María José Mellado Peña

Genetic characterization of complex inter‐recombinant HIV‐1 strains circulating in Spain and reliability of distinct rapid subtyping tools

Genetic recombination and high rate of mutation increase HIV‐1 diversity, allowing viruses to escape more easily from the host immune response or antiretroviral drugs. The recombinant nature of full‐length HIV‐1 genomic sequences derived from viruses infecting five epidemiologically unlinked individuals carrying HIV‐1 non‐B variants was investigated. Overlapping PCR amplifications followed by direct sequencing of viral products derived from plasma and phylogenetic analyses were carried out. Four viral sequences clustered with CRF06_cpx and one with CRF02_AG. However, subtyping of separate genes within the same genome revealed that four were recombinant forms involving different subtypes and/or CRFs with distinct breakpoints. Two specimens included CRF02_AG and CRF06_cpx sequences with several fragments from other HIV‐1 clades along their genomes. Three rapid subtyping tools (Stanford, NCBI, and REGA) showed discrepant results when interpreting these viral sequences. This is the first description of CRF02_AG/CRF06_ cpx recombinants in Spain. The results highlight the tremendous heterogeneity of HIV‐1 recombinant strains currently in circulation. J. Med. Virol. 80:383–391, 2008.

Utilidad de la reacción en cadena de la polimerasa en el diagnóstico de las infecciones herpéticas del sistema nervioso

Objetivo Evaluar la rentabilidad de la reaccion en cadena de la polimerasa (PCR) en liquido cefalorraquideo (LCR) para el diagnostico de las infecciones del sistema nervioso producidas por los herpesvirus y estimar la incidencia de encefalitis por virus del herpes simple tipo 1 (VHS-1) en la poblacion adulta de la isla de Gran Canaria. MEtodos Se incluyeron 330 muestras de LCR de 312 pacientes (281 no infectados por el VIH y 31 infectados) remitidos con sospecha clinica inicial de encefalitis y/o meningitis o para estudio de neuropatias y enfermedades desmielinizantes. Se utilizo una tecnica de PCR que detecta los VHS-1 y VHS-2, virus de la varicela-zoster (VVZ), citomegalovirus humano, virus de Epstein-Barr (VEB) y herpesvirus humano tipo 6 (VHH-6). Se revisaron las historias clinicas de los pacientes para establecer el diagnostico definitivo. Resultados Nueve muestras de 8 pacientes (2,6%) presentaron un resultado positivo (9,7% de los pacientes con LCR patologico y ninguno con LCR normal). Los 8 pacientes presentaron hallazgos clinicos y analiticos de infeccion del sistema nervioso por herpesvirus: se detecto ADN de VHS-1 en 4 casos de encefalitis, ADN del VHS-2 en un paciente con meningitis, ADN de VVZ en 2 pacientes con meningitis y ADN de citomegalovirus en un paciente infectado por el VIH con encefalitis. Los herpesvirus fueron responsables del 50% de las encefalitis y del 10% de las meningitis. La incidencia de encefalitis herpetica por VHS-1 fue de 5 casos por millon de habitantes/ano. Conclusiones La deteccion de herpesvirus en LCR mediante PCR no es rentable si el LCR presenta parametros normales. La incidencia de encefalitis herpetica es mas elevada que en otros estudios (5 casos por millon de habitantes/ano).

Brote epidémico de meningitis por virus Echo serotipo 13 en la isla de Gran Canaria

Introduccion Desde la introduccion de la vacuna de la parotiditis, los enterovirus son la causa mas frecuente de meningitis viral en ninos. En Espana, los mas frecuentemente aislados son los virus Echo serotipo 30, 9, 6 y 4 Objetivos Describir las caracteristicas clinicoepidemiologicas de un brote de meningitis por virus Echo serotipo 13 Metodos Se detectaron 152 casos de meningitis por virus Echo serotipo 13 durante el ano 2000. Las muestras fueron sembradas en fibroblastos de pulmon de feto humano (MRC-5) y celulas de rabdomiosarcoma. Los virus se identificaron con anticuerpos monoclonales y se tipificaron por neutralizacion Resultados El aislamiento en liquido cefalorraquideo (LCR) del virus fue positivo en 131 de 152 (86,2%). En los 21 pacientes con cultivo de LCR negativo, el diagnostico se realizo por cultivo del frotis faringeo y/o heces. El efecto citopatico se detecto en todos los casos en rabdomiosarcoma. La edad media de los pacientes fue de 67 meses (intervalo, 1-350) y la relacion varon:mujer 2:1. La mayoria presentaron fiebre, cefalea y otros signos meningeos. El 52,6% de los ninos requirieron ingreso. La evolucion fue buena en todos los casos. La mayor incidencia se produjo de abril a junio Conclusiones No habia constancia de la circulacion del virus Echo serotipo 13 en Espana en los ultimos anos hasta la aparicion de nuestro brote. El aislamiento del virus de otras localizaciones diferentes del LCR ayudan en el diagnostico y manejo del paciente. La tipificacion del virus es esencial para conocer la actividad enteroviral en la poblacion, que puede ocurrir de forma esporadica o epidemica

