Series de Pediatría Garrahan. El niño y las infecciones / Garrahan Pediatrics Series. The child and the infections

Las consultas pediátricas por temas infectológicos son frecuentes y relevantes durante toda la infancia, desde la etapa neonatal hasta la adolescencia. En este nuevo volumen de las Series Garrahan: El ñino y las infecciones, se han seleccionado temas específicos, sobre la base de la actualización del conocimiento, los cambios epidemiológicos y de las conductas clínicas ocurridos en los últimos años y la necesidad del manejo adecuado de estas afecciones, ya sea ambulatorio o durante la internación. Entre sus aspectos sobresalientes se incluyen: El estudio de temas destacados como el abordaje del niño febril; las infecciones de piel y partes blandas, incluidas las asociadas con mordeduras; las infecciones en el recién nacido; las infecciones respiratorias bajas, incluida la tuberculosis; y las infecciones osteoarticulares, del sistema nervioso central e intraabdominales. La inclusión de un capítulo especial sobre la prevención de infecciones para ayudar a reducir su incidencia. El enfoque práctico, con discusión de casos clínicos y definición de conductas, y ubicando al pediatra en un papel central como coordinador de la atención interdisciplinaria. Aspectos clave y lecturas recomendadas en el cierre de cada capítulo. Una obra actualizada que aporta información científica y la experiencia de los profesionales del Hospital Garrahan, dedicada a todos los miembros del equipo de salud que atienden y cuidan niños dondequiera que trabajen al servicio de la salud infantil

Meningoencefalitis: etiología infecciosa en pacientes pediátricos de un hospital de referencia / Meningoencephalitis: infectious etiology in pediatric patients at a reference hospital

Resumen Introducción: Las causas de meningoencefalitis, meningitis o encefalitis pueden ser infecciosas o no infecciosas. Para el diagnóstico microbiológico se requieren cultivos y pruebas moleculares. El objetivo del estudio fue describir las causas infecciosas de meningoencefalitis y su presentación clínica. Métodos: Estudio transversal realizado en el Hospital Civil de Guadalajara Dr. Juan I. Menchaca. Se incluyeron pacientes mayores de 28 días de vida con síndrome de meningitis, encefalitis o meningoencefalitis. Se identificó la etiología infecciosa mediante cultivos, tinciones de Gram y pruebas moleculares de líquido cefalorraquídeo. Se compararon las características de pacientes con y sin diagnóstico etiológico. Resultados: Se incluyeron en el estudio 50 pacientes con meningoencefalitis (n = 25), meningitis (n = 19) o encefalitis (n = 6). La mediana de edad fue de un año y el 62% de los pacientes fueron de sexo masculino. Se realizó diagnóstico etiológico infeccioso en el 42%: el 65.2% (n = 15) se debió a virus y el 34.8% (n = 8) a bacterias. En los pacientes con diagnóstico etiológico, se presentó un mayor número de leucocitos en líquido cefalorraquídeo (92 leu/mm3 vs. 12 leu/mm3, p = 0.001). Fue más frecuente el antecedente de gastroenteritis (razón de momios [RM]: 3.5; intervalo de confianza al 95% [IC 95%]: 1.007-12.1; p = 0.04) y ante la exploración, fue más frecuente la rigidez de cuello (RM: 3.8; IC 95%: 1-15.2; p = 0.04). Conclusiones: El 42% de los pacientes con meningitis, encefalitis o meningoencefalitis tuvieron diagnóstico etiológico infeccioso. La causa más frecuente fue el enterovirus.

Abstract Background: The etiologies of meningoencephalitis, meningitis or encephalitis may be infectious or non-infectious. For the microbiological diagnosis it is necessary to perform cultures and molecular tests. The objective of this study was to describe the infectious causes of meningoencephalitis and their clinical presentation. Methods: Cross-sectional study performed at the Hospital Civil de Guadalajara Dr. Juan I. Menchaca. Patients older than 28 days of life with meningitis, encephalitis or meningoencephalitis syndrome were included in the study. Infectious etiology was identified through cultures, Gram stains, and molecular tests of cerebrospinal fluid. The characteristics of patients with and without etiological diagnosis were compared. Results: Fifty patients with meningoencephalitis (n = 25), meningitis (n = 19) or encephalitis (n = 6) were included in the study. The mean age was one year and 62% were male. An infectious etiological diagnosis was performed in 42%; 65.2 % (n = 15) were viruses and 34.8% (n = 8) bacteria. In patients with etiological diagnosis, a higher number of leukocytes were found in cerebrospinal fluid (92 leu/mm3 vs. 12 leu/mm3, p = 0.001); the history of gastroenteritis was more frequent (odds ratio [OR]: 3.5; 95% confidence interval (CI): 1.007-12.1; p = 0.04) and upon examination, neck stiffness was more common (OR: 3.8; 95% CI: 1-15.2; p = 0.04). Conclusions: 42 % of the patients with meningitis, encephalitis or meningoencephalitis had an infectious etiological diagnosis; the most frequent cause was enterovirus.

