Tuğçe Tural Kara

A case with atypical hand-mouth-foot disease accompanying with onicomadesis and a small-scale outbreak

Hand-mouth-foot disease is generally caused by Coxsackievirus A16 and Enterovirus 71, which are subtypes of enteroviruses, and it can lead to outbreaks in the people. Recently, an atypical form of disease has been described which consists of different characteristics from classical form. It differs from the classical form of disease with widespread distribution of vesiculobullous skin lesions on the trunk and neck, high rate of ulcerate and bullous formation, crusted and scabbed lesions and onychomadesis. Herein, we reported a 17-month-old child with atypical hand-foot-mouth disease. He was firstly diagnosed with eczema herpeticum, lead to a small outbreak, and healed with onicomadesis. We pointed out atypical enteroviral diseases in infants especially presented with eczema herpeticum and negative tests for herpesviruses. Unnecessary use of acyclovir could be avoided if atypical manifestations of disease are well known. Also, hospital and community outbreaks can be prevented by taking protective measures.

P266 An outbreak of stenotrophomonas maltophilia pseudobacteremia in a paediatric hospital associated with contaminated citrated tube

In this report, we describe pseudobacteremia of Stenotrophomonas maltophilia in a paediatric hospital. S. maltophilia was isolated from blood cultures of 14 patients with in 2 months. Most of the patients with positive blood culture were given treatment because of underlying diseases, but pseudobacteremia was suspected since majority of these patients have no clinical and laboratory findings of sepsis and consecutive blood cultures were negative. The collected environmental samples were negative. Upon these isolations continued, it was considered that contamination might occur from the citrated coagulation, hemogram or biochemical tubes. Then S. maltophilia with same antibiogram was isolated from the citrated coagulation tubes. Nine of the patients received levofloxacin for average 7 days due to underlying disease. Medical staff were re-educated about blood culture drawing procedure. After the education no further isolates of S. maltophilia have been encountered to date.

P268 Bloodstream infections in paediatric immunocompromised patients, responsible pathogens, antibiotic susceptibility patterns and treatment outcomes: experience of single centre in turkey

Background and aims Bloodstream infections are the major cause of morbidity, increased cost, prolonged hospitalisation and mortality in paediatric haematology and oncology patients. We aimed to identify causative microorganisms and their antimicrobial susceptibilities in paediatric immunocompromised patients. Methods Patients with haematological and/or oncological diseases who admitted to our hospital with fever between January 2010 and November 2015 were included in this study. Patients’ demografic and clinical findings were collected from hospital information systems and microbiology laboratory records retrospectively. Results Totally 71 paediatric patients who had 111 bloodstream infection episodes were included in this study. The median age of patients was 90 (3-247) months. The most underlying disease was acute lymphoblastic leukaemia. While 31 patients had only peripheral blood culture positivity, 80 patients had catheter related blood stream infections. Of 80.2% blood stream infections occurred in neutropenic period. Responsible pathogens were detected as follows: 35.1% gram-positive microorganisms, 60.5% gram-negative bacteria and 4.4% fungi. The most causative gram negative pathogen was Escherichia coli and the most isolated gram positive microorganism was meticillin resistant coagulase negative Staphylococci. Extended spectrum beta lactamase was produced by 60% of Klebsiella spp. and 42.1% of E. coli. In addition carbapenemase producing E. coli and Klebsiella spp. were 15.8% and 26.7% respectively. Enterococcus spp. had 88.9% ampicillin resistance and%33.3 vancomycin resistance. Bloodstream infection related mortality rate was 2.7%. Conclusion Gram negative microorganisms were predominant pathogens in bloodstream infections. Extended spectrum beta lactamase and carbapenem resistance were increasingly important and they limited treatment options. The choice of empiric antimicrobial drug in immunosuppressed patients is life-saving. For all these reasons, the choice of empirical antibiotics should be made according to the clinical condition of the patient and the prevalent microorganisms in the current clinic, as favourable antimicrobial therapy will be able to achieve positive clinical outcomes.