Molecular epidemiology of enterovirus and parechovirus infections according to patient age over a 4‐year period in Spain

The epidemiology and clinical association of enterovirus (EV) and parechovirus (HPeV) infections, as well as the type‐distribution‐according‐to‐age, were determined during a 4‐year study period in Spain. During 2010–2013, a total of 21,832 clinical samples were screened for EV and the detection frequency was 6.5% (1,430). Of the total EV‐negative samples, only 1,873 samples from 2011 to 2013 were available for HPeV testing. HPeV was detected in 42 (2%) of them. Positive samples were genotyped using PCR and sequencing. EV infections occurred in all age groups of patients: neonates (17%), children 28 days to 2 years (29%), children 2–14 years (40%), and adults (14%). Thirty‐four different EV types were identified. HPeV infections were detected exclusively in infants <8 m (70% neonates, P < 0.05). All but one HPeV were HPeV‐3. Differences in type frequency detection were found according to age and clinical manifestation. Coxsackievirus (CV)‐B4 (61%), CV‐B5 (83%), and HPeV‐3 (64%) were more frequent in neonates than in older patients (P < 0.05). Echovirus (E)‐3 (60%), E‐18 (47%), E‐25 (62%), CV‐A6 (61%), CV‐A16 (72%), and EV‐71 (75%) were mainly detected in children 28 days to 2 years (P < 0.05), whereas, E‐6 (79%), E‐20 (88%), and E‐30 (85%) were predominant in children >2 years and adults (P < 0.05). Clinically, meningitis was associated with EV (P < 0.01) whereas, encephalitis was more frequent in HPeV‐infected patients. CV‐B types were associated with myocarditis (90%; P < 0.05) and EV species A with hand–foot–mouth‐disease/atypical exanthema (88%; P < 0.05). J. Med. Virol. 89:435–442, 2017.

Utilidad, implementación e impacto de la red TEDDY en Europa

La Red de Excelencia Task-force in Europe for Drug Development for the Young (TEDDY) se ha implementado durante un periodo de 5 años (junio de 2005junio de 2010), con el soporte del VI Programa marco de la UE (FP6), dentro del apartado de Investigación y Tecnología y el tema prioritario: Ciencias de la Vida, Genómica y Biotecnología de la Salud (Proyecto: LSHB-CT-2005-005216)1. La coordinación se ha realizado desde el Consorzio Per Valutazione Biologiche e Farmacologiche de Pavia, Italia. El objetivo principal de TEDDY ha sido promover la accesibilidad y seguridad de las medicinas disponibles en niños en Europa, integrando la experiencia existente con las normas de buena práctica y estimulando al mismo tiempo la futura investigación. Los objetivos secundarios de TEDDY han sido: optimizar el uso pediátrico de los fármacos disponibles, promover el desarrollo de nuevos medicamentos, armonizar la investigación pediátrica, incorporando aplicaciones farmacogenéticas y desarrollar guías para una mejor práctica clínica. En la Red de Excelencia han participado 17 miembros pertenecientes a 9 países de la UE (Italia, Alemania, Francia, Holanda, Reino Unido, España, República Checa, Bélgica, Suecia) además de Rumanía (miembro de la UE desde el 1 de enero de 2007) e Israel. En España se ha ido desarrollando desde 2005 una red de colaboradores compuesta por un total de 106 investigadores en la actualidad. TEDDY-España ha desarrollado una estrecha colaboración con Sociedades Científicas nacionales e internacionales: Asociación Española de Pediatría (AEP), Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Sociedad Española de Pediatría de Madrid y Castilla La Mancha (SPMYCM), Asociación Española de Pediatría de Atención Primaria (AEPAP), Sociedad Española de Infectología Pediátrica (SEIP), Secretaría Técnica del Plan Nacional del SIDA del Ministerio de Sanidad y Consumo (PNS-MSC), Agencia para la Formación, Investigación y Estudios Sanitarios de la Comunidad de Madrid Pedro Laín Entralgo, Sociedad Europea de Infectología Pediátrica (ESPID) y Fundación PENTA (Pediatric European Network for Treatment of AIDS). a p P b

