Marie-Hélène Perez

Capillary leak leading to shock in Kawasaki disease without myocardial dysfunction.

Kawasaki disease is an acute vasculitis of childhood. Its clinical presentation is well known, and coronary artery aneurysms are classical complications. Shock and pleural or pericardiac effusion are rare presentations of the disease. In intensive care units, the disease may be mistaken for septic shock or toxic shock syndrome. Owing to the fact that immunoglobulin therapy improves the course of the disease, especially if given early, and thus the diagnosis should not be delayed.

Mycoplasma hominis necrotizing pleuropneumonia in a previously healthy adolescent

BackgroundMycoplasma hominis is a fastidious micro-organism causing systemic infections in the neonate and genital infections in the adult. It can also be the cause of serious extra-genital infections, mainly in immunosuppressed or predisposed subjects.Case PresentationWe describe a case of severe pneumonia and pericarditis due to Mycoplasma hominis in a previously healthy adolescent who did not respond to initial therapy.ConclusionsMycoplasma hominis could be an underestimated cause of severe pneumonia in immunocompetent patients and should be particularly suspected in those not responding to standard therapy.

Substitution of exudative trace element losses in burned children

We describe an intravenous copper-selenium-zinc substitution policy in children with major burns using adult doses adapted to total body surface area. Blood levels and clinical course confi rm its safety, with a rapidly favourable clinical evolution. Major burn injuries are associated with trace element defi ciencies, which lead to impaired wound healing and infectious complications. Low plasma levels of zinc (Zn) and copper (Cu) are inadequately compensated for during hospitalization [1], and enteral supplements are unsuccessful in correcting the status [2]. Additionally, there are currently no clear recommendations regarding trace element requirements in children. Th e aim of the present study was to determine if our trace element supplementation policy for adults adapted to total body surface area would achieve normalization of plasma concen trations of trace elements in burned children.

Placental Immaturity, Endocardial Fibroelastosis and Fetal Hypoxia

We describe a term newborn who, after a normal gestational course, presented at birth with absent cardiac activity and no spontaneous breathing. Death occurred within 30 h. Autopsy revealed placental villous immaturity, multiple acute hypoxic lesions, but also chronic hypoxic lesions like endocardial fibroelastosis. This striking association of endocardial fibroelastosis and placental villous immaturity is reviewed and correlated with 2 other cases of placental villous immaturity that led to in utero death at 39 and 41 weeks of gestation. Placental villous immaturity must be suspected and looked for by both pediatricians and obstetricians in every case of stillbirth or perinatal asphyxia of unclear origin. In order to minimize the risk of recurrence in further pregnancies, elective cesarean section may be considered.

Performance of Predictive Equations Specifically Developed to Estimate Resting Energy Expenditure in Ventilated Critically Ill Children

Objective To determine, based on indirect calorimetry measurements, the biases of predictive equations specifically developed recently for estimating resting energy expenditure (REE) in ventilated critically ill children, or developed for healthy populations but used in critically ill children. Study design A secondary analysis study was performed using our data on REE measured in a previous prospective study on protein and energy needs in pediatric intensive care unit. We included 75 ventilated critically ill children (median age, 21 months) in whom 407 indirect calorimetry measurements were performed. Fifteen predictive equations were used to estimate REE: the equations of White, Meyer, Mehta, Schofield, Henry, the World Health Organization, Fleisch, and Harris‐Benedict and the tables of Talbot. Their differential and proportional biases (with 95% CIs) were computed and the bias plotted in graphs. The Bland‐Altman method was also used. Results Most equations underestimated and overestimated REE between 200 and 1000 kcal/day. The equations of Mehta, Schofield, and Henry and the tables of Talbot had a bias ≤10%, but the 95% CI was large and contained values by far beyond ±10% for low REE values. Other specific equations for critically ill children had even wider biases. Conclusions In ventilated critically ill children, none of the predictive equations tested met the performance criteria for the entire range of REE between 200 and 1000 kcal/day. Even the equations with the smallest bias may entail a risk of underfeeding or overfeeding, especially in the youngest children. Indirect calorimetry measurement must be preferred.

Recombinant factor VIIa for intractable life-threatening bleeding in patients with circulatory assist devices.