P269 Responsible pathogens of paediatric implantable long term catheter related blood stream infections and effectiveness of antibiotic lock therapy

Background Catheter related blood stream infections (CRBSIs) are important problem in paediatric haematology, oncology and immunology patients with central venous catheter. This study aimed to determine incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in paediatric patients. Methods Between January 2010 and November 2015 all hospitalised paediatric haematology, oncology and immunology patients who were diagnosed as CRBSIs, were retrospectively included in this study. Causative microorganisms and their antibiotic susceptibility, success rate of ALT, treatment failure, recurrence, catheter removal, complications and mortality are analysed. Results Seventy eight CRBSIs episodes were detected in 60 paediatric patients. The median age was 106.4±66.6 (86, 3–240) months. Male/female ratio was 1.9/1. The incidence of CRBSIs was 4.20/1000 catheter days. Most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Antibiotic lock therapy was administered in 42 patients. Success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. Relapse was observed in 1 (1.3%) episodes and mortality was detected in 3 (3.8%) episodes. Conclusion Catheter related blood stream infections are important cause of morbidity and mortality in paediatric patients. However, incidence may be decreased with antiseptic procedures and hand hygiene. Antibiotic lock therapy is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs except in some cases catheter removal must be necessary. Antibiotic lock therapy helps to prevent unnecessary catheter removing in paediatric immunocompromised patients.

P278 First day fever: diagnosis? hyperimmunoglobulinemia d syndrome

An 18-week-old girl, second child of non-consanguineous parents presented to our hospital due to nasal discharge, fever. On physical examination,her vital signs included a temperature of 39.2°C. Other findings were hyperemic oropharynx, right cervical 1*1 cm lymphadenopathy and macular rash with more markedly in the flexor surface of the forearm which has become prominent in the febrile period and than disappeared. A white whole blood count of 61.280/mm³(88% neutrophils, 9% lymphocytes, 2%monocyte) and ESR rate was 52 mm/h and CRP was 143.8 mg/L. Biochemical and urine analysis,.chest x-ray was normal. Medical history of the patient revealed that she had been admitted to neonatal service in an out centre upon fever developed at the postnatal 20th hour. Her physical examination was normal. White blood cell count of 23.160/mm³ and a CRP level of 31.6 mg/L. Patient who had normal chest x-ray and urinalysis had been put on iv vancomycin and meropenem. Cultures remained were negatif. Her fever had dropped at the 4th day and leukocytosis had regressed in the non-febrile period (14060/mm³). Patient whose fever had raised again to 39°C at the 8th day had a normal physical examination and developed leukocytosis (22.390/mm³), CRP (306 mg/L) Because the patient whose fever lasted 3 days had become febrile again at the 15th day of life, Cerebrospinal fluid was normal,ciprofloxacin iv had been added to the treatment and her fever had dropped after 3 days. The patient’s discharged was planned at the 22nd day. Following non-febrile period of 40 days, patient had fever after vaccination when she was 60-day-old which had been attributed to vaccination since she had no any other symptom. In follow-up performed at the 75, 90, 106 and 120th days, patient had no any symptom except fevers lasting 3 day. The patient presented to our hospital when she was 130-day-old. Her family stated that, these rashes occurred during the last fever episodes and they attributed them to fever and in addition they reported that her vomiting was increasing in febrile periods. Upon fever episodes seen once in 15 days lasting 3 days accompanied by rash, vomiting, lymphadenopathy, elevated acute phase reactants and increased urinary mevalonic acid excretion, genetic analysis was ordered. Patient’s MVK gene analysis I268T was found heterozygote and her diagnosis is hyperimmunoglobulinemia D syndrome.

P263 Nosocomial pneumonia caused by legionella pneumophila in a paediatric hematopoietic stem cell transplantation recipient for thalassemia major

A nosocomial pneumonia caused by Legionella pneumophilaserogroup 2oc–14oc curred in a 7-year-old patient following allogeneic hematopoietic stem cell transplantation for thalassemia major. The patient was diagnosed as nosocomial Legionella pneumonia by a polymerase chain reaction (PCR) from bronchoalveolar lavage and a culture of L. pneumophilaserogroup 2–14 from patient’s room faucet water. Legionella was eradicated from our hospital’s water distribution system by superheating and chemical eradication methods (hyper-chlorination and hydrogen peroxide). We did not detect any case after this event. Early recognition of contamination of hospital water system with Leigonella proves the importance of prevention new cases.

