Yassuhiko Okay

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in São Paulo, Brazil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in childrens nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.

Clinical and laboratorial features of visceral toxocariasis in infancy

Forty children with a diagnosis of Visceral Toxocariasis were evaluated prospectively from February 1982 to June 1989. Diagnosis was established by clinical, laboratory and serological (ELISA - ES Toxocara canis antigen) evaluations. A great clinical polymorphism was found in our patients, ranging from unspecific or absent manifestations to an exuberant symptomatology. The laboratory findings were: leukocytosis, eosinophilia and elevation of serum gammaglobulin and isohemagglutinin levels. No significant relationship between clinical findings and laboratory parameters was found. Serology (ELISA) was a method of great diagnostic support but did not show a correlation with clinical and laboratory findings in this study. There was a significant relationship between pulmonary manifestations and the presence of signs and/or symptoms, when the patients were sent to us. Our findings, especially the high incidence of pulmonary manifestations, suggest that Visceral Toxocariasis has to be included in the differential diagnostic of children with pulmonary manifestations, characteristic epidemiological data and associated eosinophilia.

Perfil etiológico das diarréias agudas de crianças atendidas em São Paulo

Objetivo: determinar o perfil etiologico das diarreias agudas de um grupo de criancas de baixo nivel socioeconomico atendidas em um servico regional de pronto-atendimento pediatrico. Metodo: durante dois anos, as criancas com diarreia aguda atendidas durante um horario pre-estabelecido do dia e da semana foram incluidas no estudo. Os outros criterios seletivos eram: a) idade inferior a 5 anos; b) nao utilizacao de antibiotico no mes precedente; c) ausencia de viagem para fora da cidade no mes precedente. Foram pesquisados nas fezes: a) rotavirus (imunofluorescencia e contra-imunoeletroforese); b) bacterias - cultura em agar MacConkey, agar SS, agar Columbia, verde brilhante, soroaglutinacao, deteccao de toxinas - INV, LT,ST,SLT I, SLT II, teste de Sereny, deteccao de fatores de virulencia -- EAF, eae ,BFP; c) protozoarios (Hoffman e Faust). No mesmo periodo, um grupo controle sem diarreia foi tambem avaliado para os mesmos patogenos fecais. Resultados: no periodo de marco de 1994 a junho de 1996, foram selecionadas para o estudo 154 criancas com diarreia aguda (GDA) e 42 criancas sem diarreia (GSDA). Foram detectados agentes enteropatogenicos em 112 casos (72,8%) do GDA, e em 9 (21,5%) do GSDA. A associacao de dois ou mais enteropatogenos ocorreu em 47 (30,5%) casos do GDA, e em 3 (7,1%) do GSDA. Os patogenos encontrados por caso, do GDA, foram: rotavirus 32 (20,8%), bacterias 53 (34,4%), ambos 25 (16,2%), e 2 (1,4%) com Giardia lamblia (em um caso associada a rotavirus e noutro a bacteria). No GSDA, foram detectadas bacterias em 8 casos (19,1%), e bacteria associada a Giardia lamblia em 1 (2,4%) caso. Das 105 bacterias isoladas no GDA, 90 eram Escherichia coli (EPEC 27, DAEC 24, ETEC 21, EAEC 18), 12 eram Shigella sp, 2 eram Salmonella sp, e uma era Yersinia sp. As criancas com infeccao mista - viral e bacteriana - apresentaram maior ocorrencia de vomitos repetidos, desidratacao e internacao.Conclusoes: as bacterias foram os enteropatogenos mais detectados nos casos de diarreia aguda, sendo a Escherichia coli a mais frequente. Na maior parte, as cepas de Escherichia coli eram de biovariedade nao-EPEC, habitualmente nao investigadas nos laboratorios de patologia clinica. O rotavirus foi encontrado em grande parcela dos casos, muitas vezes em associacao com as bacterias. Os protozoarios tiveram importância reduzida.

