Healthcare-Associated Ventriculitis in Children during COVID-19 Pandemic: Clinical Characteristics and Outcome of a First Infection.

During the COVID-19 pandemic, patients in need of neurosurgical care suffered. Elective procedures were postponed, and emergency care visits decreased. Healthcare-associated ventriculitis (HAV) is a serious problem in children, with poor outcomes and frequent relapses. Our objective was to describe the clinical characteristics and the factors associated with a first HAV in children during two years of the pandemic. A retrospective cross-sectional study was performed from January 2021 to December 2022. The inclusion criteria were patients who developed a first HAV after a primary cerebrospinal fluid diversion procedure. The controls included patients without a first infection. Intraoperative and clinical data were extracted from medical records. A total of 199 CSF diversion surgeries were registered. A first infection occurred in 17 patients (8.5%), including 10 with external ventricular drain (EVD) and 6 with ventricular shunts. Gram-positive cocci were identified in 70.6%. Six patients recovered uneventfully, eight had relapse or superinfections, and three eventually died. Twenty patients were included as controls. Factors associated with a first infection were a younger age (median 9 vs. 102 months, p < 0.01), malnutrition (23.5% vs. 0%, p = 0.03), and an EVD placement (58.8% vs. 10%, p = 0.03). None of the intraoperative factors showed statistically significant differences. The rate of HAV was high. Most cases presented in children <1 year and with an EVD.

Fatal case of co-infected of rickettiosis and dengue virus in Mexico / Caso fatal de coinfectada de rickettsiosis y virus del dengue en México

Background: Rocky Mountain spotted fever (RMSF) is a disease spread by an infected tick and it is lethal if patient is not treated on time. Symptom similarities with other exanthematous diseases may delay the diagnosis, which leads to its mortality. Clinical case: We show the lethal case of a patient with medical record of high blood pressure and no history of travel, who lived in Sonora, Mexico. At the beginning, it was suspected that the patient had a dengue virus infection, which was confirmed positive by an ELISA test. Patient's rapid deterioration, multi-organic failure and the characteristics of her exanthema led to the suspicion of the presence of RMSF. We started doxycycline treatment; however, patient died after seven days of evolution. It was confirmed a co-infection of Rickettssia spp. and dengue virus. Conclusion: In rickettsial endemic zones, treatment with doxycycline should be employed in patients with similar symptoms, even though there is evidence of the presence of other etiologic agents.

Introducción: La fiebre maculosa de las Montañas Rocosas (FMMR) es una enfermedad transmitida por garrapatas y es fatal si el paciente no recibe tratamiento. La similitud de sus síntomas con otras enfermedades febriles exantemáticas puede retrasar la sospecha diagnóstica, lo cual contribuye a su mortalidad. Caso clínico: Presentamos el caso fatal de una paciente con antecedente de hipertensión arterial y sin historial de viajes, que era residente de Sonora, México. Al principio se sospechó la presencia de una infección por virus del dengue, confirmada por prueba de ELISA. Su rápido deterioro, la falla multiorgánica y las características de su exantema orientaron la sospecha de FMMR. Se inició tratamiento con doxiciclina; sin embargo, la paciente falleció al séptimo día de evolución. Se confirmó una coinfección de Rickettssia spp. y virus del dengue. Conclusión: En zonas donde la Rickettssia es endémica, el tratamiento con doxiciclina debería iniciarse ante un paciente con síntomas compatibles, aun cuando se tenga evidencia de la presencia de otros agentes etiológicos.

[A fatal case series of Rocky Mountain spotted fever in Sonora, México].

