Acute Suppurative Thyroiditis in Children: Clinical Decision-Making.

Acute suppurative thyroiditis are infrequent infections, although their early and proper management are needed to reduce complications and recurrences. We review the clinical presentation, etiology, clinical outcome and management of 9 cases of thyroid infections diagnosed in children, and analyze the existence of predisposing factors for these infections.

Fatal Pulmonary Veno-Occlusive Disease and Systemic Juvenile Idiopathic Arthritis: Case Report and Literature Review.

Systemic juvenile idiopathic arthritis (sJIA) is a chronic childhood inflammatory disease. SJIA accounts for approximately 5-15 per cent of all cases of JIA and has a high morbidity and mortality rate. In this disease, pulmonary complications (PC) other than pleuritis are much less frequent and not easily recognised by clinicians. Pulmonary hypertension, the most severe PC, is associated with uncontrolled disease and use of biologic therapies. We present a case of a school-age female with sJIA who died of acute cardiopulmonary instability secondary to pulmonary venous-occlusive disease demonstrated by necropsy. We describe her clinical evolution. We also undertook a narrative review of the literature about PC in sJIA to discuss the current state of the art regarding this complication. High disease activity and the use of multiple therapies include disease-modifying anti-rheumatic drugs should be a red flag for clinicians when discounting PC and pulmonary hypertension. The combination of chest X-ray, electrocardiogram and echocardiogram appear to be the best tests to achieve an early diagnosis.

Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives.

INTRODUCTION: In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS: A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS: 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P < .001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P < .001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72 h. CONCLUSIONS: The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

[Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives]. / Descenso del uso de broncodilatadores en el manejo de la bronquiolitis tras aplicar iniciativas de mejora.

INTRODUCTION: In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS: A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS: 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6%-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P<.001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P<.001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72h. CONCLUSIONS: The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

Acute Appendicitis in Children During the COVID-19 Pandemic: Neither Delayed Diagnosis Nor Worse Outcomes.

AIM: The aim of this study was to describe the incidence of complicated appendicitis during the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic lockdown. METHODS: This was a retrospective study of pediatric patients diagnosed with acute appendicitis in a single pediatric institution that assumed care responsibility for most of the pediatric emergencies during the lockdown period in Madrid (Spain). A control group was made up of the same number of patients diagnosed the previous year. RESULTS: One hundred fifty-one patients diagnosed with acute appendicitis were included (77 during self-quarantine and 74 during the previous year). The incidence of complicated appendicitis was 38.9% versus 28.3%, showing no significant differences. The 2 groups were homogeneous, with no differences in time elapsed between symptom onset and first emergency department visit, laboratory test results, median length of stay, intensive care admissions, or patients correctly diagnosed on their first visit. CONCLUSIONS: COVID-19 (coronavirus disease 2019) self-quarantine has not increased the incidence of complicated appendicitis, and children who developed complicated appendicitis did not have worse clinical outcomes. Parents did not delay presenting for medical attention, and emergency department pediatricians did not fail to diagnose this condition. Reorganization of hospital resources, fast-track treatment protocols for noncomplicated appendicitis, and extended use of home-stay hospitalization for complicated appendicitis could have contributed to these favorable outcomes.

Clinical spectrum and risk factors for complicated disease course in children admitted with SARS-CoV-2 infection.

