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Rationale: Although World Health Organization guidelines emphasize contact investigation for tuberculosis (TB)-exposed children, data that support chest radiography as a useful tool are lacking. Objectives: We evaluated the diagnostic and prognostic information of chest radiography in children exposed to TB and measured the efficacy of isoniazid preventive therapy (IPT) in those with relevant radiographic abnormalities. Methods: Between September 2009 and August 2012, we enrolled 4,468 TB-exposed children who were screened by tuberculin skin testing, symptom assessment, and chest radiography. Those negative for TB disease were followed for 1 year for the occurrence of new TB diagnoses. We assessed the protective efficacy of IPT in children with and without abnormal chest radiographs. Measurements and Main Results: Compared with asymptomatic children with normal chest films, asymptomatic children with abnormal radiographs were 25.1-fold more likely to have coprevalent TB (95% confidence interval [CI], 1.02-613.76) and 26.7-fold more likely to be diagnosed with incident TB disease during follow-up (95% CI, 10.44-68.30). Among the 29 symptom-negative and CXR-abnormal child contacts, 20% (3/15) of the isoniazid recipients developed incident TB, compared with 57% (8/14) of those who did not receive IPT (82% IPT efficacy). Conclusions: Our results strongly support the use of chest radiography as a routine screening tool for the evaluation of child TB contacts, which is readily available. Radiographic abnormalities not usually considered suggestive of TB may indicate incipient or subclinical disease, although TB preventive treatment is adequate in most cases.
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Isoniazida , Tuberculose , Antituberculosos/uso terapêutico , Criança , Humanos , Isoniazida/uso terapêutico , Radiografia , Tuberculina , Tuberculose/diagnóstico por imagem , Tuberculose/tratamento farmacológicoRESUMO
BACKGROUND: Pneumonia is the leading cause of mortality in pediatric population. The etiology of pneumonia in this population is variable and changes according to age and disease severity and where the study is conducted. Our aim was to determine the etiology of community-acquired pneumonia (CAP) in children aged 1 month to 17 years admitted to 13 Colombian hospitals. METHODS: Prospective cohort study. Hospitalized children with radiologically confirmed CAP and ≤ 15 days of symptoms were included and followed together with a control group. Induced sputum (IS) was submitted for stains and cultures for pyogenic bacteria and Mycobacterium tuberculosis, and multiplex PCR (mPCR) for bacteria and viruses; urinary antigens for pneumococcus and Legionella pneumophila; nasopharyngeal swabs for viruses, and paired serology for atypical bacteria and viruses. Additional cultures were taken at the discretion of primary care pediatricians. RESULTS: Among 525 children with CAP, 71.6% had non-severe pneumonia; 24.8% severe and 3.6% very severe pneumonia, and no fatal cases. At least one microorganism was identified in 84% of children and 61% were of mixed etiology; 72% had at least one respiratory virus, 28% pyogenic bacteria and 21% atypical bacteria. Respiratory syncytial virus, Parainfluenza, Rhinovirus, Influenza, Mycoplasma pneumoniae, Adenovirus and Streptococcus pneumoniae were the most common etiologies of CAP. Respiratory syncytial virus was more frequent in children under 2 years and in severe pneumonia. Tuberculosis was diagnosed in 2.3% of children. IS was the most useful specimen to identify the etiology (33.6%), and blood cultures were positive in 3.6%. The concordance between all available diagnostic tests was low. A high percentage of healthy children were colonized by S. pneumoniae and Haemophilus influenzae, or were infected by Parainfluenza, Rhinovirus, Influenza and Adenovirus. CONCLUSIONS: Respiratory viruses are the most frequent etiology of CAP in children and adolescents, in particular in those under 5 years. This study shows the challenges in making an etiologic diagnosis of CAP in pediatric population because of the poor concordance between tests and the high percentage of multiple microorganisms in healthy children. IS is useful for CAP diagnosis in pediatric population.
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Infecções Comunitárias Adquiridas , Pneumonia , Adolescente , Criança , Infecções Comunitárias Adquiridas/epidemiologia , Técnicas e Procedimentos Diagnósticos/efeitos adversos , Humanos , Lactente , Mycoplasma pneumoniae , Pneumonia/complicações , Estudos ProspectivosRESUMO
Tuberculosis (TB) in the pediatric population is a major challenge. Our objective was to describe the clinical and microbiological characteristics, radiological patterns, and treatment outcomes of children and adolescents (from 1 month to 17 years) with community-acquired pneumonia (CAP) caused by TB. We performed a prospective cohort study of a pediatric population between 1 month and 17 years of age and hospitalized in Medellín, Colombia, with the diagnosis of radiologically confirmed CAP that had ≤ 15 days of symptoms. The mycobacterial culture of induced sputum was used for the bacteriological confirmation; the history of TB contact, a tuberculin skin test, and clinical improvement with treatment were used to identify microbiologically negative TB cases. Among 499 children with CAP, TB was diagnosed in 12 (2.4%), of which 10 had less than 8 days of a cough, 10 had alveolar opacities, 9 were younger than 5 years old, and 2 had close contact with a TB patient. Among the TB cases, 50% (6) had microbiological confirmation, 8 had viral and/or bacterial confirmation, one patient had multidrug-resistant TB, and 10/12 had non-severe pneumonia. In countries with an intermediate TB burden, Mycobacterium tuberculosis should be included in the etiological differential diagnosis (as a cause or coinfection) of both pneumonia and severe CAP in the pediatric population.