INTRODUCTION: Rocky Mountain spotted fever is a highly lethal infectious disease, particularly if specific treatment with doxycycline is given belatedly. OBJECTIVE: To describe the clinical profile of fatal Rocky Mountain spotted fever cases in hospitalized patients in the state of Sonora, México. MATERIALS AND METHODS: We conducted a cross-sectional study on a series of 47 deaths caused by Rickettsia rickettsii from 2013 to 2016. The diagnosis of Rocky Mountain spotted fever was confirmed in a single blood sample by polymerase chain reaction (PCR) or by a four-fold increase in immunoglobulin G measured in paired samples analyzed by indirect immunofluorescence. Clinical and laboratory characteristics were compared stratifying subjects into two groups: pediatric and adult. RESULTS: There were no differences in clinical characteristics between groups; petechial rash was the most frequent sign (96%), followed by headache (70%) and myalgia (67%). Although that doxycycline was administered before the fifth day from the onset of symptoms, death occurred in 55% of patients. In clinical laboratory, thrombocytopenia, and biomarkers of liver acute failure and acute kidney failure were the most frequent. CONCLUSION: Rocky Mountain spotted fever remains as one of the most lethal infectious diseases, which may be related not only to the lack of diagnostic suspicion and delayed administration of doxycycline, but to genotypic characteristics of Rickettsia rickettsii that may play a role in the variability of the fatality rate that has been reported in other geographical regions where the disease is endemic.

Una serie de casos fatales de fiebre manchada de las Montañas Rocosas en Sonora, México / A fatal case series of Rocky Mountain spotted fever in Sonora, México

Resumen Introducción. La fiebre manchada de las Montañas Rocosas es una infección muy letal, particularmente si no se diagnostica y se trata oportunamente. Objetivo. Describir el perfil clínico de los casos fatales de pacientes con fiebre manchada de las Montañas Rocosas, hospitalizados en Sonora, México. Materiales y métodos. Se analizó una serie de 47 defunciones por fiebre manchada de las Montañas Rocosas en el periodo de 2013 a 2016. El diagnóstico se confirmó mediante reacción en cadena de la polimerasa (PCR) o la cuadruplicación de los títulos de inmunoglobulina G (IgG) en muestras de suero pareadas analizadas mediante inmunofluorescencia indirecta. Se compararon las características clínicas y de laboratorio, estratificando a los sujetos en dos grupos: pediátricos y adultos. Resultados. No hubo diferencias en las manifestaciones clínicas entre los grupos; el exantema petequial fue el signo más frecuente (96 %), seguido por cefalea (70 %) y mialgias (67 %). La muerte ocurrió en el 55 % de los sujetos a pesar de haber recibido doxiciclina antes del quinto día del inicio de los síntomas. Los marcadores de laboratorio más frecuentes fueron trombocitopenia, falla hepática e insuficiencia renal. Conclusión. La fiebre manchada de las Montañas Rocosas es una enfermedad muy letal, lo cual puede estar relacionado con la ausencia de sospecha del diagnóstico y el retraso en la administración de doxiciclina, pero también con características atribuibles a Rickettsia rickettsii que inciden en la variabilidad de los resultados adversos que se han observado en regiones donde la enfermedad es frecuente.

Abstract Introduction: Rocky Mountain spotted fever is a highly lethal infectious disease, particularly if specific treatment with doxycycline is given belatedly. Objective: To describe the clinical profile of fatal Rocky Mountain spotted fever cases in hospitalized patients in the state of Sonora, México. Materials and methods: We conducted a cross-sectional study on a series of 47 deaths caused by Rickettsia rickettsii from 2013 to 2016. The diagnosis of Rocky Mountain spotted fever was confirmed in a single blood sample by polymerase chain reaction (PCR) or by a four-fold increase in immunoglobulin G measured in paired samples analyzed by indirect immunofluorescence. Clinical and laboratory characteristics were compared stratifying subjects into two groups: pediatric and adult. Results: There were no differences in clinical characteristics between groups; petechial rash was the most frequent sign (96%), followed by headache (70%) and myalgia (67%). Although that doxycycline was administered before the fifth day from the onset of symptoms, death occurred in 55% of patients. In clinical laboratory, thrombocytopenia, and biomarkers of liver acute failure and acute kidney failure were the most frequent. Conclusion: Rocky Mountain spotted fever remains as one of the most lethal infectious diseases, which may be related not only to the lack of diagnostic suspicion and delayed administration of doxycycline, but to genotypic characteristics of Rickettsia rickettsii that may play a role in the variability of the fatality rate that has been reported in other geographical regions where the disease is endemic.

Rocky Mountain Spotted Fever and Pregnancy: Four Cases from Sonora, Mexico.

