Does multiple gastric aspirate collection increase sensitivity of M. tuberculosis detection in children with pulmonary tuberculosis?

This study aims to investigate the sensitivity of microscopy, culture and polymerase chain reaction on three gastric aspirates (GAs) in the microbiological confirmation of active pulmonary tuberculosis (TB) and to identify possible changes in sensitivity derived from the collection of a different number of aspirates. Children with clinical and radiological diagnoses of active pulmonary TB who underwent three GAs between March 2007 and June 2019 were retrospectively evaluated. Clinical, radiological, and microbiological data were collected. The sensitivity of microbiological tests on GAs was calculated. Moreover, differences in sensitivity according to age and radiological pattern were investigated. Overall, 156 children with active pulmonary TB were enrolled with a median age of 51.5 (IQR: 25.2-113.2) months. Microbiological investigations on the first GA showed a sensitivity of 34% (95%CI 26.7, 42), the cumulative sensitivity of first and second GAs was 40.4% (95%CI 32.7, 48.5) and of the three GAs was 47.4% (95%CI 39.8, 55.2). The collection of three GAs leads to an overall increase in sensitivity of the first GA by 13.4% (95%CI 2.8, 24.1%; p=0.014). Moreover, the increase in sensitivity was significantly higher in children ≤ 4 years of age and in those with uncomplicated TB (p=0.008).Conclusions: Performing a higher number of GAs increases the sensitivity of microbiological confirmation of active pulmonary TB, particularly in children ≤ 4 years and with an uncomplicated radiological pattern. What is known: • The diagnosis of paediatric tuberculosis is a challenge for paediatricians • Despite their low sensitivity gastric aspirates represent the standard sample for microbiological confirmation of active pulmonary tuberculosis in children • Most international guidelines recommend performing three sequential gastric aspirates on three consecutive days What is new: • A significant increase in global sensitivity by 13.4% was found by the collection of three gastric aspirates compared to the first one • Performing a higher number of gastric aspirates increases the sensitivity of microbiological confirmation, particularly in children ≤ 4 years and with an uncomplicated radiological pattern.

Unbalanced serum immunoglobulins in clinical subtypes of pediatric tuberculosis disease.

Immune response to tuberculosis (TB) has been extensively studied in the past decades and classically involves cellular immunity. However, evidence suggests that humoral immunity may play a relevant role. Past studies regarding serum immunoglobulin (Ig) levels in TB are dated and only involve adult subjects. In this study, we retrospectively studied a cohort of 256 children with TB disease and analyzed 111 patients screened for total serum Ig at diagnosis. According to the severity and extent of organ involvement, subjects were divided into four groups, namely, uncomplicated pulmonary TB (UCPTB, 56.3% of patients), complicated pulmonary TB (CPTB, 22.5%), lymph node extrapulmonary TB (LN-EPTB, 7.2%), and extra-nodal extrapulmonary TB (EN-EPTB, 13.5%). Serum IgG and IgA levels were significantly higher in more severe and extended TB disease. Median IgG levels progressively increased from uncomplicated to complicated pulmonary and nodal forms, reaching their highest values in diffuse extra-pulmonary TB. In parallel, UCPTB showed significantly lower frequencies of patients presenting a substantial increase in IgG levels when compared with the other three groups. No relevant differences in IgM levels were detected. Ig screening at follow-up showed a significant reduction in IgG and IgA levels. Finally, we unveiled three cases of selective IgA and one case of selective IgM deficiencies (SIgMD), the latter with a severe clinical course. Serum IgG and IgA may be a useful clinical tool to assess the severity and monitor the treatment response in pediatric TB disease. Moreover, immunological workup in children with TB disease may unmask primary defects of humoral immunity.

Artesunate monotherapy versus artesunate plus quinine combination therapy for treatment of imported severe malaria: a TropNet retrospective cohort study.

