Maria João Brito

High prevalence of ST121 in community-associated methicillin-susceptible Staphylococcus aureus lineages responsible for skin and soft tissue infections in Portuguese children.

In order to evaluate the incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Portugal, we analyzed a collection of 38 S. aureus isolates recovered from 30 children attending the pediatric emergency department of a central hospital in Lisbon due to skin and soft tissue infections. Molecular characterization identified seven clonal lineages among the 35 methicillin-susceptible S. aureus (MSSA) isolates, of which the major lineage PFGE A/t159/ST121 included 63% of the isolates. The three MRSA isolates belonged to the Pediatric clone PFGE D/t535/ST5-IV (nu2009=u20092) and to the European CA-MRSA clone PFGE G/t044/ST80-IVc (nu2009=u20091). All isolates harbored several virulence factors, namely, leukocidins. Panton–Valentine leukocidin (PVL) was produced by isolates from five MSSA lineages and by the ST80 MRSA. Of interest, this is the first reported isolation of CA-MRSA ST80 in Portugal.

Staphylococcus aureus Reservoirs and Transmission Routes in a Portuguese Neonatal Intensive Care Unit: A 30-Month Surveillance Study

Although Staphylococcus aureus is a major cause of outbreaks in neonatal intensive care units (NICUs), there are no studies on the epidemiology of S. aureus isolates responsible for infection in Portuguese NICUs. Between July 2005 and December 2007, a total of 54 methicillin susceptible S. aureus (MSSA) isolates were recovered from 16 infected infants, parents, health care workers (HCWs), and the environment in a level III NICU. Isolates were characterized by pulsed-field gel electrophoresis (PFGE), spa typing, and multilocus sequence typing. Virulence determinants were detected by multiplex polymerase chain reaction. Three major MSSA clones were endemic in the NICU, representing 70% (n=38) of the isolates: PFGE type A-ST5 (n=17); type B-ST30 (n=12); and type C-ST1 (n=9). Leukotoxins and hemolysins were present in all isolates, although none of them carried PVL. HCWs, plastic folders protecting clinical files, and mothers nipples were identified as potential reservoirs and/or vehicles of dissemination of S. aureus. Consequently, additional infection control measures were implemented in this NICU.

Anti-N-methyl-D-aspartate receptor encephalitis with positive serum antithyroid antibodies, IgM antibodies against mycoplasma pneumoniae and human herpesvirus 7 PCR in the CSF.

We report the case of a boy with an encephalopathy associated with extrapyramidal and psychiatric symptoms and anti-N-methyl-D-aspartate receptor antibodies. He had positive serum antithyroid antibodies, IgM antibodies against Mycoplasma pneumoniae and human herpesvirus 7 polymerase chain reaction in the cerebrospinal fluid. He was successfully treated with rituximab, after steroids, intravenous immunoglobulin and plasma exchange. The pathophysiology of this disorder may be post-infectious and autoimmune.

Twelve Years of Kawasaki Disease in Portugal: Epidemiology in Hospitalized Children

Background: Kawasaki disease (KD) is the leading cause of acquired heart disease in developed countries. Reported incidences vary worldwide but incidence of KD has not been established in Portugal. Aim: The aims of the study were to describe the epidemiologic characteristics and estimate incidence rates of KD among hospitalized children in Portugal. Methods: This study was a descriptive, population-based study, which used hospital discharge records of patients <20 years of age diagnosed with KD from the Hospital Register database for 2000–2011. Incidence rates were calculated using the number of KD patients and corresponding National census data. Results: There were 533 hospitalizations of 470 patients with KD as the primary diagnosis in Portugal, 63 hospitalizations were transfers of patients between hospitals and there were no relapses. The mean age at admission was 2.8 years, with male predominance (male-to-female ratio: 1.6:1). Children <5 years and infants <1 year represented 83% and 23% of all the patients admitted, respectively. Mean annual incidence was 6.5 per 100,000 children <5 years, 4.5 per 100,000 infants <1 year and 7.8 per 100,000 infants 1–4 years. We found considerable differences between national territorial regions, with majority of cases in most dense regions. The mean length of hospital stay was 9 days, and the incidence peaked in spring (35%) and spring/winter (63%). Coronary aneurysms were reported in 8.5% of patients with a higher male-to-female ratio (3.4:1) and a lower mean age (1.93 years). Reported mortality was 0.4%. Conclusions: This is the first large-scale epidemiologic study of KD in Portugal. The highest incidences occurred among male children 1–4 years of age and in spring/winter.