Etiologic profile of acute diarrhea in children in São Paulo

OBJECTIVE: To evaluate the etiologic profile of acute diarrhea in socioeconomically deprived children assisted at a regional pediatric emergency care service. METHODS: During two years all children with acute diarrhea assisted at a previously established day and week time schedule were included in the study. Other selective criteria were: a) age less than 5 years; b) nonuse of antibiotics in the previous month; and c) no travel outside the city in the previous month. Stool examination was used for the detection of the following microorganisms: a) rotavirus (immunofluorescence and counterimmunoelectrophoresis); b) bacteria - culture in MacConkey agar, SS agar, Columbia agar, bright green, serotyping, detection of toxins - INV, LT,ST,SLT I, SLT II, Sereny test, detection of virulence factors- EAF, eae, BFP; and c) protozoa (Hoffman and Faust). In the same period, a control group without diarrhea was also evaluated for the same fecal pathogens. RESULTS: Between March 1994 and June 1996, 154 children with acute diarrhea (AD) and 42 control children (WAD), that is, without acute diarrhea, were selected. In the AD group, intestinal pathogens were detected in 112 (72.8%) cases, and in 9 (21.5%) cases in the WAD group. The association of two or more intestinal pathogens occurred in 47 (30.5%) cases in the AD group, and in 3 (7.1%) cases in the WAD group. The pathogens identified in the AD cases were: Rotavirus: 32 (20.8%), bacteria: 53 (34.4%), both: 25 (16.2%), and 2 (1.4%) with Giardia lamblia (in one case associated with Rotavirus and in another one associated with bacteria). In the WAD group, only bacteria were detected in 8 (19.1%) cases, and bacteria associated with Giardia lamblia in 1 (2.4%) case. Altogether, there were 105 bacteria isolated in the AD group: 90 were Escherichia coli (EPEC 27, DAEC 24, ETEC 21, EAEC 18), 12 were Shigella sp, 2 were Salmonella sp, and one was Yersinia sp. Children with mixed infections (viral and bacterial) had increased incidence of severe vomiting, dehydration and hospitalization. CONCLUSIONS: Bacteria were the most frequent pathogens detected in acute diarrhea cases, among which Escherichia coli was highly predominant. The majority of Escherichia coli strains belong to non-EPEC varieties, strains that are not routinely evaluated in clinical laboratories of pathology. Rotavirus was found in a great number of diarrhea cases, often associated with bacteria. Protozoa showed reduced importance.

Comparison between casual blood pressure and ambulatory blood pressure monitoring parameters in healthy and hypertensive adolescents.

Casual blood pressure measurements were compared with mean ambulatory blood pressure values during wakefulness and sleep in 45 normotensive and 30 hypertensive adolescents of both sexes aged 10-18 years. Two sets of auscultatory casual blood pressure were obtained, one in a pediatric office setting (office blood pressure), performed by the physician, and one in the ambulatory blood pressure monitoring (ABPM) unit, performed by a trained nurse, prior to the initiation of ABPM (pre-ABPM blood pressure). In normotensive and hypertensive subjects of both sexes, the mean office systolic blood pressure (SBP) was lower than the mean pre-ABPM SBP, and the mean office diastolic blood pressure (DBP) was lower than the mean pre-ABPM DBP. In normotensive participants, the mean pre-ABPM SBP/DBP was lower than the mean ABPM SBP/DBP while awake, the mean ABPM SBP/DBP during sleep being lower than the mean ABPM SBP/DBP values while awake and the mean pre-ABPM SBP/DBP. No statistical difference was demonstrated between the mean office SBP and the mean ABPM SBP during sleep, the mean ABPM DBP during sleep being lower than the mean office DBP. The hypertensive adolescents presented a blood pressure profile similar to that of the normotensive group, albeit shifted upwards, with no significant difference between the mean pre-ABPM SBP and the mean ABPM SBP while awake but a higher mean pre-ABPM DBP than mean ABPM DBP while awake. This study suggests that, by evaluating the casual blood pressure in different environment/observer situations, the power of casual blood pressure to predict inadequate blood pressure control, manifested as abnormal ABPM parameters, can be enhanced. Our data indicate ABPM to be the method of choice for the early diagnosis and adequate follow-up of adolescent hypertension.

