Zumrut Sahbudak Bal

Proven and probable invasive fungal infections in children with acute lymphoblastic leukaemia: results from an university hospital, 2005–2013

Despite improvements in diagnosis and treatment, invasive fungal infections (IFIs) are still a major cause of morbidity and mortality in immunocompromised patients. The data on IFI among children with acute lymphoblastic leukaemia (ALL) are still scarce, and our aim was to estimate the risk, aetiology and outcome of proven and probable IFIs in children with ALL who did not receive primary prophylaxis over an 8‐year period. Between January 2005 and February 2013, 125 children who were treated for ALL at the Pediatric Hematology Department of the Medical School of Ege University were retrospectively reviewed. Proven and probable IFIs were defined according to revised definitions of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group. The proven and probable IFI incidence was 30/125 (24%). Profound neutropenia was detected in 18 (60%) patients, and prolonged neutropenia was detected in 16 (53.3%) of the patients. The most isolated agents were non‐albicans Candida spp. The crude and attributable mortality was 20% and 13.3% respectively. Profound neutropenia was associated with mortality (P < 0.05). The younger patients were especially at risk for proven IFI. Prolonged neutropenia, to be in the induction phase of chemotherapy, and profound neutropenia were found to be the most common predisposing factors for IFI episodes.

The first reported catheter-related Brevibacterium casei bloodstream infection in a child with acute leukemia and review of the literature

Brevibacterium spp. are catalase-positive, non-spore-forming, non motile, aerobic Gram-positive rods that were considered apathogenic until a few reports of infections in immunocompromised patients had been published. To the best of our knowledge, this is the first report of B. casei catheter-related bloodstream infection in a child with acute leukemia. We aim to enhance the awareness of pediatric hematology and infectious disease specialists about this pathogen and review of the literature.

Tuberculous otomastoiditis complicated by sinus vein thrombosis.

Tuberculosis (TB) is a rare cause of chronic suppurative otitis media and mastoiditis, therefore it is usually not considered in the differential diagnosis of chronic infections of this area, especially when evidence of pulmonary tuberculosis is absent.1 This diagnosis should be considered in patients that do not respond to empirical therapy. An 11-year-old previously healthy male was admitted to our hospital with swelling in the mastoid area. Left ear discharge and otalgia had started two months prior. Empirical antibiotic therapy had been prescribed by a pediatrician. Symptoms had persisted despite appropriate antibacterial treatment. Temporal MRI revealed inflammatory swelling in the left middle ear and the mastoid air cells (Fig. 1). The patient was treated with surgery, metronidazole, and cefazolin. The pathological specimen showed granulomatous tissue with necrosis and Langhans giant cells. Acid-resistant bacilli was positive in the tissue. The patient’s history was reviewed. His grandfather had received treatment for tuberculosis one year prior, thus our patient had taken prophylaxis, but for an inadequate period and improperly. The 48-hour tuberculin test (PPD) measured 21 mm (positive), one BCG scar was observed, and the chest X-ray was normal. Acid-resistant bacilli was

Brain Abscess in Children: A Rare but Serious Infection:

Brain abscess is a rare disease in childhood requiring prompt medical and/or surgical treatment. The objective was to review presentation, management, and outcome of brain abscess in children. We reviewed the clinical and radiological features and outcomes of 18 children (10 females, 8 males), with a median age of 48 months (range 1-182), that presented with brain abscesses and admitted to a tertiary pediatric infectious department between December 2010 and January 2017. One (5.5%) patient underwent craniotomy and 14 (77.7%) had burr hole aspirations. The most common localization was the frontal lobe (33.3%). The survival rate was 94.4%, and long-term neurological sequelae affected 27.7% of the patients. Empiric treatment choices require knowledge of common pathogens and local resistance. The most predominant infections were still upper respiratory infections. Clinicians may treat the children with appropriate choice and duration of antibiotic treatment for upper respiratory tract infections.

Response to a letter to the Editor regarding the prospective evaluation of risk factors and clinical influence of carbapenem resistance in children with gram-negative bacteria infection