BACKGROUND: The addition of intravenous quinine (IVQ) to intravenous artesunate (IVA) has been recently suggested by World Health Organization  in areas where artemisinin resistance is highly prevalent. Since IVA is not yet widely available as "Good Manufacturing Practices" product, for several years combination treatment with IVA and IVQ was used in some Italian centers to mitigate the legal risks in using an unlicensed drug. METHODS: A retrospective cohort study was designed to compare IVA + IVQ and IVA treatment for imported severe malaria. We collected data from three Italian centers. Adult and pediatric cohorts were analyzed separately. RESULTS: Forty-nine patients treated with IVA and 44 with IVA + IVQ were enrolled, 45 were adults and 48 children. All acquired malaria in Sub-Saharan Africa. In the adult cohort, median of fever clearance time (FCT) was similar in both groups (48 h vs 48 h, p = 0.19) but number of patients who reached apyrexia within 48 h (FCT48) was higher in IVA group (20/24, 83.3% vs 8/17, 47%, p = 0.002). The parasite clearance time (PCT) measure did not differ (median 48 h vs 48 h, p = 0.669). In the pediatric cohort, FCT did not differ in the two groups (median 30 vs 48 h, p = 0.50) while PCT was longer in IVA + IVQ group (median 72 vs 48 h, p = 0.002). Adverse events (AEs) in adults were more common in the combination treatment group (6/19, 31.58% vs 2/26, 7.69%, p = 0.055). CONCLUSION: IVA + IVQ treatment did not show better outcome with respect to IVA monotherapy. AEs were more frequent in the IVA + IVQ group compared to the monotherapy. Further studies are necessary to investigate whether IVA + IVQ could be an efficient strategy to treat severe malaria cases in areas at high risk of artemisinin resistance.

Real-life isoniazid and rifampicin plasma concentrations in children: a tool for therapeutic drug monitoring of tuberculosis.

BACKGROUND: Low plasma levels of first-line antitubercular drugs can be counted among the main causes of poor response to antitubercular therapy, and therapeutic drug monitoring has been proposed as a method to promote tailored treatments for both child and adult patients. The main aim of the study was to evaluate serum concentrations of isoniazid (INH) and rifampicin (RIF) and to investigate reasons for sub-therapeutic plasma concentrations in order to fix dosages. METHODS: Children with TB were prospectively enrolled from January to August 2019. Two venous blood samples were collected (the first at least 15 days after the beginning of antitubercular treatment, and the second between 1 and 8 weeks later). Plasma concentrations were determined by a validated high-performance liquid chromatography method. RESULTS: In all, 45 children were included. Seventy blood samples for INH plasma concentration were collected between 120 and 240 min after drug intake. Adjusting for dose (mg/kg/day) and time of INH administration, when considering three different age groups (≤ 2 years, 2-12 years, > 12 years), a statistically significant lower INH plasma concentration was observed in younger children compared to the older age groups in the multivariate analysis (p < 0.001 and p < 0.001). A total of 68 blood samples were evaluated for RIF concentrations. Both for INH and RIF a statistically significant lower plasma concentration was also observed in adolescents (p < 0.001). Fifteen children (15/45, 33%) presented drug concentrations under the referral therapeutic range. CONCLUSIONS: Based on our findings, monitoring patients' drug plasma concentrations in children under 2 years of age and in adolescents can make treatment more patient-tailored.

Strongyloidiasis in Children Outside the Tropics: Do We Need to Increase Awareness?

Strongyloidiasis belongs to the group of neglected tropical diseases, due to diagnostic difficulties and the lack of systematic screening. Studies on strongyloidiasis prevalence are often heterogenous and mainly performed in adults in endemic countries. We retrospectively enrolled 2633 children referred to a tertiary care hospital in Italy between 2009 and 2020 and tested for S. stercoralis infection. Sixty-one (2.3%) had a positive serology and for 55 of them, clinical and epidemiological information were available. Thirteen cases (24%) were diagnosed in Italian children without history residency or travel to foreign countries, while the remaining were internationally adopted or migrant children. Seropositive patients were mostly asymptomatic, and often eosinophilia was the only sign of strongyloidiasis. Sero-reactivity to Toxocara canis was found in 1/3 of patients. Ivermectin was used in 37 (75.5%) treated patients. A significant reduction of eosinophil levels and IgG titer was seen after treatment. Our study confirms that strongyloidiasis is usually asymptomatic in children. However, due to the ability of the parasite to cause a life-long infection together with the risk of a severe form in case of immunosuppression, it is important to identify and treat infected children. Special consideration should be reserved to high-risk groups, such as immigrants and international adoptees, where screening for S. stercoralis is indicated. However, the study highlights that sporadic cases of autochthonous strongyloidiasis in Italy may occur. Therefore, pediatricians should be aware of this condition, which is often under-recognized.