Recomendaciones para la elaboración y administración de fármacos antituberculosos en niños. Segunda fase del Proyecto Magistral de la Red Española de Estudio de la Tuberculosis Pediátrica (pTBred)

The Spanish Network for the Study of Paediatric Tuberculosis has shown a lack of national consensus on the treatment of tuberculosis in children, partly due to the unavailability of paediatric presentations of antituberculosis drugs. The harmonisation of tuberculosis treatment in children is a priority in Spain. A joint action is proposed by a group of Spanish experts in childhood tuberculosis and in the area of Paediatric Pharmacology. To this end, a pTBred-led workgroup of members from five scientific bodies has been created. Drug pharmaceutical compounding in oral suspensions or oral solutions are recommended as follows: isoniazid 50mg/mL, pyrazinamide 100mg/mL, and ethambutol 50mg/mL. Raw materials, period of validity, and storage conditions are specified. Recommendations for the use of fixed-dose combination drugs are also established. If oral solutions/suspensions or fixed-dose combination drugs are not appropriate, the use of crushed tablets is recommended. Adherence to treatment and optimal dosing of antituberculosis drugs are critical in the control and eradication of TB. This multidisciplinary document provides an opportunity to promote the appropriate treatment of paediatric tuberculosis in Spain, and should become a useful tool for paediatricians and pharmacists.

Actualización del tratamiento de la tuberculosis en niños

Tuberculosis (TB) is the most important infectious disease all over the world, with a high morbidity and mortality. Pediatric tuberculosis has been a neglected epidemic, due to the difficulties in assessing its global impact, reduced incidence and lower infectivity compared to adults. In 2015, the WHO reported 1 million cases of paediatric TB and 169,000 deaths. In Europe, the emergence of MDR TB is a major concern, representing 16% of the new diagnosis in Eastern Europe. In 2014, it was estimated that about 219,000 children were infected by MDR-TB-strains in Europe, and 2,120 developed the disease. Spain is the Western European country with more paediatric cases, with an incidence 4.3/100,000 inhabitants in 2014. Paediatric tuberculosis mortality in Spain is rare, but extra-pulmonary disease is associated with significant complications. The prevalence of paediatric drug resistant TB in Spain is over 4%, higher than the estimated incidence in adult population, representing mayor difficulties for therapeutic intervention. These data reveal that paediatric TB is still a Public Health priority in our country. The difficulties in diagnosis and the lack of optimal paediatric drug formulations are the major challenges for controlling the childhoods tuberculosis epidemic. A group of national paeditric TB experts has reviewed the international guidelines and the most recent evidences, and has established new recommendations for the management of paediatric TB contacts, latent infection and active TB disease, especially focused in drug resistant cases. This document replaces the former national guidelines from the Spanish Society for Pediatric Infectios Diseases, although the prior recommendations on the diagnosis remain valid.

Tuberculosis osteoarticular en la edad pediátrica, revisión de casos en 20 años en un hospital terciario