Dear Editor, Circulatory assist devices require tight anticoagulation therapy and may be complicated by severe bleeding. Despite warnings related to potential lethal thrombotic complications, offlabel use of recombinant factor VIIa (rFVIIa) is increasingly reported for refractory hemorrhage, including after cardiac surgery [1, 2]. However, its use in patients with circulatory assist devices has seldom been reported and its safety remains to be established [3–5]. We reviewed 12 consecutive patients with surgically implanted devices who received rFVIIa as rescue treatment for intractable lifethreatening bleeding between March 2004 and November 2009 (Table 1). According to strict and constringent local consensus guidelines, a systematic cross-check for aggressive correction of hypothermia, acidosis, and coagulation factors with parallel surgical control for bleeding or embolization was obtained before rFVIIa administration in all cases. The median age of patients was 45 years. The rFVIIa was administered in the operating room (3/12), in the intensive care unit (7/12), or both (2/12). Underlying conditions were cardiovascular surgery (11/12, including 4 heart transplantations) and bipulmonary transplantation (1/12). The device was an extracorporal membrane oxygenator (9/12) and a left ventricular assist device (3/12). Median dose of rFVIIa was 95 lg/kg (45–180), administered in one (3/12) or several doses (9/12). In these otherwise terminal patients, the bleeding assessed by the number of ml/kg of packed red blood cells and fresh frozen plasma requirement within 12 h before and after rFVIIa administration was significantly reduced. Six patients (50%) died within 30 days, including 2 (18%) from persistent bleeding. A careful analysis of coagulation and other physiological parameters did not reveal significant difference between responders and non-responders.

Invasive pneumococcal infection despite 7-valent conjugated vaccine

Despite good cover with 7-valent vaccination, invasive pneumococcal infections may still be misdiagnosed and may lead to lifethreatening situations or death in young children. New serotypes are emerging and, therefore, clinicians must keep a high level of suspicion in young children regardless of their vaccination status. We report three cases of invasive pneumococcal infection due to new serotypes not covered by the 7-valent conjugated vaccine, two of which led children to death.

Streptococcus pneumoniae–Associated Hemolytic and Uremic Syndrome With Cholestasis A Case Report and Brief Literature Review

Streptococcus pneumoniae (Sp)–associated hemolytic and uremic syndrome (HUS) accounts for 5% to 15% of all HUS with an incidence of 0.4% to 0.6% following Sp infections. Epidemiology of invasive pneumococcal disease changed since the introduction of antipneumococcal conjugated vaccine and SpHUS appeared to follow the serotype shift. Presently, SpHUS seems to be mostly due to the serotype 3, 6B, 7, 8, 9V, 14, 19, and 23F. Renal complication of SpHUS is well known, and 10% to 16% of cases will develop an end-stage renal failure (ESRF). However, hepatic complications are rare and uncommon. Here, we describe a child with SpHUS associated with severe cholestatic jaundice secondary to acute liver injury.

Respiratory distress in a one‐month‐old child suffering brachial plexus palsy

This paper describes a one‐month‐old girl presenting with respiratory and growth failure due to diaphragmatic paralysis associated with left brachial plexus palsy after forceps delivery. Despite continuous positive pressure ventilation and nasogastric feeding, the situation did not improve and a laparoscopic diaphragmatic plication had to be performed. When dealing with a child born with brachial plexus palsy, one must think of this possible association and if necessary proceed to the complementary radiological examinations. The treatment must avoid complications like feeding difficulties and failure to thrive, respiratory infections or atelectasis. It includes intensive support and a good evaluation of the prognosis of the lesion to decide the best moment for a surgical therapy.

Estimation of Resting Energy Expenditure Using Predictive Equations in Critically Ill Children: Results of a Systematic Review.

Provision of adequate energy intake to critically ill children is associated with improved prognosis, but resting energy expenditure (REE) is rarely determined by indirect calorimetry (IC) due to practical constraints. Some studies have tested the validity of various predictive equations that are routinely used for this purpose, but no systematic evaluation has been made. Therefore, we performed a systematic review of the literature to assess predictive equations of REE in critically ill children. We systematically searched the literature for eligible studies, and then we extracted data and assigned a quality grade to each article according to guidelines of the Academy of Nutrition and Dietetics. Accuracy was defined as the percentage of predicted REE values to fall within ±10% or ±15% of the measured energy expenditure (MEE) values, computed based on individual participant data. Of the 993 identified studies, 22 studies testing 21 equations using 2326 IC measurements in 1102 children were included in this review. Only 6 equations were evaluated by at least 3 studies in critically ill children. No equation predicted REE within ±10% of MEE in >50% of observations. The Harris-Benedict equation overestimated REE in two-thirds of patients, whereas the Schofield equations and Talbot tables predicted REE within ±15% of MEE in approximately 50% of observations. In summary, the Schofield equations and Talbot tables were the least inaccurate of the predictive equations. We conclude that a new validated indirect calorimeter is urgently needed in the critically ill pediatric population.).