Surface TREM-1 as a Prognostic Biomarker in Pediatric Sepsis.

OBJECTIVES: To investigate the association between the triggering receptor expressed on myeloid cells-1 (TREM-1) levels and prognosis in septic children. METHODS: Patients admitted to pediatric intensive care units (PICU) of three tertiary centers were included in this prospective observational study. Serum samples were taken at admission from patients who were hospitalized with sepsis. RESULTS: Of the 87 patients included, 34 (39.1%) had severe sepsis and 53 (60.9%) had septic shock. The median age was 2 y (2 mo to 16 y). TREM-1 values were found to be significantly higher in septic shock patients 129 pg/ml (min 9.85- max 494.90) compared to severe sepsis 105 pg/ml (min 8.21- max 289.17) (p = 0.048). Despite higher TREM-1 levels been measured in non-survivors compared to survivors, it was not statistically significant [168.98 pg/ml (min 9.85- max 494.90) vs. 110.79 pg/ml (min 8.21- max 408.90), (p = 0.075)]. CONCLUSIONS: Admission TREM-1 levels were higher in septic shock compared to severe sepsis patients. There was no association between mortality and TREM-1 levels in sepsis. TREM-1 measurements should be used carefully in pediatric sepsis prognosis.

Osteomyelitis Caused by Bacillus Calmette-Guérin Vaccination in a Healthy Toddler.

Bacillus Calmette-Guérin (BCG) osteomyelitis in immunocompetent children is a rare complication of BCG immunization which presents with nonspecific findings and often leads to delayed diagnosis. We report a 1-year and 10-month-old male infant with complaining of knee pain and limping for 5 months. He received surgical debridement due to suspicion of malignancy but BCG osteomyelitis of the distal femur was diagnosed with the culture of the specimens which revealed to have Mycobacterium bovis-BCG strain. He was successfully treated with antituberculous therapy lasting for 1 year.

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.

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.

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.

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

Abstract 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.

Diagnostic Accuracy of Interleukin-6, Interleukin-8, and Interleukin-10 for Predicting Bacteremia in Children with Febrile Neutropenia.

Despite improvements in diagnosis and treatment, infections are still a major cause of morbidity and mortality in children with febrile neutropenia. In the majority of febrile episodes, the source of infection cannot be defined. In this study, we aimed to identify the earlier predictors of bacteremia/fungemia and a useful cytokine to identify the source of infection and to discriminate the patients with culture-confirmed bacterial/fungal infection. The most sensitive cytokine was interleukin (IL)-10 and the most specific was IL-8 in predicting culture-confirmed cases. IL-8 had greater sensitivity and specificity in determination of gram-negative bacterial infections with a higher negative predictive value; therefore, IL-8 can be used particularly to rule out gram-negative bacterial infections. IL-6, IL-8, and IL-10 circulating levels were shown to be higher in cases of infection. Further studies are needed to recommend a routine practice for predicting culture-confirmed bacterial infections.

Mild encephalitis/encephalopathy with reversible splenial lesion (MERS) associated with Streptococcus pneumoniae Bacteraemia.

Mild encephalopathy with a reversible splenial lesion (MERS) is a clinico-radiological syndrome that can be related to infectious and non-infectious conditions. Patients present with mild neurological symptoms, and magnetic resonance imaging typically demonstrate a reversible lesion with transiently reduced diffusion in the splenium of the corpus callosum. Here, we describe MERS in a 10-year-old boy who presented with fever and consciousness and who completely recovered within a few days. Streptococcus pneumoniae was the causative agent. Although viruses (especially influenza A and B) are the most common pathogen of MERS, for proper management, bacteria should be considered, as they may also lead to this condition.

Utility of the serum galactomannan assay for the diagnosis of invasive aspergillosis in children with acute lymphoblastic leukemia.

OBJECTIVES: Invasive aspergillosis (IA) is an important cause of mortality and morbidity in children with hematological malignancies. The monitoring of serum galactomannan (GM) antigen is considered useful in the diagnosis of IA . The aim of this study was to determine the utility of serum GM monitoring in the early diagnosis of IA and the role of positive antigenemia in the management of children with acute lymphoblastic leukemia (ALL). METHODS: The cases of 141 children who were being treated for ALL in the Division of Pediatric Hematology of the Medical School of Ege University between January 2006 and February 2015 were reviewed retrospectively. Cases of proven and probable IA were defined according to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. RESULTS: The incidence of proven and probable IA was 3.5% (5/141). The incidence of positive GM antigenemia among 3264 serum samples was 5.5% (n=179). Of the cases detected, 21.7% were true-positive, 52.1% were false-positive, and the remaining 26.1% were classified as 'undetermined.' An increase in the incidence of true-positive tests and induction of antifungal therapy was determined through multiple consecutive positive tests. CONCLUSIONS: GM may be detected in the serum before the clinical signs of IA appear, but its sensitivity and specificity are variable. False-positivity is a significant disadvantage, and consecutive positive GM must be taken into account in the case of clinical and imaging findings that are relevant to IA.

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.

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.

Comparison of endotracheal aspirate and non-bronchoscopic bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia in a pediatric intensive care unit.