INTRODUCTION: At this time there are still major questions about the characteristics of disease caused by the new coronavirus (COVID-19) in children as well as factors associated with the development of severe forms of the disease. STUDY DESIGN: Retrospective study including patients under 18 years of age admitted with SARS-CoV-2 infection from March 1 to April 30, 2020. Infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) or antibody testing. We describe the epidemiological and clinical data, laboratory and imaging findings, as well as treatment and outcome in these patients. In light of these findings, patients were classified into two severity groups and then compared. RESULTS: Thirty-nine children were included, with a median age of 9 years (range 12 days-16 years); 23 were boys. Cases with uncomplicated disease course (24) mostly presented to the emergency department (ED) with fever and/or respiratory symptoms without significant alterations in laboratory findings. Of the 15 children with a complicated course, 12 developed shock. In addition to fever, they frequently presented altered appearance, extreme tachycardia, abdominal pain, vomiting, diarrhea, rash, and/or conjunctival hyperemia. They also showed greater lymphopenia (p = 0.001), elevated neutrophil/lymphocyte ratio (p = 0.001), C-reactive protein (p < 0.001), procalcitonin (p = 0.001), D-dimer (p < 0.001), and ferritin (p < 0.001). CONCLUSIONS: SARS-CoV-2 infection in admitted children presents with great clinical variability. When provided supportive care, patients with predominant respiratory symptoms without altered laboratory-test results generally have an uncomplicated course. Patients with complicated disease present mainly with fever and abdominal and/or mucocutaneous symptoms. Most develop shock. Elevation of inflammatory markers may allow for early detection and the final outcome is good.

INTRODUCCIÓN: En este momento existen todavía grandes interrogantes acerca de las características de enfermedad causada por el nuevo coronavirus (COVID-19) en los niños, así como acerca de los factores asociados al desarrollo de formas graves de la enfermedad. MÉTODOS: Estudio retrospectivo que incluye pacientes menores de 18 años ingresados debido a infección por SARS-CoV-2. La infección fue confirmada por la reacción en cadena de la transcriptasa inversa-polimerasa (RT-PCR) en tiempo real o por serología. Describimos los datos epidemiológicos y clínicos, los hallazgos de laboratorio y de imágenes, así como el tratamiento y la evolución de estos pacientes. Los pacientes se clasificaron en dos grupos de gravedad y luego se compararon. RESULTADOS: Se incluyeron 39 niños, con una mediana de edad de nueve años (rango 12 días-16 años); 23 eran varones. Los casos con evolución no complicada (24) se presentaron en su mayoría con fiebre y/o síntomas respiratorios sin alteraciones significativas en los hallazgos de laboratorio. De los 15 niños con enfermedad complicada, 12 desarrollaron shock. Además de la fiebre, frecuentemente presentaban alteraciones de la apariencia, taquicardia extrema, dolor abdominal, vómitos, diarrea, erupción cutánea y/o hiperemia conjuntival. También mostraron mayor linfopenia (p = 0,001), elevación de la proporción neutrófilos/linfocitos (p = 0,001), proteína C reactiva (p < 0,001), procalcitonina (p = 0,001), dímero D (p < 0,001) y ferritina (p < 0,001). CONCLUSIONES: La infección por SARS-CoV-2 en niños ingresados se presenta con una gran variabilidad clínica. Cuando se les proporciona tratamiento de soporte, los pacientes con síntomas respiratorios que no tienen alteración de las pruebas de laboratorio, generalmente tienen una enfermedad no complicada. Los pacientes con enfermedad complicada se presentan principalmente con fiebre y síntomas abdominales y/o mucocutáneos, la mayoría desarrollan un shock. La elevación de los marcadores inflamatorios puede permitir una detección temprana y el pronóstico final es bueno.

[Clinical spectrum and risk factors for complicated disease course in children admitted with SARS-CoV-2 infection]. / Espectro clínico y factores de riesgo de enfermedad complicada en niños ingresados con infección por SARS-CoV-2.