Viral infections in hospitalized children affected by acute lower respiratory tract disease

OBJECTIVE: To evaluate the frequency of the main respiratory viruses in hospitalized children affected by acute lower respiratory tract disease at a university hospital. METHODS: This is a prospective trial that included two cohorts of hospitalized children in the period from April to July 1996. The groups were selected according to the presence of lower respiratory tract disease on admission: Group A- with acute disease (history of less than 7 days) and B- without present or recent respiratory disease. The parameters for defining lower respiratory tract disease included physical and/or radiological pulmonary changes. Clinical and radiological criteria were established for the classification of lower respiratory tract diseases in group A. Nasopharyngeal swab was collected from all children on admission for viral detection by cellular cultures and direct immunofluorescence. RESULTS: 201 cases were selected, 126 in group A and 75 in group B. Viruses were identified in 71 children from groupA(56.4%) and only in 3 from group B (4.0%). The predominant agent in group A was respiratory syncytial virus, identified in 66 cases; adenovirus (4) and influenza (1) were detected in other patients. In group B two patients with respiratory syncytial virus and one with adenovirus were identified. The patients from group A affected by respiratory syncytial virus were younger (median age 3 months versus 13 months) and more wheezy on physical examination (78.7%) than the other patients of the group (33.3%). This virus was associated to most of the bronchiolitis cases (84%) and to half of the pneumonia cases (46.4%). CONCLUSION: The authors found a significant presence of viruses in the majority of children hospitalized with acute lower respiratory tract disease. The respiratory syncytial virus was the predominant agent identified. These results are similar to others previously reported both in developed and some developing countries. The authors emphasize that the present study evaluated only partially the possibility of simultaneous infection by other pathogens and that the present protocol was conducted during the season with the highest incidence of respiratory syncytial virus.

Sequelae from meningococcal meningitis in children: a critical analysis of dexamethasone therapy

OBJECTIVE To evaluate the effectiveness of dexamethasone as an adjunctive therapy to antibiotics in children with meningococcal meningitis. METHOD A total of 81 children diagnosed with meningococcal meningitis hospitalized in sequence were studied at the University Hospital of São Paulo University, with the objective of evaluating the presence of sequelae in four different groups of patients, following the administration of dexamethasone: Group I - 25 patients who received the first dose at least 10 minutes before the introduction of the antibiotic therapy; Group II - 19 patients who received the corticosteroid concomitantly; Group III - 14 patients for which the dexamethasone was administered after beginning the antibiotic scheme; Group IV - 23 patients that did not receive dexamethasone. The groups were evaluated for homogeneity through the prognostic indexes and clinical and laboratory characteristics, based on the records obtained at hospitalization. RESULTS Some degree of sequelae occurred in 16 (26.22%) of the survivors and 23 patients (28.39%) coursed with sequelae or died. The mean period of neurological attendance was 36.97 months and neurological alterations were detected in 16.17% of the patients. No significant difference was found between the four groups. There was also no statistical difference in the comparison of the neurological sequelae in the children from group IV with the children of groups I and II or even with groups I, II and III analyzed as a whole. The presence of hearing loss occurred in 11.11% of the patients, again there was no significant difference between the four groups. Psychological evaluation was performed using the WPSSI and WISC tests. A mild mental disability was detected in one patient from group I and another in group III. The overall analysis of the sequelae (neurological, auditory and intellectual level) also did not demonstrate any significant difference between the four groups. Comparing the children from groups I and II together and also groups I, II and III as a whole with the children in group IV also failed to detect a significant difference arising from the use or nonuse of the corticosteroid. CONCLUSION Dexamethasone was not proven to be effective in decreasing the number of sequelae among patients with meningococcal meningitis.