Resistance Patterns from Urine Cultures in Children Aged 0 to 6 Years: Implications for Empirical Antibiotic Choice.

PURPOSE: Urinary tract infection (UTI) is a frequent disorder of childhood, caused mainly by Gram negative Enterobacterales. The aim of this study is to evaluate etiology and antimicrobial susceptibility patterns of bacterial isolates in urine cultures of children under the age of 6 and to analyze the relationship between previous hospitalization or antibiotic prescriptions and antimicrobial resistance rates. PATIENTS AND METHODS: A retrospective study on positive urine cultures from 13 public laboratories in Tuscany, Italy was conducted. Data were obtained by reviewing records of the "Microbiological and Antibiotic-Resistance Surveillance System" (SMART) in Tuscany, Italy. A total of 2944 positive urine cultures were collected from 2445 children. RESULTS: Escherichia coli represented the majority of isolates (54,2%), followed by Enterococcus faecalis (12,3%), Proteus mirabilis (10,3%) and Klebsiella pneumoniae (6,6%). Isolated uropathogens showed high resistance rates to amoxicillin-clavulanate (>25%), particularly in children under one year of age or hospitalized within the 12 months before the sample collection. High susceptibility rates were reported of aminoglycosides, cephalosporins and quinolones (>90%). Previous antibiotic prescriptions by general pediatricians did not increase resistance rates. CONCLUSION: Our results show a rate of amoxicillin-clavulanate resistance of 25%. Higher resistance rates were reported in children under one year of age and with previous hospitalization. Hence, amoxicillin-clavulanate should be used carefully in young children and those with severe symptoms.

Epidemiology and clinical features of intestinal protozoan infections detected by Real-time PCR in non-native children within an Italian tertiary care children's hospital: A cross-sectional study.

BACKGROUND: Enteric parasite infections are underestimated due to the limited sensitivity and specificity of microscopy, which remains the diagnostic gold standard in routine clinical practice. This could be a major problem in high-income countries, where the burden of parasitic diseases is low. In recent years, Multiplex Real-Time polymerase chain reaction (RT-PCR) based methods have been implemented. Therefore, the aim of this study was to evaluate the prevalence of four enteric protozoan species detected by RT-PCR in non-native children in Italy, and to describe their clinical characteristics. METHODS: Adopted and immigrant children, evaluated for migration health assessment between 2017 and 2020 in a tertiary care children's hospital in Italy, were enrolled. Molecular analysis for Giardia lamblia, Dientamoeba fragilis, Blastocystis hominis, and Entamoeba histolytica, was conducted by in-house RT-PCR. RESULTS: Overall, 209 children were enrolled and 70% of them resulted positive by RT-PCR for at least one enteric parasite. B. hominis (47.8%) was the most commonly identified protozoa, followed by D. fragilis (44.5%). Co-infections with multiple pathogens were detected in 35.4% of the samples. Almost 80% of parasite-positive children were asymptomatic and the most common symptom was flatulence (60.7% of symptomatic children). Eosinophils were significantly increased in RT-PCR positive children compared to the negative ones and children with D. fragilis presented the highest eosinophils count. CONCLUSIONS: The In-house Multiplex RT-PCR assay provides a valid molecular detection system for selected enteric parasites. This novel and accurate diagnostic method can help in increasing the detection rate of parasite infection, especially in high-risk population.

Early limb paralysis in infants: do not forget about congenital syphilis.