Severe megaloblastic anaemia in an infant

Vitamin B12 or cobalamin deficiency, a rare clinical entity in pediatric age, is found most exclusively in breastfed infants, whose mothers are strictly vegetarian non-supplemented or with pernicious anaemia. In this article, the authors describe a 10-month-old infant admitted for vomiting, refusal to eat and prostration. The infant was exclusively breastfed and difficulties in introduction of new foods were reported. Failure to thrive since 5 months of age was also noticed. Laboratory evaluation revealed severe normocytic normochromic anaemia and cobalamin deficit. A diagnosis of α-thalassemia trait was also made. Maternal investigation showed autoimmune pernicious anaemia. This case shows the severity of vitamin B12 deficiency and the importance of adopting adequate and precocious measures in order to prevent potentially irreversible neurologic damage.

Acute mastoiditis in children: Middle ear cultures may help in reducing use of broad spectrum antibiotics

BACKGROUNDnAcute mastoiditis (AM) is a suppurative infection of the mastoid air cells, representing the most frequent complication of acute otitis media. AM remains an important entity in children due to its potential complications and sequelae. We aim to describe the cases of AM admitted at our department, identify risk factors potentially associated with complications and analyse the changes in clinical approach of AM over time.nnnMETHODSnCase review of clinical files of children admitted with acute mastoiditis from June 1996 to May 2013 at a Lisbon metropolitan area hospital. Data was divided into two groups (prior and after May 2005) in order to evaluate changes in AM approach over the years.nnnRESULTSn135 AM episodes were included. The median age was 3.8 years and 42% children were less than 24 months of age. Symptoms at presentation included fever (69%), ear pain (56%) and otorrhea (40%). Complications occurred in 22% patients and were more common in children under 24 months (33% vs 15%, pxa0≤xa00.01). Leukocyte count was significantly higher in children with complications (16.7 vs 14.5xa0×xa0109/μL, pxa0≤xa00.05) as was C-Reactive Protein value (13 vs 6.3xa0mg/dL, pxa0≤xa00.001). There was a significant association between the development of complications and C-Reactive Protein value at admission (OR 1.892; IC95%: 1.018-2.493, pxa0≤xa00.01). The optimal cut-off value was 7.21xa0mg/dL. Over time there was a significant increase in middle ear cultures obtained by tympanocentesis during surgery (2% vs 16%, pxa0≤xa00,01) and also a decrease in the use of broad spectrum antibiotherapy as initial treatment (52% vs 25%,pxa0≤xa00,001).nnnCONCLUSIONSnChildren under 24 months, with high leukocyte count or with high C-Reactive Protein value should be monitored closely since complications tend to be more frequent. A CRP value of 7.21xa0mg/dL at admission seems to be a good cut-off to monitor children for potential complications. Throughout the period analysed more cultures were performed allowing identification of the pathogens and implementation of appropriate antibiotic therapy.

Treatment of multidrug-resistant and extensively drug-resistant tuberculosis in adolescent patients

The authors describe 2 pediatric patients with drug-resistant tuberculosis in whom new diagnostic and therapeutic approaches were crucial to good clinical evolution. Although there was good clinical outcome, important side effects with linezolid and amikacin occurred, namely medullary hypoplasia and neurosensorial hypoacusia, respectively. A multidisciplinary approach with close follow up was of major importance in managing these patients.

Rhinoscleroma in a 5-year-old Portuguese Child.

Rhinoscleroma is a chronic granulomatous infectious disease that is rare in Western Europe. We report the case of a 5-year-old Portuguese boy diagnosed with rhinoscleroma in the context of recurrent epistaxis. He had a 6-month course of antibiotic (amoxicillin plus clavulanate) therapy with full recovery.

Bilateral facial palsy: a form of neuroborreliosis presentation in paediatric age

Bilateral facial palsy (BFP) is a very uncommon entity, particularly in the paediatric age group. Despite its several aetiologies, neuroborreliosis should be suspected, especially in children from endemic areas presenting with acute neurological disease of unknown cause. We present two cases of BFPs as the presenting forms of neuroborreliosis.

Pseudotumor cerebri as the presentation of Lyme disease in a non-endemic area

Intracranial hypertension is a rare entity in prepubertal children, and its differential diagnosis includes a number of systemic diseases, drugs, vitamin deficiencies and excesses, and hereditary conditions. Infectious aetiology is rare. The case of a 9-year-old boy with intracranial hypertension secondary to acute neuroborreliosis is described. He presented with daily pulsatile frontotemporal headache, pallor, photophobia and phonophobia. His neurological examination revealed papilledema with no nuchal rigidity. The lumbar puncture showed increased pressure (50u2009cm H2O) and lymphocytic pleocytosis. Serum and cerebrospinal fluid (CSF) Borrelia burgdorferi antibodies were positive. This kind of infection is rare in Portugal but a trip to an endemic area was identified. A careful history, considering the exposure to rural areas together with the intracranial hypertension and inflammatory CSF, are important clues to the diagnosis, allowing the institution to select appropriate treatment.