Disseminated toxoplasmosis in a patient with advanced acquired immunodeficiency syndrome

Extracerebral toxoplasmosis, with pulmonary involvement and shock, is a rare form of toxoplasmosis in patients with advanced AIDS. It can mimic pneumocystosis, histoplasmosis, and disseminated tuberculosis, and should be considered in the differential diagnosis of causes of respiratory failure and fulminant disease in this group of individuals, especially in areas where the Toxoplasma gondii infection is highly prevalent and in those without proper use of antimicrobial prophylaxis. We report the case of a 46-year-old male patient who presented to the emergency department with uremia, requiring urgent dialysis. During the laboratorial investigation, the patient had confirmed HIV infection, with a low CD4+ peripheral T-cell count (74 cells/µL). During hospitalization, the patient presented drug-induced hepatitis due to trimethoprim/sulfamethoxazole in a prophylactic dose, requiring interruption of this medication. On the 55th day of hospitalization, the patient developed refractory shock and died. At the autopsy, disseminated toxoplasmosis with encephalitis and severe necrotizing pneumonia were diagnosed, with numerous tachyzoites in the areas of pulmonary necrosis.

Encefalitis de Bickerstaff / Bickerstaff encephalitis

La encefalitis de tallo cerebral es un síndrome que se presenta con alteración del estado de conciencia, oftalmoplejia, ataxia y signos piramidales. Esta condición neurológica rara que fue descrita en 1950 por primera vez, presenta similares características clínicas a Síndrome de Guillain-Barré, por lo que representa un reto diagnóstico para el clínico. En este artículo se presenta el caso clínico de una paciente de 51 años de edad que se presenta con alteración del estado de conciencia, es llevada a unidad de cuidado intensivo de adulto donde se considera el diagnóstico de encefalitis de Bickerstaff, tras un exhaustivo abordaje diagnostico; el cual se describe, al igual que sumanejo y evolución...(AU)

Brain stem encephalitis is a syndrome that presents with altered state of consciousness, ophthalmoplegia, ataxia and pyramidal signs. This rare neurological condition that was described in1950 by The first time, it presents similar clinical characteristics to Guillain-Barré syndrome, which represents a diagnostic challenge for the clinician. This article presents the clinical case of a 51-year-old patient who presents with altered state of consciousness, is taken to the adult intensive care unit where the diagnosis of Bickerstaff encephalitis is considered, after an exhaustive diagnostic approach ; which is described, as well as its management and evolution ... (AU)

Clinical and cerebrospinal fluid findings contribute to the early differentiation between infectious and noninfectious encephalitis

Early recognition and prompt specific treatment are crucial factors influencing the outcome of patients with acute encephalitis. The aim of this study was to determine the main causes of acute encephalitis in our population and to find predictors that may lead to specific diagnosis. Adult patients admitted to our hospital with suspected diagnosis of encephalitis in the period 2006-2013 were included. One hundred and five medical records were analyzed. Eighty-two patients with infectious encephalitis were identified (78% of total cases), 53 (65%) men and 29 (35%) women, mean age 47.8 years. The most common microorganisms identified were: HSV-1 (11%), VZV (10%), HSV-2 (5%) and EBV (5%). Twenty-three patients (22% of the series) had non-infectious encephalitis. Headache (p < 0.0001) and fever (p = 0.008) were more frequent in encephalitis of infectious origin. Protein levels and white blood cell counts in the cerebrospinal fluid were significantly higher in patients affected by infectious encephalitis than in those affected by noninfectious encephalitis (OR 95% CI 12.3 [2.9-51.7] and OR 95% CI 7.4 [2-27], respectively). Identifying specific causal agents of acute encephalitis remains a major challenge. Cerebrospinal fluid markers, as well as specific clinical findings, may however contribute to initial differentiation between infectious and noninfectious causes.