Tuberculosis (TB) is one of the most prevalent infectious diseases worldwide. Paediatric patients are at significantly higher risk than adults of progressing to tuberculosis disease and developing disseminated and extrapulmonary forms of TB. In addition, in recent years we have witnessed an emergence of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis (MTB) in Spain, especially in immigrants from highly endemic countries. Extrapulmonary forms of TB, and osteoarticular TB in particular, pose a considerable diagnostic challenge on account of their insidious course and atypical manifestations. Osteoarticular TB amounts to approximately 1--5% of all cases of paediatric TB, and to 10--17% of extrapulmonary TB cases. However, few case series have been published on this form in the literature, and most of these studies were conducted in highly endemic countries. The aim of our study was to define the characteristics of paediatric osteoarticular TB in Spain. We made a retrospective review of cases of osteoarticular TB diagnosed in patients aged less than 14 years in the Hospital Universitario La Paz over a period of 20 years (January 1996--Debember 2015). We collected epidemiologic, clinical, radiologic, microbiologic, treatment and outcome data. We considered that skin tuberculin tests were positive when the induration was 5 mm or greater at 48--72 h from the intradermal injection of 2 units of RT-23 tuberculin in 0.1 mL solution (Statens Serum Institut; Copenhagen, Denmark). We entered and analysed the data in Excel (Microsoft; Redmond, USA). We identified 213 cases of children with confirmed TB, of which 11 (5.2%) presented with osteoarticular involvement. This presentation was the third most frequent following pulmonary TB (132 cases, 62%) and tuberculous lymphadenitis (41 cases, 19%). Of the 11 patients with osteoarticular involvement, 4 (36.4%) received a diagnosis of spinal TB (3 dorsal, 1 lumbar); 5 (45.4%) of articular TB (2 in the knee, 1 in the hip, 1 in the ankle, and 1 with polyarticular TB with hip, knee and shoulder involvement); and 2 (18.2%) of isolated osteomyelitis (1 in the femur, 1 in the mastoid process). Five cases (45%) presented with concomitant pulmonary involvement. The male to female ratio was 1.2:1, and the mean age at diagnosis was 5.3 ± 3.6 years. The median delay in diagnosis was 12 months (range, 2 weeks-3

La nueva AEP: innovación, investigación, unión e independencia. Liderazgo y recambio generacional

In the first quarter of the 21st century, in any country in the world, there is still no more vulnerable population than children, and yet, paradoxically, they will form the critical mass of the active population in the coming decades and will determine every country’s level of socio-cultural development. There is therefore an obvious need for professional experts in the care of children and adolescents, extending the paediatric age range to 18 years to provide comprehensive care up to the end of physiological growth and development. Paediatricians are responsible for curing their illnesses, but particularly for preventing them, thereby creating an impact of incalculable dimensions on public health and an outstanding added health benefit for the general population. Paediatrics is nowadays an indispensable discipline for ensuring the health of children and adolescents in any community and an index of the development of modern societies. The Spanish Association of Paediatrics (AEP) arose in Spain more than 6 decades ago, responding to the need to unify and channel every aspect of the development of paediatricians as regards their training and continuous updating, without losing sight of the common factor of good clinical practice, attaining excellence through expert learning in the paediatric specific training areas (PSTAs). This ensures that unified, focused, specific procedures are applied, making paediatric specialists the most effective

Características epidemiológicas y clínicas de los lactantes hospitalizados por infecciones por parechovirus humanos. Estudio prospectivo en España

INTRODUCTION Human parechovirus (HPeV) is one of the recently described picornaviridae viruses that have been associated with fever of unknown origin (FUO), clinical sepsis, gastroenteritis, meningitis, or encephalitis in very young infants. The aim of this study is to describe the epidemiology and clinical features of these viruses. PATIENTS AND METHODS A prospective multicentre 3-year study was conducted in 12 hospitals in Spain. Out of 850 specimens examined, 47 were positive (5.52%), with HPeV-3 being the most frequent (29 cases). Infections occurred throughout the year, but mainly in May and July, and a biennial distribution was observed. More than half (57%) were neonates, and only 2 children were older than 3 months. Fever was present in all children, with irritability in 45%, rash in 18.6%, and diarrhoea in 14%. The results of biochemical tests were all in normal range. The most common final diagnosis was FUO (61%), followed by clinical sepsis (29%). Up to 29% of infants were admitted to the intensive care unit, but only one patient had sequelae. RESULTS Out of 850 specimens examined, 47 were positive (5.52%) for HPeV, with HPeV-3 being the most frequent (29 cases). Infections occurred throughout the year, but mainly in May and July, and a biennial distribution was observed. More than half (57%) were neonates, and only 2 children were older than 3 months. Fever was present in all children, with irritability in 45%, rash in 18.6%, and diarrhoea in 14%. The results of biochemical tests were all in normal range. The most common final diagnosis was FUO (61%), followed by clinical sepsis (29%). Up to 29% of infants were admitted to the intensive care unit, but only one patient had sequelae CONCLUSIONS: HPeV circulates in our country, mainly during spring and summer, and affects young infants with a FUO and clinical sepsis. Molecular diagnostic techniques in all hospitals could help in improving the management of patients with these infections.