[Correctly adDRESS the cause of hemophagocytic lymphohistiocytosis]. / Pièges diagnostiques d'un syndrome d'activation macrophagique.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe syndrome usually associated with a cytotoxicity deficiency, which leads to an excess of immune response driven by activated macrophages and cytotoxic T cells. In children, HLH can be genetic, as part of a familial lymphohistiocytosis, or secondary: the most frequent causes are systemic-onset juvenile idiopathic arthritis, hematological malignancies, and severe infections, especially with Ebstein-Barr virus or leishmaniosis. We report on the case of a 3-year-old girl with no past medical history, who presented inaugural Pseudomonas aeruginosa maxillary osteitis, with secondary HLH. The rarity of this osteitis, the characteristics of the pathogen, and the onset of HLH oriented the diagnosis toward primary immunodeficiencies, malignancies, or systemic diseases. Steroids were initiated at 2mg/kg/day and were very effective in improving the systemic symptoms. Antibiotic therapy was continued unchanged. A few days after discontinuation of steroids, while the patient was still under antibiotics, she presented with erythroderma. Skin biopsy revealed eosinophil infiltrate in line with the diagnosis of a drug reaction with eosinophilia and systemic symptoms (DRESS), even though we only observed very transient eosinophilia, up to 0.98G/L, during HLH. Stopping antibiotics normalized the symptoms without using systemic corticosteroids. Patch tests confirmed an allergy to piperacillin. These atypical manifestations of DRESS underline that causative diagnosis of HLH is challenging, and DRESS syndrome should be considered.

Bacterial meningitis antibiotic treatment.

The implementation of pneumococal conjugate vaccines (PCVs) 7 then 13 valent (Prevenar13®) in 2010-2011 has significantly changed the profile of pneumococcal meningitis. Since 3 years, the National Pediatric Meningitis Network of the Pediatric Infectious Disease Group (GPIP) and the National Reference Centre of Pneumococci have reported no cases of meningitis due to pneumococcus resistant to third-generation cephalosporins (3GC): cefotaxime or ceftriaxone. In the light of these new data, vancomycin should no longer be prescribed at the initial phase of pneumococcal meningitis treatment (confirmed or only suspected) and this antibiotic should only be added when 3GC minimum inhibitory concentration of the strain isolated is greater than 0.5mg/L. For meningococcal meningitis, nearly 20% of strains have decreased susceptibility to penicillin and amoxicillin, but all remain susceptible to 3GC. The National Pediatric Meningitis Network is a valuable tool because it has been sufficiently exhaustive and sustainable over 15 years. Maintaining this epidemiologic surveillance will allow us to adapt, if necessary, new regimens for subsequent changes that could be induced by vaccination and/or antibiotic uses.

Early impact of 13-valent pneumococcal conjugate vaccine on community-acquired pneumonia in children.

BACKGROUND: Pneumococcal serotypes 1, 3, 5, 7F, and 19A were the most implicated in community-acquired pneumonia (CAP) after implementation of 7-valent pneumococcal conjugate vaccine (PCV7). In France, the switch from PCV7 to 13-valent pneumococcal conjugate vaccine (PCV13) occurred in June 2010. An active surveillance network was set up to analyze the impact of PCV13 on CAP. METHODS: An observational prospective study performed in 8 pediatric emergency departments from June 2009 to May 2012 included all children between 1 month and 15 years of age with chest radiography-confirmed pneumonia. Three 1-year periods were defined: pre-PCV13, transitional, and post-PCV13. RESULTS: During the 3-year study period, among the 953 274 pediatric emergency visits, 5645 children with CAP were included. CAP with pleural effusion and documented pneumococcal CAP were diagnosed in 365 and 136 patients, respectively. Despite an increase (4.5%) in number of pediatric emergency visits, cases of CAP decreased by 16% (2060 to 1725) between pre- and post-PCV13 periods. The decrease reached 32% in infants in the same periods (757 to 516; P < .001). Between pre- and post-PCV13 periods, the proportion of CAP patients with a C-reactive protein level >120 mg/dL decreased from 41.3% to 29.7% (P < .001), the number of pleural effusion cases decreased by 53% (167 to 79; P < .001) and the number of pneumococcal CAP cases decreased by 63% (64 to 24; P = .002). The number of additional PCV13 serotypes identified decreased by 74% (27 to 7). CONCLUSIONS: Our data suggest a strong impact of PCV13 on CAP, pleural effusion, and documented pneumococcal pneumonia, particularly cases due to PCV13 serotypes.

