Yariv Fruchtman

Dramatic increase in laboratory-diagnosed human cutaneous leishmaniasis cases in southern Israel, 2007–2013

Abstract Background: Cutaneous leishmaniasis (CL) is an endemic zoonosis in southern Israel. In recent years, substantial urbanization has been taking place in this region. The introduction of populations into endemic foci was previously reported to facilitate human CL outbreaks. Our aim was to describe a continuous CL outbreak in southern Israel, through laboratory reports of CL diagnosis. Methods: The Soroka University Medical Center parasitology laboratory is the major laboratory confirming CL cases in our region. Data regarding patients referred to the hospital for CL diagnosis were collected retrospectively. Cases were defined by microscopic findings of skin lesion biopsies. Results: The annual number of cases sent for CL laboratory confirmation increased from a mean of 77 ± 9 in the years 2007–2010 to 178, 327, and 528 in the years 2011, 2012, and 2013, respectively. The respective increase in annual confirmed/positive cases of CL was from 36 ± 12 to 117, 171, and 282, leading to respective increase in CL rate (per 100 000) from 5.8 ± 1.9 to 18.4, 26.3, and 42.7. The outbreak was mainly (> 60%) observed in the north-west area of the region. Conclusions: In conclusion, a sevenfold increase in laboratory-confirmed CL was observed in southern Israel in 2007–2013, probably reflecting a bigger outbreak, possibly related to urban expansion bordering with CL foci.

Morbidity characteristics of patients with congenital insensitivity to pain with anhidrosis (CIPA)

Abstract Background: Congenital insensitivity to pain with anhidrosis (CIPA) is a congenital autonomic sensory neuropathy. In southern Israel, there are many patients with this disease. We here tried to characterize the different infections acquired by children with CIPA. Methods: We collected all the available data about CIPA patients in southern Israel in the year 1991–2005, including the lesion types, area in the body where the infection occurs, and the treatment given. Results: The current study included 30 children with CIPA, out of 44 known CIPA patients in southern Israel (68.2%). A total of 382 different episodes of infections, fever, orthopedic lesions, and jaw and mouth lesions led our patients to our outpatient clinic or resulted in hospitalization. Conclusion: We found that children with CIPA mainly have infections of the skin and skeleton, and that the most frequent pathogen is Staphylococcus aureus. We also found that a fair amount of these pathogens are resistant to conventional treatment regimens.

The diagnostic accuracy of the 'classic meningeal signs' in children with suspected bacterial meningitis.

To prospectively determine the diagnostic accuracy of nuchal rigidity, Kernig’s sign, and Brudzinski’s sign in children with suspected bacterial meningitis. Children 3 months to 17 years old diagnosed with bacterial meningitis and matched controls without bacterial meningitis were enrolled. The diagnostic accuracy was calculated independently for each test and for a combinations of tests. Of 86 children, 40 (46.5%) had bacterial meningitis. The sensitivity, specificity, LR+, and LR− were 64.5%, 53.5%, 1.4, and 0.7 for nuchal rigidity, 52.6%, 77.5%, 2.3, and 0.6 for Brudzinski’s sign, and 51.4%, 95.0%, 10.3, and 0.5 for Kernig’s sign. The three tests did not yield any better results in the subsets of children with moderate or severe meningeal inflammation, nor in relation to any of the causative pathogens. In children with suspected meningitis, the three classic signs did not have a high diagnostic value and better bedside diagnostic signs are required.