Tumor necrosis factor-alpha, interleukin-1beta and interleukin-6 in the cerebrospinal fluid of newborn with meningitis

OBJECTIVE To analyze the usefulness of determining the cerebrospinal fluid (CSF) levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta) and interleukin-6 (IL-6) for the early diagnosis and evaluation of the prognosis of neonatal meningitis. METHOD We studied 54 newborn that underwent lumbar puncture. Thirty patients had meningitis and 24 were the control group. CSF and sera were obtained at the moment of suspicion of meningitis and stored at -70 degrees C. Cytokines were performed by enzyme-linked immunosorbent assay method. RESULTS CSF cytokines were detected in all the newborn with meningitis. TNF-alpha was detected in the CSF in 63.3% of the neonates, IL-1beta in 73.3% and IL-6 in 96.6%. The CSF levels were significantly higher than serum in neonates with meningitis. There was no correlation between the CSF levels of cytokines and neurologic complications. CONCLUSION The detection of TNF-alpha, IL-1beta and IL-6 in the CSF is of great value in order to achieve a early diagnosis of neonatal meningitis. Among the three cytokines analyzed, IL-6 was the best indicator of meningeal inflammation.

Cervical necrotizing fasciitis in an infant caused by Haemophilus non influenzae

We describe a rare case of cervical necrotizing fasciitis caused by Haemophilus non influenzae in a 5-month-old infant who was concomitantly affected by bacteremia, pneumonia and meningitis. The patient had a satisfactory evolution after treatment with antibiotics, intensive clinical support, and five surgical debridements of the lesion. A previously healthy 5-month-old boy was brought to the Emergency Room with fever and enlargement of the neck associated with vomiting and irritability during the 3 previous days. There was no history of previous trauma nor significant infections. The immunization schedule had not included a vaccine against Haemophilus. The infant was found to be febrile, irritable, pale and dehydrated, with signs of respiratory distress and upper airway obstruction. Examination of the oral cavity revealed the presence of a purulent secretion covering the pharynx. The skin in the cervical region appeared stretched and erythematous, and there were dark purple spots in the right submandibular area. The tissues had a hard consistency without fluctuation points. Lung auscultation showed bilateral rales and inspiratory stridor. X-rays of the cervical area showed a hyperextended cervical lordosis and a diffuse radiolucent area in the retropharyngeai region. Ultrasonographic and computerised tomography (CT) of the neck and skull revealed extensive swelling of the soft cervical tissues. The chest scan disclosed condensations in the lower two thirds of the right lung and in the left pulmonary base, which were barely visible in the X-ray. The infant was admitted to the Intensive Care Unit where laboratory tests conducted showed some abnormal blood results: anaemia, leukopenia withneutrophil ia, increased prothrombin and activated partial thromboplastin time, and analysis of the arterial gases revealed hypoxemia. The cerebrospinal fluid yielded an elevated cellularity mostly of polymorphonuclear cells, as well as high protein and low glucose content. CSF bacterioscopy presented intraand extra-cellular gram-negative pleomorphic bacilli, but the culture was found to be negative. Three blood cultures in brain heart infusion (BHI) medium were performed and subsequently replicated in chocolate agar incubated in carbon dioxide [1]. Samples for culture in tryptic soy broth (TSB) with polianetol sodium sulphonate in anaerobiosis were also collected. The clinical laboratory picture led to a diagnosis of necrotizing fasciitis of the cervical region with meningitis and bilateral bronchopneumonia. Due to his respiratory insufficiency, the infant was submitted to orotracheal intubation and mechanical ventilation. Parenteral antimicrobial therapy was started with clindamycin and ceftriaxone. Surgical intervention was subsequently performed to decompress the airways and remove necrotic tissues. Bacterioscopic examination of the secretion showed the presence of gram-negative coccobacilli which, however, did not grow either in BHI subcultured in chocolate agar under CO 2 or in TSB under anaerobiosis. The patient s initial outcome was unfavourable. Another CT scan disclosed the presence of gas in the soft tissues of the cervical region. The blood cultures allowed the identification of Haemophilus sp. non influenzae, resistant to the antibiotics in use but susceptible to chloramphenicol [2]. After the therapeutic change to chloramphenicol, the infant showed overall improvement. However, the cervical lesion continued to show new necrotic areas and four other debridements were performed. The patient was discharged on day 34 and was followed up by the outpatient clinic team for I year, showing no functional impairment or relevant infections. Immunologic evaluation tests remained normal throughout this period. Our literature review revealed that this is the first documented case of necrotizing fasciitis caused by Haemophilus non influenzae in children, although other previous cases may have not been recognized [3, 4]. There are two reports of necrofizing fasciitis in infants caused by Haemophihts influenzae [5, 6]. The first is similar to the one described here in its pharyngeal onset and cervical involvement: however, three other pathogens including two anaerobic bacteria were also involved [5]. In the other case, the bacteria caused an isolated infection in a 13-month-old infants leg where there might have been a previous trauma [6]. In a recent literature review, only Haemophihts influenzae is mentioned among the various bacteria potentially causing necrotizing fasciitis in children, whereas this aetiology is recognized in adults [7, 8]. The most frequent causal agents of necrotizing fasciitis are group A beta-hemolytic streptococci and Staphylococcus aureus which may act separately, in conjunction with, or associated with other pathogens. For the other aerobic and anaerobic bacteria, a synergistic action is considered essential to the occurrence of necrosis of the fascia and other deep soft tissues, but this was not observed in the present case [5, 10]. In our infant, only Haemophihts sp. was isolated from the blood and observed in the material collected from the cervical lesion and the spinal fluid [111 . The hypothesis of a simultaneous occurrence of infection caused by strictly anaerobic bacteria was considered, given the high fiequency of these agents in deep infections of the neck and the local presence of gas revealed by the CT scan [5]. The fact that these agents were neither observed at the microscopy nor isolated from the specific culture led us to the conclusion that these bacteria are probably not involved. It is possible that the tissue gas was produced by Haemophilus non influenzae which can act as a gas-producing facultative anaerobic bacterium [3]. The occasional pathogenicity of Haemophilus non influenzae in various severe diseases in.children as well as its frequent presence in the upper airways are recognized [3]. The high virulence of~the strain involved in the case reported here could be indirectly inferred through observation of multiple infectious sites caused in this immunocompetent infant. Unfortunately, the loss of viability of the strain in culture did not permit a conclusive identification of the species of this Haernophilus non influenzae. There is, however, indirect evidence of the species involved. The bacterial growth was found to be dependent only on factor X

