The patients were divided into four groups: latent TB (LTB group; n = 81); no-TB (NTB group; n = 41); TB group (n = 104); and TB/HIV group (n = 13). We studied the clinical, radiological and laboratory findings according to the scoring system. RESULTS Reports of fever, cough, asthenia and weight loss for at least two weeks were significantly higher in the TB group (p < 0.0001). The proportion of cases with a history of any contact and household contact with a TB patient was, respectively, 95.0% and 86.1% in the TB group, versus 75.0% and 58.3% in the TB/HIV group. In the TB and TB/HIV groups, respectively, chest X-rays revealed parenchymal alterations in 75.0% and 53.9%, revealing combined parenchymal/lymph node alterations in 18.2% and 30.8%. There were no significant differences among the groups regarding the tuberculin skin test results. In the TB group, 16.3% of the patients were malnourished (p < 0.005 vs. the LTB group). The mean NMH system scores in the LTB, NTB, TB and TB/HIV groups were, respectively, 24.2, 18.5, 45.3 and 41.5. CONCLUSIONS The NMH system scores were significantly higher in the TB and TB/HIV groups than in the other two groups. Therefore, this scoring system was valid for the diagnosis of pulmonary TB in this population, regardless of HIV status.

Signs and symptoms indicative of community-acquired pneumonia in infants under six months

OBJECTIVE Evaluation of the clinical signs and symptoms predicting bacterial and viral pneumonia, in accordance with the Brazilian National Control Program for Acute Respiratory (ARI). METHODS Observational prospective study. Seventy-six children from birth to six months of age who had pneumonia were studied in the emergency room. The patients were subdivided into two groups, based on radiological findings (gold-standard): 47 had bacterial pneumonia, and 29 had viral pneumonia. The frequencies, sensitivities, and specificities of the signs and symptoms were evaluated. RESULTS The sensibilities and sensitivities of general findings in bacterial pneumonia were, respectively: fever 53.2%/40.0%; hypoactivity 68.4%/55.6% and prostration detected by the doctor 72.7%/55.0%. The same findings in viral pneumonias showed, respectively: 37.9%/40.0%, 66.7%/55.6% and 66.7%/55.6%. The sensibilities and sensitivities of respiratory findings in bacterial pneumonia were, respectively: coughing 66.0/38.1%, Respiratory rate = 50 ripm 76.6%/38.1%, altered respiratory auscultation 91.3%/10.5%, and chest indrawing 46.7%/80.0%. The same findings in viral pneumonias were, respectively: 69.0%/38.1%, 86.2%/38.1%, 85.7%/10.5% and 44.8%/80.0%. CONCLUSION Analysis of signs and symptoms in each group did not distinguish bacterial from viral pneumonia. Our findings reinforce the adequacy of the ARI program in Brazil, which gives an early diagnosis of pneumonia, independent of its etiology.

Idiopathic pulmonary hemosiderosis treated with azathioprine in a child

Idiopathic pulmonary hemosiderosis (IPH), the main cause of pulmonary hemosiderosis in children, is characterized by intermittent alveolar bleeding and hemosiderin-laden macrophages in sputum and in gastric lavage. The treatment is based on corticosteroids and cytotoxic drugs, under special conditions. We describe the case of a 7-year-old girl with IPH who achieved partial clinical remission with high doses of corticosteroids. However, the treatment had to be discontinued because the patient developed Cushings syndrome. Treatment was started with an azathioprine-corticosteroid combination and then changed to azathioprine alone, which was maintained for four years, with excellent results.

Radiologic findings of pulmonary tuberculosis in adolescents

OBJECTIVE To describe radiologic findings of pulmonary tuberculosis (TB) in adolescents. METHODS Retrospective, cross-sectional, observational study of 850 patients with TB, aged 10 to 19 years, and notified to the Brazilian Ministry of Health. Data were collected from the TB notification and medical records in the cities of Manaus, Amazonas State, and Salvador, Bahia State, in the 19962003 period. Data are shown in tables and analyzed using the chi-square and Mann-Whitney tests, with a 5% significance level. RESULTS Mean age was 15.6 years; 443 (52.1%) patients were males. The most common radiologic lesion was the upper pulmonary lobe infiltrate (53.3%), and isolated cavitation was found in 32.4% of the patients. Both lungs were affected in 29.2% of the patients. The finding of bilateral radiologic lesions was significantly associated with longer disease duration (p = 0.0005). CONCLUSIONS Pulmonary TB in adolescents has similar characteristics to TB in adults, evidencing the important role played by adolescents in community disease transmission.

Tracheobronchopathia osteochondroplastica in a 5-year-old girl

Tracheobronchopathia osteochondroplastica (TO) is considered an orphan disease with exceptional occurrence in children. We report a 5-year-old female child who was referred to us with chronic cough and recurrent pneumonia. After several investigations, bronchoscopy showed multiple nodules in the tracheobronchial lumen, whose distribution was consistent with TO. The patient was followed for four years, with no change in the pattern of the disease.

Preoperative pulmonary assessment of children for liver transplantation

Abstract:  Pulmonary assessment should be part of the preoperative investigation of pediatric patients with chronic liver disease undergoing liver transplantation, as it allows the identification of pulmonary alterations that influence candidacy for transplantation and survival. To describe pulmonary changes found in pediatric patients who were candidates for liver transplantation. Retrospective study of 17 pediatric liver transplant candidates undergoing preoperative pulmonary evaluation assessing pulmonary clinical data, arterial blood gas analysis, CXR, respiratory function test by spirometry, pulmonary scintigraphy, and CEE. Ten patients presented normal chest roentgenograms. The most common radiographic change was interstitial infiltrate in the lung bases. Of the five patients with PaO2 <70 mmHg, four had cyanosis and dyspnea and two were diagnosed with HPS with intrapulmonary shunt evidenced by contrast echocardiogram. Two patients presented with intrapulmonary shunt but without hypoxemia. Spirometry was normal in six patients, restrictive disturbance was evidenced in one patient, obstructive in three, and combined in two. The most common scintigraphic change was heterogeneous pulmonary perfusion. Pulmonary assessment should be performed routinely in pediatric patients prior to liver transplantation, even in asymptomatic patients. Pulmonary assessment may indicate changes such as HPS that can increase postoperative morbidity/mortality.