We describe the case of a 2-month-old baby with congenital syphilis, presenting with limb paralysis. The radiological investigations showed periosteal thickenings of the limb. Despite negative maternal serology during the first trimester of pregnancy, clinical and radiological features led to the suspicion of pseudoparalysis of Parrot, which was confirmed by blood tests. Delayed diagnoses or misdiagnoses are possible when uncommon presentations of forgotten diseases occur. The needing for a second screening for syphilis in high-risk pregnant women should be evaluated.

Criteria for referral of pediatric SARS-CoV-2 infection: a real-life experience in the pandemic era.

A practical guidance on the management of children with COVID-19 to insure homogeneous criteria for referral to a higher-level facility, according to the disease severity, is pivotal in the pandemic era. A panel of experts in pediatric infectious diseases and intensive care at the tertiary-care Meyer Children's University Hospital, Florence, Italy, issued a practical document shared with Tuscany hospitals. The rationale was to target the referral for those children at risk of requiring an intensive support, since the above mentioned hospital has the pediatric intensive care unit. Overall, 378 patients between 0 and 19 years of age were diagnosed with COVID-19 infection in the Tuscany region with 24 (6.3%) hospitalizations. Only three children were centralized to Meyer Children's University Hospital according to reported criteria. Considering that appropriate referral criteria have been associated with reduced mortality in other conditions, our document might be useful to improve outcomes of children with COVID-19.

Clinical features and outcomes of lymphadenopathy in a tertiary children's hospital.

AIM: The aim of the present study is to describe the clinical features and outcomes of childhood lymphadenopathy and to define factors able to predict neoplastic aetiology or may improve its prognosis. METHODS: All children evaluated for lymphadenopathy in our tertiary children's hospital and who underwent their first examination between 1 January, 2015 and 31 December, 2017 were enrolled in this retrospective observational study. Data were analysed using SPSS.Statistics, 24.0. RESULTS: A total of 322 children, aged between 0 and 18 years (median 4.5; interquartile range 2.5-9), were enrolled. A specific diagnosis was achieved in almost half of the cases (n = 159, 49.4%) by using one or more methods, including serological, microbiological, biomolecular or histological investigations on surgical samples. Epstein Barr virus and non-tuberculous mycobacteria were the most common etiological agents among acute/sub-acute and chronic lymphadenopathy, respectively. At the end of the study period, two-thirds (210, 65.2%) of enrolled patients were successfully treated. Malignancies and non-tuberculous mycobacteria infections had the longest time to resolution. CONCLUSIONS: Our data suggest that lymphadenopathy is a benign condition in most cases. Of note in our study, 2.5% of lymphadenopathy cases were found to be due to oncologic conditions. The most frequent infective causes were Epstein Barr virus, bacteria and non-tuberculous mycobacteria infections. No haematic or ultrasonographic features were independently able to provide sufficient evidence for a conclusive diagnosis. However, utilising these findings alongside evaluation for clinical criteria can guide decision-making for physicians. Lymphadenectomy is the most appropriate process to follow in the event of chronic lymphadenopathy with undefined diagnosis.

Multiple-dose versus single-dose ivermectin for Strongyloides stercoralis infection (Strong Treat 1 to 4): a multicentre, open-label, phase 3, randomised controlled superiority trial.