We appreciate the interest in our study and would like to respond to the issues raised in relation to statistical bias. We agree with the concern that inadequate data for the combination of prior carbapenem exposure and acquisition of carbapenem-resistant gramnegative (CRGN) infection because there were 28 patients with carbapenem-sensitive gram-negative infection of whom only 1 patient had prior carbapenem exposure. Due to the design of this study, all categorical and demographic variables were recorded by the same author—Nur Bekmezci. The variables of the patients were cross-checked by Zumrut Sahbudak Bal. As a result of your concerns of bias, all statistical data have been reexamined. Relative risk (RR) is a standard measure in biomedical research. It shows the risk of the outcome in 1 group when compared with another group and is generally expressed as the risk ratio in cohort studies and clinical trials. In terms of low incidences of outcomes (<10%), the odds ratio is close to RR. For case-control studies, the estimated frequency of outcome is usually rare, so the odds ratio suggests a method of getting an approximate RR.1 However, if the frequency is higher—as was the case in our study— the odds ratio will overestimate the risk ratio.2 Following reanalysis, we realize that our findings calculated using this formula were presented as RR values. We want to correct the oversight. Fortunately, this in no way directly affected our conclusions. The RR and 95% confidence interval were calculated according to RR = ART / ARC, where ART = the absolute risk of events in the treatment group and ARC = the absolute risk of events in the control group, and are given in Table 1.1 Safiri et al3 reanalyzed the data and found a smaller RR estimate for prior carbapenem exposure (RR, 5.721) with a more precise 95% confidence interval of 1.144-28.607. We reanalyzed the data and found a RR of 8.2963 with 95% confidence interval of 1.110-61.9521. Prior carbapenem exposure has been found to be a major risk factor for acquisition of CRGN infections. We stand by our original aims of enhancing clinicians’ awareness regarding CRGN infections and increasing their adherence to antibiotic stewardship programs.

A fatal case of tuberculous meningitis in a child with juvenile idiopathic arthritis: a diagnostic challenge

The prognosis of tuberculous meningitis, a rare form of extrapulmonary tuberculosis, depends on the stage of treatment initiation. We report a fatal case of tuberculous meningitis. The patient had received successive tumor necrosis factor (TNF) antagonists and abatacept to treat juvenile idiopathic arthritis, with negative results for polymerase chain reaction and acid-fast bacilli on smear, had normal cerebrospinal fluid (CSF) adenosine deaminase and glucose levels. Six weeks post-admission, the CSF culture demonstrated Mycobacterium tuberculosis. The altered immunological responses caused by anti-TNF treatment made the diagnosis challenging. Clinicians should bear this in mind and, if suspected, treatment should be initiated immediately.

The prospective evaluation of risk factors and clinical influence of carbapenem resistance in children with gram-negative bacteria infection

Background: Carbapenem‐resistant gram‐negative (CRGN) infections have been increasing in recent years and associated with significant morbidity, mortality, and health care costs. The aim of this study was to evaluate the epidemiologic and clinical risk characteristics, risk factors, and outcome of CRGN infections and to compare with carbapenem‐sensitive gram‐negative (CSGN) infections in children. Methods: Newly diagnosed CRGN infections in hospitalized children younger than age 18 years were prospectively recorded and all patients infected with a CSGN pathogen in the same unit within 48 hours of diagnosis were included in a control group between April 1, 2014, and December 31, 2014. Results: Twenty‐seven patients with CRGN infections and 28 patients with CSGN infections were enrolled in this study. Ventilator‐associated pneumonia was the most common type of infection in both groups. Prior exposure to carbapenems (relative risk [RR], 11.368; 95% confidence interval [CI], 1.311‐98.589), prolonged hospitalization (RR, 5.100; 95% CI, 1.601‐16.242) were found to be independent risk factors for acquiring CRGN infections. Septic shock was significantly more frequent in the CRGN group (RR, 9.450; 95% CI, 1.075‐83.065). The in‐hospital mortality was higher in the CRGN group (RR, 7.647; 95% CI, 1.488‐39.290). Conclusions: Prior carbapenem exposure and prolonged hospitalization are the most important risk factors for acquiring CRGN infections in our hospital. This study demonstrated, similar to previous reports, that carbapenem resistance increases morbidity, mortality, and health care costs.

Immune thrombocytopenic purpura as sole manifestation and hemophagocytic lypmhohistiocytosis as sole manifestation of Hepatitis A virus infection in two children

Hepatitis A virus (HAV) infection is often asymptomatic or mildly symptomatic in pediatric population, the severity of the disease increases by age. Immune-mediated extrahepatic extrahepatic manifestations and hematologic complications are mainly reported in adults with acute and chronic hepatitis B and C. However, they are relatively rare in children with HAV infection. There are few available pediatric reports in English literature about autoimmune complications of HAV infection. We reported hematologic manifestations of HAV infection including hemophagocytic lymphohistiocytosis (HLH) and immune thrombocytopenic purpura as sole manifestations of HAV infection therefore in patients with these hematologic disorders, HAV infection should be kept in mind in the differential diagnosis even if they are not jaundiced.

Risk Factors for Hospital-Acquired Infection in Pediatric Intensive Care Unit

Ayşe Berna Anıl, Murat Anıl, Nihal Önal Özdemir, Nuri Bayram, Zümrüt Şahbudak Bal, Engin Köse, Nisel Yılmaz, Mehmet Helvacı, Nejat Aksu S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Yoğun Bakım Kliniği, İzmir, Türkiye S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Acil Kliniği, İzmir, Türkiye S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Sağlığı ve Hastalıkları Kliniği, İzmir, Türkiye S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Enfeksiyon Hastalıkları Kliniği, İzmir, Türkiye S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Mikrobiyoloji Kliniği, İzmir, Türkiye S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Çocuk Nefroloji Kliniği, İzmir, Türkiye