[Vaccination coverage among health care workers in the pediatric emergency and intensive care department of Edouard Herriot hospital in 2007, against influenza, pertussis, varicella, and measles]. / Couverture vaccinale du personnel hospitalier du service d'urgences et de réanimation pédiatriques de l'hôpital Edouard-Herriot de Lyon en 2007, concernant la grippe, la coqueluche, la varicelle et la rougeole.

AIM: The aim of this study was to determine the vaccination coverage among the medical and paramedical health care workers of the pediatric intensive care and emergency department of Edouard Herriot hospital in Lyon, with respect to influenza, pertussis, varicella, and measles, 4 diseases with air transmission and vaccination recommendations. METHOD: During February and March 2007, a questionnaire was given by hand to 123 health care workers by a medical student working there or available in the intensive care unit. RESULTS: The response rate to the questionnaire was 68.3%. The vaccination coverage against influenza was 42.8%; men and medical health care workers were better vaccinated. With respect to vaccination against pertussis, one third had received an injection in adulthood, adults under age 30 and medical health care workers were better vaccinated, but the difference was not statistically significant. Ten health care workers were not vaccinated and had no history of measles: only 1 had had a measles serology and none were vaccinated. Eleven had no history of varicella: 6 had had a varicella serology and none were vaccinated. CONCLUSIONS: Vaccination coverage against influenza is higher than what has been reported in the literature, possibly because of a mobile vaccination campaign against influenza made during winter 2006 in this pediatric department. Vaccination coverage against pertussis is encouraging and probably the consequence of an awareness of the gravity of the disease among infants. Individual information is necessary for health care workers on the nosocomial risk for influenza and pertussis in infants, and vaccination must be proposed. Serology against varicella and measles is compulsory for all health care workers with no history and no vaccination against these 2 diseases, to track and vaccinate the nonimmunized personnel. Occupational physicians have a very important role to play in meeting this goal.

[Analysis of delayed cerebrospinal fluid sterilization of pneumococcal meningitis in children]. / Stérilisations retardées du liquide céphalorachidien au cours des méningites à pneumocoque de l'enfant.

OBJECTIVE: Delayed cerebrospinal fluid sterilization is defined by a positive second lumbar puncture, recommanded according to the guidelines from the French Consensus Conference of 1996 between the 36th and 48th hours after the beginning of antibiotics prescribed for pneumococcal meningitis. The aim of this study was to analyze specifically delayed cerebrospinal fluid sterilization, identified during the first 5 years of the French observatory of children bacterial meningitis. PATIENTS AND METHODS: The Groupe de Pathologie Infectieuse Pédiatrique (GPIP) and Association Clinique et Thérapeutique Infantile du Val de Marne (ACTIV) has set up since the first of January 2001 a descriptive national multicenter network, to determine incidence, main characteristics, and prognosis of bacterial meningitis in children. A questionnaire, available in all paediatric unit taking care of bacterial meningitis, was completed by a referral doctor. It contained reasons for inclusion in the study, anamnesis, clinical examination, treatment, pneumococcal characteristics, and short term prognosis. Delayed cerebrospinal fluid sterilization were identified, and the analysis of their medical records completed the questionnaire. RESULTS: From 1st January 2001 to 31 December 2005, 616 pneumococcal meningitis were identified. Among them, 442 had a second lumbar puncture, and 8 had delayed cerebrospinal fluid sterilization. The analyis of their medical records were reviewed to describe their characteristics. Two had an osteomeningeal breach, one a ventriculoperitoneal valve. All received previously an antibiotic, and were treated with a curative antibiotic by cephalosporins. Vancomycin was given in 6 cases. The antibiotic was inadapted to the French guidelines for 1 patient. There are 4 vaccine type pneumococci and only 1 strain was resistant to penicillin, and intermediate to cephalosporins. The controlled lumbar puncture was made between 36.5 and 179.4hours after beginning antibiotics. One patient has received a double dose of steroids. Three were in a coma, had convulsions, and were ventilated, none died. One patient has a sequellar paired deafness, two a severe disability, four a normal psychomotor development. CONCLUSION: The delay of sterilization is a rare situation and represented only 1.8 % of pneumococcal meningitis during the first five years of the observatory. These results suggest that a second lumbar puncture to assess sterilization could be proposed only in cases of unfavourable clinical course, MIC greater than or equal 0.5mg/l to 3GC, risk factors for delayed cerebrospinal fluid sterilization and high bacterial inoculum.