BACKGROUND: Strongyloides stercoralis infection is a neglected condition that places people who are immunocompromised at risk of hyperinfection and death. Ivermectin is the drug of choice for the treatment of S stercoralis infection, but there is no definitive evidence on the optimal dose. This trial aimed to assess whether multiple doses of ivermectin were superior to a single dose for the treatment of non-disseminated strongyloidiasis. METHODS: Our study was designed as a multicentre, open-label, phase 3, randomised controlled superiority trial. Participants were enrolled in four centres in Italy, three in Spain, and two in the UK, and recruiting sites were predominantly hospitals. Eligible patients were older than 5 years, weighed more than 15 kg, were residents in an area not endemic for S stercoralis, and either were positive for S stercoralis in faecal tests and on serology (any titre) or had a positive serological test with high titres, irrespective of the result of faecal tests. Patients were randomly assigned (1:1) using a computer-generated, blinded allocation sequence (with randomly mixed block sizes of six, eight, and ten participants) to receive either one dose of ivermectin 200 µg/kg or four doses of ivermectin 200 µg/kg (given on days 1, 2, 15, and 16). The primary endpoint was the proportion of participants with clearance of S stercoralis infection at 12 months, which was assessed in all randomly assigned participants who were not lost to follow-up (modified full-analysis set) and in participants in the modified full-analysis set who did not deviate from the assigned treatment regimen (per-protocol set). All participants were included in the safety analysis. The trial was registered with ClinicalTrials.gov, NCT01570504, and is now closed for recruitment. FINDINGS: Of the 351 patients assessed for eligibility, 309 recruited between March 26, 2013, and May 3, 2017, were randomly assigned to one dose (n=155) or four doses (n=154) of ivermectin. At 12 months in the modified full-analysis set, 86% (95% CI 79 to 91; 102 of 118 participants) had responded to treatment in the single-dose group compared with 85% (77 to 90; 96 of 113 participants) in the four-dose group (risk difference 1·48%, 95% CI -7·55 to 10·52; p=0·75); similar results were observed in the per-protocol set. Adverse events were generally of mild intensity and more frequent in the multiple-dose than in the single-dose group. The trial was terminated early due to futility. INTERPRETATION: Multiple doses of ivermectin did not show higher efficacy and was tolerated less than a single dose. A single dose should therefore be preferred for the treatment of non-disseminated strongyloidiasis. FUNDING: There was no funding source for this study.

Role of Mycobacterium avium lysate INF-γ, IL-17, and IL-2 ELISPOT assays in diagnosing nontuberculous mycobacteria lymphadenitis in children.

Nontuberculous mycobacteria are the most frequent cause of chronic cervical lymphadenitis in childhood. The aim of the study was to evaluate the performance of IL-2, IL-17, and INF-γ in-house enzyme-linked immunospot assays using a Mycobacterium avium lysate, in order to identify a noninvasive diagnostic method of nontuberculous mycobacteria infection. Children with subacute and chronic lymphadenopathies or with a previous diagnosis of nontuberculous mycobacteria lymphadenitis were prospectively enrolled in the study. Sixty children with lymphadenitis were included in our study: 16 with confirmed infection (group 1), 30 probable infected (group 2) and 14 uninfected (group 3). Significantly higher median cytokine values were found in group 1 vs group 2, in group 1 vs group 3, and in group 2 vs group 3 considering IL-2-based enzyme-linked immunospot assay (p = 0.015, p < 0.001, p = 0.004, respectively). INF-γ-based enzyme-linked immunospot assay results were significantly higher in group 2 vs group 3 (p = 0.010). Differences between infected and uninfected children were not significant considering IL-17 assays (p = 0.431). Mycobacterium avium lysate IL-2 and INF-γ-based enzyme-linked immunospot assays seem to be promising noninvasive diagnostic techniques for discriminating children with nontuberculous mycobacteria lymphadenitis and noninfected subjects.

Should Pediatricians Be Aware of Cystic Echinococcosis? A Literature Review.

Among parasitic hepatic cystic lesions, the most common disease is represented by cystic echinococcosis (CE), especially in high endemic countries. European epidemiology of CE in children is difficult to assess because of under-reporting but is increasing, because of high immigration flows from endemic countries and an increased awareness. Hydatidosis can be localized in every part of the body. The liver and lungs are the most common localizations in both children and adults. Multiorgan involvement is rarely reported in children. Different tests are available. Usually the sensitivity of serological screening tests is variable, ranging between 60% and 90%. The immunoblot assay is used as a confirmatory test because of its higher sensitivity and specificity. Radiological tests are the criterion standard for diagnosis of CE, with an ultrasound accuracy of approximately 90%. In case of inactive and uncomplicated cysts the watch-and-wait approach is recommended. Albendazole, currently used for 3 to 6 months consecutively represents the most commonly used drug in children even if there is limited experience in treating children younger than 6 years of age. Percutaneous treatment with the puncture, aspiration, injection, and reaspiration technique is a minimally invasive procedure. Surgery is indicated based on cyst characteristics in case of big cysts with multiple daughter cysts, single superficial cysts at risk of spontaneous or traumatic rupture, cysts related with the biliary tract in which the percutaneous treatment is contraindicated, and cysts compressing related structures.