Influence of nephrotic state on the infectious profile in childhood idiopathic nephrotic syndrome

UNLABELLED Patients with idiopathic nephrotic syndrome present alterations in their cellular and humoral immune reactions that predispose them to the development of infectious processes. PURPOSE To characterize the infectious processes in patients with idiopathic nephrotic syndrome. PATIENTS AND METHODS Ninety-two children and adolescents with idiopathic nephrotic syndrome were assessed retrospectively. The types of infection were grouped as follows: upper respiratory tract infections; pneumonia; skin infections; peritonitis; diarrhea; urinary tract infection ; herpes virus; and others. The patients were divided into 2 groups: Group I (steroid-responsive) n = 75, with 4 subgroups-IA (single episode) n = 10, IB (infrequent relapsers) n = 5, IC (frequent relapsers) n = 14, and ID (steroid-dependent) n = 46; and Group II (steroid-resistant) n = 17. The incidence-density of infection among the patients was assessed throughout the follow-up period. Comparisons for each group and subgroup were done during the periods of negative and nephrotic proteinuria. RESULTS The analysis revealed a greater incidence-density of infections during the period of nephrotic proteinuria in all the groups and subgroups, with the exception of subgroup IA. During the period of nephrotic proteinuria, subgroups IC, ID, and Group II presented a greater incidence-density of infections as compared to subgroup IA. For the period of negative proteinuria, there was no difference in the incidence-density of infections between the groups and subgroups. Upper respiratory tract infections were the most frequent infectious processes. CONCLUSION The nephrotic condition, whether as part of a course of frequent relapses, steroid dependence, or steroid resistance, conferred greater susceptibility to infection among the patients with idiopathic nephrotic syndrome. The results of this study suggest that the best preventive action against infection in this disease is to control the nephrotic state.