Influenza A/H1N1 in Pediatric Oncology Patients

Background: Our aim was to determine the clinical and epidemiological features of pandemic influenza A/H1N1 in immunocompromised children with solid tumors and hematological malignancies. Patients and Methods: A prospective study was conducted during the H1N1 pandemic between August 2009 and February 2010 in a pediatric hematology-oncology unit. Demographic and clinical data were obtained from all children with suspected H1N1 infection (high fever with or without respiratory symptoms). Laboratory diagnosis of influenza A/H1N1 was performed by means of polymerase chain reaction analysis of nasopharyngeal wash specimens. Results: We identified 57 episodes of suspected influenza A/H1N1 infection in 40 children. In all episodes, children were treated with oseltamivir and antibiotics until influenza A/H1N1 results were received. Of all episodes, 13 (22.8%) tested positive for influenza A/H1N1. Two of the H1N1-positive children (15.4%) had been previously immunized against influenza A/H1N1. No differences between H1N1-positive and H1N1-negative children were noted in terms of demographic features, clinical presentation, laboratory findings, and underlying disease. Three polymerase chain reaction-positive (23.0%) children and 1 H1N1-negative (2.3%) child were admitted to the pediatric intensive care unit and were mechanically ventilated (P=0.03). One (7.7%) H1N1-positive patient died versus none of the H1N1-negative patients (P=0.2). The condition of all other children in both the groups improved rapidly during hospitalization. Conclusions: Febrile hospitalized pediatric oncology patients, with and without pandemic influenza A/H1N1, had a similar demographic and clinical presentation with a relatively good outcome. This was probably because of early antiviral treatment and possibly because of the relatively low virulence of the virus. Immunization should be encouraged in these patients.

Skin Necrosis and Purpura Fulminans in Children With and Without Thrombophilia—A Tertiary Center's Experience

Purpura fulminans (PF) is a very rare clinicopathologic skin disorder comprising dermal microvascular thrombosis associated with perivascular hemorrhage of multiple origins. It may occur as the presenting symptom of severe congenital deficiency of protein C (PC) or protein S (PS) during the newborn period, or later in life following oral anticoagulant therapy with vitamin K antagonists, or of sepsis that may be associated with disseminated intravascular coagulation. Treatment consists of anticoagulants and PC concentrates during acute episodes. We report our experience in the diagnosis and management of pediatric PF. The medical records of the 6 children aged 2–16 years (median: 5 years) who presented with PF to our tertiary care center between 1996 and 2013 were studied. The thrombophilia workup revealed either the presence of congenital homozygous PC deficiency, prothrombotic polymorphisms (factor V Leiden and FIIG20210A heterozygosity), acquired PC/PS deficiency, or no discernible thrombophilia. The skin necrosis resolved following conservative fresh-frozen plasma/anticoagulant therapy in 2 cases, whereas 3 children required interventional plastic surgery. The sixth case, a 10-year-old child with severe PC deficiency, heterozygous factor V Leiden, and FIIG20210A, received recombinant activated PC. PF in childhood is rare and has multiple etiologies. Understanding of the variable pathogenesis and risk factors will facilitate diagnosis and appropriate clinical management.

Parental acceptability of the watchful waiting approach in pediatric acute otitis media

AIM To determine parental knowledge about acute otitis media (AOM) and its antibiotic therapy, antibiotic resistance and the willingness to comply with the watchful waiting (WW) approach in primary care settings in southern Israel. METHODS The study was conducted in 3 primary care clinics and the pediatric emergency room of Soroka University Medical Center. Questionnaires (20 questions on education background, previous AOM experience, knowledge on antimicrobial resistance and attitude vs the WW approach) were filled by 600 parents (150 at each centers) of children < 6 years of age. RESULTS Mothers represented 69% of parents; 2% had an education of < 10 school years, 46% had high-school education and 17% had an academic degree. 69% parents reported previous experience with AOM and 56% thought that antibiotics represent the only treatment for AOM. Knowledge on bacterial resistance to antibiotics was reported by 57% of the parents; 86% parents were willing to accept/probably accept the WW approach for their children. Logistic regression analysis revealed a significant association between parental education and knowledge about bacterial resistance to antibiotics and that previous experience with AOM was significantly associated with reluctance to accept the WW approach. More parents with knowledge on bacterial resistance were willing to accept the WW approach compared with parents without such knowledge. No correlation was found between the education level and willingness to accept the WW approach. CONCLUSION A significant correlation was found between previous parental education and experience with AOM and the knowledge about antibiotic use, bacterial resistance and acceptance of the WW approach.