El reconocimiento temprano y la instauración del tratamiento adecuado son dos elementos de gran relevancia en el pronóstico de las encefalitis agudas. El objetivo del presente trabajo es determinar las principales causas de encefalitis aguda en nuestro medio, así como buscar predictores que permitan orientar a un diagnóstico determinado. Se revisaron de manera retrospectiva las historias clínicas de todos los pacientes adultos que consultaron en nuestro centro entre 2006 y 2013 con el diagnóstico presuntivo de encefalitis. Ciento cinco pacientes fueron finalmente incluidos en nuestro estudio. Se identificaron 82 pacientes con encefalitis de origen infeccioso (78%), 53 (65%) fueron hombres y 29 (35%) mujeres, con una edad promedio de 47.8 años. Los agentes infecciosos más frecuentes fueron virus: HSV-1 12 (11%), VZV 11 (10%), HSV-2 5 (5%) y EBV 5 (5%). Se diagnosticó encefalitis no infecciosa en 23 (22%) pacientes. La cefalea (p < 0.0001) y la fiebre (p = 0.008) fueron más frecuentes en las encefalitis de origen infeccioso. Además, los niveles de proteínas y células en el LCR fueron significativamente mayores en los casos de etiología infecciosa que en los de etiología no infecciosa (OR 12.3 95%CI [2.9-51.7] y OR 7.4 95%CI [2-27], respectivamente). La identificación de la etiología específica de las encefalitis agudas continúa siendo un gran desafío y en la mayoría de los casos no se identifica el agente causal. Determinados marcadores en el LCR pueden contribuir a la identificación inicial de las encefalitis de etiología infecciosa versus no infecciosa.

Experimental neurocysticercosis: absence of IL-4 induces lower encephalitis / Neurocisticercose experimental: ausência de IL-4 induz menos encefalite

ABSTRACT Neurocysticercosis (NCC) is the most severe clinical manifestation of cysticercosis. One of the factors responsible for its symptomatology is the host inflammatory response. Therefore the influence of interleukin 4 (IL-4) on the induction of encephalitis in experimental NCC was evaluated. Methods BALB/c (WT) and BALB/c (IL-4-KO) mice were inoculated intracranially with Taenia crassiceps cysticerci and euthanized at 7, 30, 60 and 90 days later, the encephala removed and histopathologically analyzed. Results The absence of IL-4 induced greater parasitism. In the initial phase of the infection, IL-4-KO showed a lower intensity in the inflammatory infiltration of polimorphonuclear cells in the host-parasite interface and intra-parenquimatous edema. The IL-4-KO animals, in the late phase of the infection, showed lower intensity of ventriculomegaly, encephalitis, and meningitis, and greater survival of the parasites in comparison with the WT animals. Conclusion The absence of IL-4 induced lower inflammatory infiltration, ventriculomegaly and perivasculitis in experimental NCC.

RESUMO A Neurocisticercose (NCC) é a manifestação clínica mais severa da cisticercose, e um dos fatores responsáveis pela sintomatologia é a resposta inflamatória do hospedeiro. Desta forma avaliou-se a influência da interleucina 4 (IL-4) na indução de encefalite na NCC experimental. Métodos Camundongos das linhagens BALB/c (WT) e BALB/c (IL-4-KO) foram inoculados intracranialmente com cisticercos de Taenia crassiceps e eutanasiados aos 7, 30, 60 e 90 dias após a infecção, os encéfalos foram removidos e analisados histopatologicamente. Resultados A ausência da IL-4 induziu um maior parasitismo nos animais. Na fase inicial da infecção os animais IL-4-KO apresentaram menor intensidade tanto de infiltrado inflamatório de polimorfonucleares na interface parasito-hospedeiro quanto de edema intraparenquimatoso. Os animais IL-4-KO, na fase tardia, apresentaram menor intensidade de ventriculomegalia, encefalite, meningite e maior sobrevivência dos cisticercos em relação aos animais WT. Conclusão A ausência da IL-4 induz menos infiltrado inflamatório, ventriculomegalia e perivasculite na NCC experimental.

Toxoplasmic encephalitis: role of Human Leucocyte Antigens/alleles associated with rapid progression to Acquired Immunodeficiency Syndrome

Abstract Background/aims The frequency of Human Leucocyte Antigens/alleles associated with rapid progression from Human Immunodeficiency Virus infection to Acquired Immunodeficiency Syndrome was evaluated in Brazilian patients with Acquired Immunodeficiency Syndrome with and without Toxoplasmic Encephalitis. Methods 114 patients with Acquired Immunodeficiency Syndrome (41 with Toxoplasmic Encephalitis, 43 with anti-Toxoplasma gondii antibodies, without Toxoplasmic Eencephalitis, and 30 without anti-Toxoplasma gondii antibodies circulating and without Toxoplasmic Encephalitis) were studied. Results Human Leucocyte Antigens/alleles associated with rapid progression to Acquired Immunodeficiency Syndrome, particularly HLA-B35, -DR3, and -DR1 allele group, were significantly less represented in patients with Toxoplasmic Encephalitis and Acquired Immunodeficiency Syndrome. Conclusion The presence of these Human Leucocyte Antigens/Alleles that predispose to Acquired Immunodeficiency Syndrome progression was associated with resistance to Toxoplasmic Encephalitis among Human Immunodeficiency Virus-1 carriers.