Ventilator-associated pneumonia (VAP) is defined as pneumonia occuring in any period of mechanical ventilation. There is no optimal diagnostic method in current use and in this study we aimed to compare two non-invasive diagnostic methods used in diagnosis of VAP in children. This prospective study was conducted in 8 bedded Pediatric Intensive Care Unit at Ege University Children´s Hospital. Endotracheal aspiration (ETA) and non-bronchoscopic bronchoalveolar lavage (BAL) were performed in case of developing VIP after 48 hours of ventilation. Quantitative cultures were examined in Ege University Department of Diagnostic Microbiology, Bacteriology Laboratory. Fourty-one patients were enrolled in the study. The mean age of study subjects was 47.2±53.6 months. A total of 28 in 82 specimens taken with both methods were negative/negative; 28 had positive result with ETA and a negative result with non-bronchoscopic BAL and both results were negative in 26 specimens. There were no patients whose respiratory specimen culture was negative with ETA and positive with non-bronchoscopic BAL. These results imply that there is a significant difference between two diagnostic methods (p < 0.001). Negative non-bronchoscopic BAL results are recognized as absence of VAP; therefore, ETA results were compared with this method. ETA's sensitivity, specificity, negative and positive predictive values were 100%, 50%, 100% and 48% respectively. The study revealed the ease of usability and the sensitivity of non-bronchoscopic BAL, in comparison with ETA.

Mannose-binding lectin gene codon 54 polymorphism susceptible to brucellosis in Turkish children.

Genetic factors are as important as environmental factors in susceptibility to brucellosis. Among these genetic factors, mannose-binding lectin (MBL) deficiency contributes to susceptibility to animal brucellosis. The aim of the study is to determine the influence of codon 54 polymorphisms in the MBL gene on susceptibility to brucellosis. Forty-three patients diagnosed with brucellosis and 106 healthy children were admitted in the study. In the patient group, 19 (44.2%) subjects had AA, 22 (51.1%) subjects had AB and 2 (4.6%) subjects had BB genotypes for codon 54 polymorphism. Eighty-two (77.4%) of the healthy children had AA genotype, while 24 (22.6%) had AB genotype. Our results revealed that genotype frequencies carrying MBL variant allele at codon 54 among the patients were significantly higher compared to those found in the control group (55.8% and 22.6%, respectively; p = 0.0001, odds ratio [OR] = 4.316, 95% confidence interval [CI]: 2.030-9.177). Our data suggest that children with MBL codon 54 AB or BB genotype are more susceptible to brucellosis.

Hemophagocytic lymphohistiocytosis associated with H1N1 virus infection and visceral leishmaniasis in a 4.5-month-old infant.

We present a case of a 4.5-month-old boy from Turkey with hemophagocytic lymphohistiocytosis (HLH) associated with H1N1 virus and Leishmania spp. coinfection. Because visceral leishmaniasis can mimic hematologic disorders like HLH, it is important to rule out this clinical condition before starting immunosuppressive therapy. In our case, treatment with liposomal amphotericin B resulted in a dramatic resolution of clinical and laboratory abnormalities.

Evaluation of device-associated infections in a neonatal intensive care unit.

Device-associated infections are common in Neonatal Intensive Care Units (NICUs) in accordance with the frequent use of invasive devices, and they must be continuously and closely monitored for infection control. Six hundred newborn infants hospitalized longer than 72 hours in Ege University Children's Hospital NICU between January 2008 and December 2010 were prospectively followed for occurrence of device-associated infections (central venous catheter- and umbilical catheter-associated blood stream infections [CVC/UC BSI] and ventilator-associated pneumonia [VAP]). In a total of 10,052 patient days, the VAP rate was 13.76/1000 ventilator days with a ventilator utilization ratio of 0.29, and the CVC/UC BSI rate was 3.8/1000 catheter days with a catheter utilization ratio of 0.24. The CVC/UC BSI rate was lower than national averages, being close to rates reported from developed countries. The VAP rate was higher than the national and international rates and was associated with prolonged mechanical ventilation and very low birth weight. VAP also appeared to be an important risk factor for mortality. The most frequent agents were gram-negative pathogens for VAP and coagulase-negative staphylococci for CVC/UC BSIs, with resistance patterns similar to the previous years. In conclusion, with device utilization rates similar to those in developed countries, our CVC/UC BSI rate was comparable, but the VAP rate was higher than that of the developed countries. Necessary precautions are urgently needed to decrease VAP rates and VAP-related mortality.

Hemophagocytic lymphohistiocytosis associated with H1N1 virus infection and visceral leishmaniasis in a 4.5-month-old infant / Linfohistiocitose hemofagocítica associada pela infecção do vírus H1N1 e leishmaniose visceral em um bebê de 4,5 meses de vida

We present a case of a 4.5-month-old boy from Turkey with hemophagocytic lymphohistiocytosis (HLH) associated with H1N1 virus and Leishmania spp. coinfection. Because visceral leishmaniasis can mimic hematologic disorders like HLH, it is important to rule out this clinical condition before starting immunosuppressive therapy. In our case, treatment with liposomal amphotericin B resulted in a dramatic resolution of clinical and laboratory abnormalities.

É relatado um caso de um menino de 4,5 meses de idade, da Turquia, com linfohistiocitose hemofagocítica (HLH) associado à coinfecção com o vírus H1N1 e leishmaniose visceral. Como a leishmaniose visceral pode imitar doenças hematológicas como HLH, é importante afastar essa condição clínica antes de iniciar a terapia imunossupressora. No caso relatado, o tratamento com anfotericina B lipossomal resultou em uma resolução dramática das anomalias clínicas e laboratoriais.