Norma González

Evaluación de dos métodos estandarizados de interpretación de radiografías de tórax en niños con neumonía

OBJECTIVE To evaluate the accuracy of World Health Organization (WHO) method of interpreting chest radiographs on identifying young children with bacterial pneumonia, and to compare its accuracy with other method. METHODS Chest radiographs from children aged under 5 years old hospitalized for pneumonia, with microbiological evidence of bacterial or viral infection, were evaluated by 3 observers blinded to other data (pediatrician [P], pulmonologist [N], radiologist [R]) according to WHO and Khamapirad scores. A WHO score=1 and a Khamapirad score >2 were selected as the thresholds suggesting bacterial pneumonia. The relationship between radiographic scores and etiology was evaluated using chi square. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values for predicting bacterial pneumonia were calculated. Interobserver agreement (P vs. N vs. R) was calculated (kappa). RESULTS 108 chest radiographs were evaluated (87 viral, 21 bacterial). WHO score= 1 was associated with bacterial pneumonia (p <0.001; OR= 6.4; CI 95%= 1.629.7), achieving a Se= 85%, Sp= 51%, PPV= 30%, NPV= 93%. Khamapirad score >2, evaluated by P, was also associated with bacterial pneumonia (p <0.0008; OR= 6.31; CI 95%= 1.8-24.4), achieving a Se= 80%, Sp= 59%, PPV= 32% NPV= 92%. Interobserver agreement was slightly better using WHO score (P vs. N= 0.82, P vs. R= 0.69, N vs. R= 0.85) than Khamapirad score (P vs. N= 0.48, P vs. R= 0.69, N vs. R= 0.82). CONCLUSIONS Both methods showed similar accuracy in order to identify bacterial pneumonia. WHO score is simpler than Khamapirad score and showed a better interobserver agreement.

Tuberculosis en niños y adolescentes: estrategias para la intervención de los trabajadores sociales

Recibido: 11-2-2017 Aceptado: 22-5-2017 RESUMEN En la asistencia de niños y adolescentes enfermos de tuberculosis, se deben conocer las dificultades que tienen muchas familias para acceder a la atención médica y al diagnóstico y tratamiento oportuno. El trabajador social actúa junto con otros integrantes del equipo de salud, lo que facilita el acceso a los recursos y beneficios asistenciales que pueden favorecer la adherencia al tratamiento y fortalecer la salud de esa población vulnerable. Si bien el propósito que engloba el accionar del trabajador social en esta enfermedad es contribuir a disminuir el riesgo de infectarse, enfermar o morir de tuberculosis, la situación epidemiológica actual de esta patología en Argentina ha puesto al trabajador social frente al desafío de replantearse nuevas estrategias de intervención y revisión de objetivos. El objetivo de este trabajo es plantear su rol y proponer acciones que pueden contribuir a disminuir la morbimortalidad por tuberculosis en niños y adolescentes. Palabras clave: tuberculosis, trabajo social, niños.

Hemophagocytic syndrome associated with tuberculosis in a patient with acquired immunodeficiency

The secondary hemophagocytic syndrome is rare in children and even rarer associated with tuberculosis. e report the case of a patient with acquired immunodeficiency syndrome, disseminated tuberculosis and hemophagocytic syndrome. An 8-year-old girl, diagnosed with acquired immunodeficiency syndrome, was admitted due to fever, vomiting and abdominal pain. She presented abdominal distension, dehydration, tachypnea, crackles and wheezing in both lungs, anemia, thrombocytopenia and coagulopathy. She received broad-spectrum antibiotics and exploratory laparotomy was performed with appendectomy and lymph node biopsy. After 72 hours the patient presented tonic clonic seizure, impaired sensory, fever, hypoxemia, hepatosplenomegaly, ascites and peripheral edema. She developed bicytopenia, hyperferritinemia and bone marrow microscopic examination with hemophagocytosis. She received intravenous gammaglobulin, steroids and blood transfusions. Mycobacterium tuberculosis was cultured in gastric aspirate, bone marrow and abdominal lymph node biopsy. She was treated with isoniazid, rifampicin, streptomycin and ethambutol, showing marked improvement.