P272 The importance of directly observed therapy in perinatal tuberculosis

9.5 month-old boy presented with a one-month history of cough and lymphadenopathy. The mother was diagnosed with pulmonary tuberculosis when the baby was 1,5 months old. Thus, the breastfeeding was stopped and isoniazid prophylactic therapy was recommended to baby. However, the treatment was only applied between 6–9 months old by the family. He was evaluated for pneumonia at first and nonspecific antibiotic therapies were started. After ten-day treatment, the symptoms didn’t get better. He was again evaluated and three serial samples of gastric aspirates that sent for ARB and Tbc PCRes were positive. Chest CT revealed that concerning the whole middle and lower lobes in the right lung at the widespread consolidation area, necrotic areas where the largest reached over 23 × 13 mm was monitored. He was administered a four-drug anti-tuberculous treatment of INH (11.5 mg/kg), rifampicin (15 mg/kg), pyrazinamide (25 mg/kg), etambuthol (18.75 mg/kg). At the first month of treatment all acid fast stains and PCR were negative. Even though ChestCT were the same, findings showed remarkable improvement After 2 months the child was discharged to his home with two-drug- maintence therapy. As well as early diagnosis and treatment, directly observed therapy is crucial in tuberculosis.

P274 An unexpected disease in an infant with pancytopenia and pulmonary abscess: glycogen storage disease type 1b

2.5-month-old boy had presented to another hospital with the complaints of wheezing and groaning. Thoracic CT of the patient revealed a heterogeneous, irregular lesions measured as 53 × 40 mm in size at the right hilar region. In addition; anaemia and neutropenia was detected. The patient had been referred to our hospital. Parents of the patient had cross-cousin marriage. In his physical examination; respiratory sounds were decreased in the middle and lower right lung, hepatomegaly (8 cm) and splenomegaly (8 cm) were detected. The whole blood count revealed a haemoglobin level of 6.1 g/dL, a white blood count of 8800/mm³ (total neutrophil count: 540/mm³), and a platelet count of 171.000/mm³. Blood glucose was 88 mg/dL, aspartate aminotransferase (AST) was mildly elevated (59 IU/mL). CT showed irregular soft tissue mass containing hypodense necrotic areas. Necrotizing pneumonia with abscess development was thought. Staphylococcus aureus was isolated in bronchoalveolar lavage collected with bronchoscopy. At the 4th day of treatment, pancytopenia was increased. Neutrophil functions, lymphocyte count and activity were normal and no chronic granulomatous disease gene and HAX-1 gene mutation was detected. Since neutropenia continued, GCSF was initiated. Hypertriglyceridemia (661 mg/dL) was found in lipid panel which was examined because of glycogen storage disease suspected due to parental consanguinity, neonatal hypoglycemia, hepatosplenomegaly and the apperance of the patient phenotypically as a doll face. Lactic acid level was found to be high (37 mg/dL), and uric acid value was at the upper limit (7 mg/dL). Compensated metabolic acidosis was observed in the blood gas. Hypoglycemia (32 mg/dL) was detected towards morning in the patient whom blood glucose was monitored. Homozygote c.1042_1043 delCT mutation was detected in the SLC37A4 gene of the patient which was considered to GSD 1b. When presenting our case, we aimed to make a contribution to early diagnosis and treatment by emphasising that GSD 1b disease should be considered in differential diagnosis even there is no symptomatic hypoglycemia in patients and particularly in often-fed infants presented with severe infection picture accompanied by hepatosplenomegaly and neutropenia and/or pancytopenia.

Staphylococcus aureus endocarditis and pyomyositis: Rare complications of rotavirus gastroenteritis

Rotavirus may cause life‐threatening complications in untreated patients during the course of gastroenteritis. Electrolyte imbalance, bacteremia and sepsis are the most common complications of rotavirus gastroenteritis (RG). It is believed that translocation of intestinal microorganisms as a result of intestinal epithelium dysfunction is the underlying mechanism of bacteremia in RG. Although Gram‐negative bacteremia has been noted as a complication in RG, Staphylococcus aureus bacteremia and endocarditis have not been reported previously. A 22‐month‐old boy was admitted with complaints of fever, diarrhea and dehydration. He was diagnosed with RG complicated with S. aureus bacteremia, pyomyositis and endocarditis. We call attention to these complications in patients with prolonged or late‐onset fever during RG as rare complications of the disease.