We present a series of four pregnant women with Rocky Mountain spotted fever (RMSF) that occurred in Sonora, Mexico, during 2015-2016. Confirmatory diagnoses were made by polymerase chain reaction or serological reactivity to antigens of Rickettsia rickettsii by using an indirect immunofluorescence antibody assay. Each patient presented with fever and petechial rash and was treated successfully with doxycycline. Each of the women and one full-term infant delivered at 36 weeks gestation survived the infection. Three of the patients in their first trimester of pregnancy suffered spontaneous abortions. RMSF should be suspected in any pregnant woman presenting with fever, malaise and rash in regions where R. rickettsii is endemic.

[Rocky Mountain spotted fever in Mexican children: Clinical and mortality factors]. / Fiebre maculosa de las Montañas Rocosas en niños y adolescentes mexicanos: cuadro clínico y factores de mortalidad.

OBJECTIVE: Characterize clinical manifestations and predictors of mortality in children hospitalized for spotted fever. MATERIALS AND METHODS: Cross-sectional study in 210 subjects with a diagnosis of Rocky Mountain spotted fever (RMSF) in a pediatric hospital in Sonora, from January 1st, 2004 to June 30th, 2015. Data were analyzed using descriptive statistics and multivariate logistic regression. RESULTS: An upward trend was observed in RMSF morbidity and mortality. Fatality rate was 30%.Three predictors were associated with risk of death: delay ≥ 5 days at the start of doxycycline (ORa= 2.95, 95% CI 1.10-7.95), acute renal failure ((ORa= 8.79, 95% CI 3.46-22.33) and severe sepsis (ORa= 3.71, 95% CI 1.44-9.58). CONCLUSIONS: RMSF causes high mortality in children, which can be avoided with timely initiation of doxycycline. Acute renal failure and severe sepsis are two independent predictors of death in children with RMSF.

Fiebre maculosa de las Montañas Rocosas en niños y adolescentes mexicanos: cuadro clínico y factores de mortalidad / Rocky Mountain spotted fever in Mexican children: Clinical and mortality factors

Resumen: Objetivo: Caracterizar las manifestaciones clínicas y predictores de mortalidad en niños hospitalizados por fiebre maculosa de las Montañas Rocosas (FMMR). Material y métodos: Estudio transversal en 210 sujetos hospitalizados por FMMR en un hospital pediátrico de Sonora, entre el 1 de enero de 2004 y el 30 de junio de 2015. El análisis se sustentó en estadística descriptiva y regresión logística multivariada. Resultados: Se apreció un incremento en la incidencia y mortalidad en los casos hospitalizados por FMMR, con una letalidad de 30%.Tres variables se asociaron con el riesgo de muerte: retraso ≥ 5 días en el inicio del uso de doxiciclina (RMa=2.95, IC95% 1.10-7.95), falla renal aguda (RMa=8.79, IC95% 3.46-22.33) y sepsis severa (RMa=3.71, IC95% 1.449.58). Conclusión: La FMMR provoca resultados fatales en niños, que puede evitarse con la administración oportuna de doxiciclina. La falla renal aguda y la sepsis severa son dos predictores de muerte en niños con FMMR.

Abstract: Objective: Characterize clinical manifestations and predictors of mortality in children hospitalized for spotted fever. Materials and methods: Cross-sectional study in 210 subjects with a diagnosis of Rocky Mountain spotted fever (RMSF) in a pediatric hospital in Sonora, from January 1st, 2004 to June 30th, 2015. Data were analyzed using descriptive statistics and multivariate logistic regression. Results: An upward trend was observed in RMSF morbidity and mortality. Fatality rate was 30%.Three predictors were associated with risk of death: delay ≥ 5 days at the start of doxycycline (ORa= 2.95, 95% CI 1.10-7.95), acute renal failure ((ORa= 8.79, 95% CI 3.46-22.33) and severe sepsis (ORa= 3.71, 95% CI 1.44-9.58). Conclusions: RMSF causes high mortality in children, which can be avoided with timely initiation of doxycycline. Acute renal failure and severe sepsis are two independent predictors of death in children with RMSF.