Tuberculosis faríngea: Caso clínico

Pharyngeal tuberculosis is a rare extrapulmonary manifestation. In Argentina, the number of cases of tuberculosis reported in children under 19 years in 2012 was 1752. Only 12.15% had extrapulmonary manifestation. A case of a 17 year old girl with pharyngeal tuberculosis is reported. The patient presented intermittent fever and swallowing pain for 6 months, without response to conventional antibiotic treatment. Chest X-ray showedbilateral micronodular infiltrate, so hospitalization was decided to study and treat. The sputum examination for acid-fast resistant bacilli was positive and treatment with four antituberculous drugs was started, with good evolution and disappearance of symptoms. Diagnostic confirmation with the isolation of Mycobacterium tuberculosis in sputum culture was obtained. The main symptoms of pharyngeal tuberculosis are sore throat and difficulty in swallowing of long evolution. It is important to consider tuberculosis as differential diagnosis in patients with chronic pharyngitis unresponsive to conventional treatment.

Validation of a simplified prediction rule to identify etiology in children with pneumonia

INTRODUCTION Identifying on admission those children with bacterial pneumonia could reduce inappropriate antibiotic use. The BPS (Bacterial Pneumonia Score) is a clinical prediction rule that accurately identifies children with bacterial pneumonia. Because the interpretation of chest X-ray included in this model could be considered difficult, a simplified version was developed, but this version has not yet been validated in a different population. OBJECTIVE To validate a simplified clinical prediction rule to identify children with an increased risk of having bacterial pneumonia. METHODS Children aged under 5 years, hospitalized for pneumonia (viral or bacterial) were included. On admission, axillary temperature, age, absolute neutrophil count, bands, and chest radiograph were evaluated. RESULTS We included 168 patients (23 with bacterial pneumonia and 145 with viral pneumonia). Those with bacterial pneumonia showed a score higher than those with viral pneumonia (5.3 ± 2.5 vs. 2.6 ± 2.02; p <0.001). A score =3 points was identified as the optimum cutoff value to predict bacterial pneumonia (aucROC= 0.79; 95% IC: 0.68-0.90), and was more frequent among patients with bacterial than viral pneumonia (19/23 vs. 42/145, p= 0.003; OR: 4.8; CI95%: 1.4-17.6), achieving 82.6% sensitivity, 50.3% specificity, 20.9% positive predictive value, 94.8% negative predictive value, 1.66 positive likelihood ratio and 0.35 negative likelihood ratio. CONCLUSIONS The evaluated simplified prediction rule showed a limited diagnostic accuracy on identifying children with bacterial pneumonia, being less accurate than the BPS.

Habilidad de la radiografía de tórax para predecir etiología en niños hospitalizados con neumonía

ABSTRACT Chest X-ray capacity to predict the etiology of pneumonia in hospitalized children Introduction: Distinguishing bacterial from viral pneumonia on admission to the hospital could guide thedecision of whether or not to use antibiotics. Objective: To evaluate the accuracy of chest radiograph topredict etiology (bacterial or viral) in 141 children aged under 10 years, hospitalized for pneumonia in whombacterial (n = 24) or viral (n = 117) etiology was identified. Methods: Chest radiograph evaluation was basedon Khamapirad score (-3 to 7 points), and blinded with regard to etiology. Results: Radiographic score washigher in bacterial pneumonias than in viral pneumonias (3.9 ± 0.92 vs – 1.6 ± 1.3 points; p < 0.0001).Optimum cut-off value for the score was identified (ROC curve) at ≥ 2 points (sensitivity: 100%; specificity:94 %; positive predictive value: 77%; negative predictive value: 100%). Conclusion: The score tested isbased on easily identifiable elements in the chest radiograph. It accurately identifies children who do notneed antibiotics, it could be helpful in the management of community acquired pneumonia.(Key words: Bacterial pneumonia, Viral pneumonia, Radiology).Arch.argent.pediatr 2006; 104 (2): 106-108RESUMENIntroduccion: Conocer la etiologia de las neumonias puede guiar la decision de usar o no antibioticos. Laradiologia puede colaborar en esa decision. Nuestro objetivo fue evaluar la capacidad de la radiografia detorax para predecir la etiologia (bacteriana o viral). Poblacion: Cientocuarenta y un ninos menores de 10anos hospitalizados por neumonia con diagnostico etiologico confirmado (viral = 117 y bacteriano = 24).Material y Metodos: La radiografia de torax fue evaluo a ciegas con respecto a otros datos mediantepuntaje de Khamapirad (de – 3 a 7 puntos). Resultados: El puntaje radiologico fue significativamentemayor en neumonias bacterianas que en virales (3,9 ± 0,92 vs – 1,6 ± 1,3 puntos; p < 0,0001). Se identifico a≥ 2 puntos (curva ROC) como el mejor nivel para identificar neumonias bacterianas (sensibilidad: 100%;CONO SURSOUTH CONE OF AMERICA