Latent tuberculosis in childhood: tolerability of two different therapeutic approaches.

BACKGROUND: Isoniazid monotherapy for six or nine months and the combination of isoniazid and rifampicin for three or four months are the most used regimens for treating latent tuberculosis. The main aim of this retrospective study is to evaluate the safety of latent tuberculosis treatment by analysing side effects in both regimens. RESEARCH DESIGN AND METHODS: Children with latent tuberculosis and treated with isoniazid or isoniazid and rifampicin were included. Periodic evaluations with clinical assessment and blood exams were carried out to detect any adverse reaction, including elevated serum transaminases. RESULTS: 441 children were included, 14.5% treated with isoniazid and 85.5% with isoniazid and rifampicin. Five patients under combined treatment developed hepatotoxicity within the first month. None of the patients under isoniazid monotherapy presented hepatotoxicity. A slight increase of transaminases level was found in both groups (18.7% in isoniazid and 10.3% in isoniazid/rifampicin groups, respectively) without causing discontinuation of treatment, with values normalization at the subsequent checks. CONCLUSIONS: Both regimens resulted safe. Hepatotoxicity occurred rarely and within the first month. For this reason, it may be appropriate to perform liver function tests after about one month from the beginning of therapy to avoid diagnostic delays.

The Risk of Mycobacterium tuberculosis Transmission from Pediatric Index Cases to School Pupils.

This study is the largest report on Mycobacterium tuberculosis transmission rate (TR) from children with pulmonary tuberculosis to school pupils. Higher TR (around 21.6%) was observed in contacts of smear-positive children. TR from pediatric smear-negative index cases was around 0. If our data are confirmed, school contacts of a smear-negative index case could be screened only by clinical evaluation and tuberculin skin test, avoiding the routine use of chest radiographs in children less than 5 years of age as well.

Infectious diseases prevalence, vaccination coverage, and diagnostic challenges in a population of internationally adopted children referred to a Tertiary Care Children's Hospital from 2009 to 2015.

Infectious diseases are common in internationally adopted children (IAC).With the objective to evaluate infectious diseases prevalence in a large cohort of IAC and to explore possible risk factors for tuberculosis (TB) and parasitic infections, clinical and laboratory data at first screening visit of all IAC (<18 years) consecutively referred to our Center in 2009 to 2015 were collected and analyzed.In total, 1612 children (median age: 5.40 years; interquartile range: 3.00-7.90) were enrolled, 123/1612 (7.60%) having medical conditions included in the special needs definition. The most frequent cutaneous infections were Molluscum contagiosum (42/1612; 2.60%) and Tinea capitis (37/1612; 2.30%). Viral hepatitis prevalence was <1% (hepatitis B virus [HBV]: 13 children, 0.80%; hepatitis C virus: 1 child, 0.10%; hepatitis A virus: 6 children, 0.40%). A parasitic infection was diagnosed in 372/1612 (23.10%) children. No risk factors for parasitosis were evidenced. Active TB was diagnosed in 4/1355 (0.3%) children, latent TB in 222/1355 (16.40%). Only 3.7% (51/1355) children had concordant positive tuberculin skin test (TST) and QuantiFERON-TB-Gold In-Tube (QFT-G-IT) results. Risk factors for TST+/QFT-G-IT- results were previous Bacille de Calmette-Guérin vaccination (adjusted odds ratio [aOR]: 2.18; 96% confidence interval [CI]: 1.26-3.79; P = 0.006), and age ≥5 years (aOR: 1.49; 95% CI: 1.06-2.11; P = 0.02). The proportion of children with nonprotective titers for vaccine-preventable diseases (VPD) ranged from 15.70% (208/1323) for tetanus to 35.10% (469/1337) for HBV.Infectious diseases were commonly observed in our cohort. The high rate of discordant TST/QFT-G results brings up questions regarding the optimal management of these children, and suggests that, at least in children older than 5 years, only QFT-G-IT results may be reliable. The low proportion of children protected for VPD, confirms importance of a timely screening.