INTRODUCTION: At this time there are still major questions about the characteristics of disease caused by the new coronavirus (COVID-19) in children as well as factors associated with the development of severe forms of the disease. STUDY DESIGN: Retrospective study including patients under 18 years of age admitted with SARS-CoV-2 infection from March 1 to April 30, 2020. Infection was confirmed by realtime reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody testing. We describe the epidemiological and clinical data, laboratory and imaging findings, as well as treatment and outcome in these patients. In light of these findings, patients were classified into two severity groups and then compared. RESULTS: Thirty-nine children were included, with a median age of 9 years (range 12 days-16 years); 23 were boys. Cases with uncomplicated disease course (24) mostly presented to the emergency department (ED) with fever and/or respiratory symptoms without significant alterations in laboratory findings. Of the 15 children with a complicated course, 12 developed shock. In addition to fever, they frequently presented altered appearance, extreme tachycardia, abdominal pain, vomiting, diarrhea, rash, and/or conjunctival hyperemia. They also showed greater lymphopenia (p = 0.001), elevated neutrophil/lymphocyte ratio (p = 0.001), C-reactive protein (p < 0.001), procalcitonin (p = 0.001), D-dimer (p < 0.001), and ferritin (p < 0.001). CONCLUSIONS: SARS-CoV-2 infection in admitted children presents with great clinical variability. When provided supportive care, patients with predominant respiratory symptoms without altered laboratory-test results generally have an uncomplicated course. Patients with complicated disease present mainly with fever and abdominal and/or mucocutaneous symptoms. Most develop shock. Elevation of inflammatory markers may allow for early detection and the final outcome is good.

Erythema multiforme-like lesions in children and COVID-19.

During examination of cases of chilblains in children and adolescents, we identified four patients who also showed skin lesions similar to erythema multiforme (EM). They had no other known triggers for EM. One of them had a positive PCR for SARS-CoV-2, while the other three were negative. Skin biopsies from two patients showed features not typical of EM, such as deep perivascular and perieccrine infiltrate and absence of necrosis of keratinocytes. Immunohistochemistry for SARS-CoV/SARS-CoV-2 spike protein showed granular positivity in endothelial cells and epithelial cells of eccrine glands in both biopsies. All patients had an excellent outcome, and had minimal or no systemic symptoms. The coincidence of EM, a condition commonly related to viruses, and chilblains in the setting of COVID-19, and the positivity for SARS-CoV/SARS-CoV-2 spike protein by immunohistochemistry strongly suggest a link between EM-like lesions and SARS-CoV-2.

Chilblains in children in the setting of COVID-19 pandemic.

BACKGROUND: Different skin manifestations of COVID-19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID-19 pandemic. MATERIAL AND METHODS: A retrospective review of 22 children and adolescents with chilblain-like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID-19 in Madrid, Spain. RESULTS: All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D-dimer results, but without systemic symptoms or other laboratory anomalies. SARS-CoV-2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow-up, all cases showed spontaneous marked improvement or complete healing. CONCLUSION: Acute chilblains were observed during COVID-19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown.

[Impact of a new acute bronchiolitis protocol on clinical practice]. / Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda.

INTRODUCTION: The prevalence and the variability of clinical practice in acute bronchiolitis make it a perfect candidate to monitor the proper use of resources. The aim of this study is to analyse the differences in the use of non-recommended resources in the management of bronchiolitis in the Emergency Department, before and after the establishment of a new protocol. METHODS: A retrospective study was conducted on a sample of patients diagnosed with acute bronchiolitis in the Emergency Department of a tertiary hospital, before (December 2014) and after (December 2016) the implementation of a new protocol. A comparison was made on the use of diagnostic tests and treatments in both groups. RESULTS: The analysis included a total of 113 patients with acute bronchiolitis examined in December 2014, and 128 patients in December 2016. The clinical characteristics in both groups were similar. In the post-protocol period, there was a significant decrease in the use of salbutamol, both in the Emergency Department (33.6% vs 19.5%, P<.01) and at discharge (46.7% vs 15.2%, P<.001); adrenaline (12.4% vs 2.4%, P=.002), and nebulised hypertonic saline solution (5.3% vs 0.8%, P=.04). Rapid respiratory syncytial virus (RSV) testing was also decreased (40.7% vs 26.6%, P=.01). This decrease was not associated with an increase in the number of admissions or re-assessments in the Emergency Department. CONCLUSIONS: The establishment of a new protocol for acute bronchiolitis decreased the use of non-recommended resources, mainly the use of bronchodilators and rapid RSV testing.