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

We described the occult bacteremia (OB) and bacteremia with diagnosed focus (BwF) picture among children managed as outpatients at the pediatric emergency room (PER) in southern Israel, before and after the introduction of pneumococcal conjugate vaccines (PCVs) introduction in a retrospective study enrolling all three- to 36-month-old patients with fever >38.0 °C during 2005–2014. Of 511 (0.82% of all febrile patients) true bacteremias, 230 (45%) were managed as outpatients; 96 of 230 (41.7%) had OB and 134 (3.59%) had BwF. OB and BwF rates were 0.22% and 3.02%, respectively. A significant decrease was noted in OB and BwF rates (p = 0.0008 and p = 0.02, respectively). S. pneumoniae (SP, 37.5%), K. kingae (11.4%) and Brucella spp. (8.7%) were the most common OB pathogens and SP (29.8%), S. viridans (13.4%), and Brucella spp. (12.7%) were the most common in BwF patients. PCV13 serotypes were not found among the serotypes isolated post-PCV13 introduction. During 2010–2014 there was an increase in non-PCV13 serotype isolation (p = 0.005). SP was the main pathogen isolated among patients with pneumonia, acute otitis media (AOM) and periorbital cellulitis (62.5%, 33.3% and 60%, respectively). OB and BwF decreased following the introduction of PCVs and SP was the main pathogen in both conditions. Vaccine-SP serotypes were not isolated in OB after PCV13 introduction and non-vaccine serotypes increased significantly.

Clinical and laboratory parameter dynamics as markers of blood stream infections in pediatric oncology patients with fever and neutropenia.

Background: Identifying markers associated with blood stream infection (BSI) in children with fever and neutropenia (FN) could lead to a substantial reduction in unnecessary treatment. Study Objective: The aim of this study was to determine the association between clinical/laboratory parameters and BSI in pediatric oncology patients with FN. Methods: This prospective study was conducted between 2007 and 2010 at the Pediatric oncology unit. Clinical and laboratory parameters were obtained from all hospitalized FN patients. Linear regression and trends were calculated to determine the association between clinical/laboratory parameters and BSI. Results: Of the 195 FN episodes in 73 children, BSIs were identified in 38 (19%) episodes. Gram-positive bacteria, gram-negative bacteria, and fungi caused 47%, 43%, and 10% of all BSIs, respectively. Mean fever duration was longer in the BSI group (5 d) compared with the non-BSI group (2 d, P=0.01). Mean (±SD) monocyte count at admission was lower in the BSI group compared with the non-BSI group (0.06±0.1 vs. 0.14±0.33 cells/mm3, respectively, P=0.05). Mean C-reactive protein (CRP) levels at hospitalization days 5 to 8 were higher in children with BSI (P<0.001). Increment trends of monocyte and platelet levels and decrement trend of CRP levels were noted in the BSI group but not in the non-BSI group (P<0.01 for all). Conclusions: Prolonged fever, lower monocyte count at admission, higher CRP levels between the fifth and the eighth hospitalization days, increment trends of monocyte and platelet levels, and CRP level decrement were associated with BSI. These factors may serve as markers for BSI in pediatric oncology patients with FN.

Urinary tract infection in young infants discharged from the emergency room with normal urinalysis

We describe the clinical, microbiologic, therapeutic, and outcome characteristics of infants under three months of age with a positive urine culture reported after discharge from emergency department with normal urinalysis.

Group A streptococcal brain abscess in children: two case reports and a review of the literature

Abstract Brain abscesses caused by group A Streptococcus (GAS) are infrequently encountered in children. We present two cases of brain abscess (one cerebellar and one located in the temporal lobe) due to GAS infection occurring in close temporal proximity in previously healthy young children living in different geographic areas of southern Israel. The relevant literature since 2000, in the context of recent epidemiological data reporting an increase in the incidence of invasive GAS infections, is reviewed.