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OBJECTIVES: This study aimed to evaluate the utility of induced sputum (IS) for the diagnosis of community-acquired pneumonia (CAP) in pediatric population. METHODS: This cross-sectional study included pediatric population aged between 1 month and 17 years who were hospitalized with a diagnosis of CAP in 13 hospitals in Colombia, in whom an IS sample was obtained. Gram staining, aerobic bacterial and mycobacterial culture tests, and polymerase chain reaction (PCR) for 6 atypical bacteria and 15 respiratory viruses were performed. We evaluated the quality of IS samples. RESULTS: IS samples were collected in 516 of 525 children included in this study. The median age was 32 months, 38.6% were younger than 2 years, and 40.9% were between 2 and 5 years. Two patients had transient hypoxemia during the procedure. The quality of the IS obtained was good in 48.4% and intermediate in 24.5%. Identification of a respiratory pathogen was achieved with an IS sample (with Gram staining, culture test, and PCR) in 372 of 516 children with CAP. CONCLUSION: Our study shows that IS is an adequate sample for the diagnosis of CAP in pediatric population that required hospitalization. The procedure was safe, well tolerated, and with better diagnostic yields compared with the rest of the samples obtained.
Assuntos
Infecções Comunitárias Adquiridas , Pneumonia , Adolescente , Bactérias , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/microbiologia , Estudos Transversais , Humanos , Lactente , Pneumonia/diagnóstico , Escarro/microbiologiaRESUMO
Children suffer a huge and often underappreciated burden of disease in tuberculosis (TB) endemic countries. Major hurdles include limited awareness among health care workers, poor integration of TB into maternal and child health approaches, diagnostic difficulties and a lack of child-friendly treatment options. Accurate disease diagnosis is particularly difficult in young and vulnerable children who tend to develop paucibacillary disease and are unable to produce an expectorated sputum sample. In addition, access to chest radiography is problematic in resource-limited settings. Differentiating between TB exposure and M. tuberculosis infection, and especially between M. tuberculosis infection and TB disease is crucial to guide clinical management. TB represents a dynamic continuum from well-contained "latent" infection to incipient and ultimately severe disease. The clinical spectrum of disease in children is broad and can be confused with a myriad of common infections. We provide a pragmatic 4-step approach to diagnose intra-thoracic TB in children and demonstrate how classifying clinical, radiological and laboratory findings into recognised clinical syndromes may provide a more refined diagnostic approach, even in resource-limited settings.
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Testes Diagnósticos de Rotina/métodos , Gerenciamento Clínico , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/patologia , Criança , Pré-Escolar , Humanos , Lactente , Recém-NascidoRESUMO
The accurate diagnosis of tuberculosis (TB) in children remains challenging. A myriad of common childhood diseases can present with similar symptoms and signs, and differentiating between exposure and infection, as well as infection and disease can be problematic. The paucibacillary nature of childhood TB complicates bacteriological confirmation and specimen collection is difficult. In most instances intrathoracic TB remains a clinical diagnosis. TB infection and disease represent a dynamic continuum from TB exposure with/without infection, to subclinical/incipient disease, to non-severe and severe disease. The clinical spectrum of intrathoracic TB in children is broad, and the classification of clinical, radiological, endoscopic, and laboratory findings into recognized clinical syndromes allows a more refined diagnostic approach in order to minimize both under- and over-diagnosis. Bacteriological confirmation can be improved significantly by collecting multiple, high-quality specimens from the most appropriate source. Mycobacterial testing should include traditional smear microscopy and culture, as well as nucleic acid amplification testing. A systematic approach to the child with recent exposure to TB, or with clinical and radiological findings compatible with this diagnosis, should allow pragmatic classification as TB exposure, infection, or disease to facilitate timely and appropriate management. It is important to also assess risk factors for TB disease progression and to undertake follow-up evaluations to monitor treatment response and ongoing evidence supporting a TB, or alternative, diagnosis.
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El pseudoquiste pulmonar secundario a trauma cerrado de tórax es una lesión cavitaria rara en el parénquima del pulmón, que carece de revestimiento epitelial. Es más frecuente en niños y adolescentes cuya pared torácica es menos rígida. Las manifestaciones clínicas son usualmente benignas y se resuelve espontáneamente en dos a cuatro meses después del trauma. Presentamos la evolución de un niño con un trauma cerrado de tórax en calidad de peatón, luego del cual apareció una lesión quística poco sintomática en el parénquima pulmonar, que se resolvió espontáneamente.
Pulmonary pseudocyst secondary to blunt chest trauma is a rare cavitary lesion in the lung parenchyma that lacks an epithelial lining. It is more common in children and adolescents in whom the chest wall is less rigid. Clinical manifestations are usually benign and resolve spontaneously in two to four months after the trauma. We present the evolution of a child who suffered a closed chest trauma as a pedestrian, after which a cystic lesion appeared in the lung parenchyma, without very obvious symptoms; subsequently the cystic image resolved when he was already asymptomatic.
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Masculino , Pré-Escolar , Lesão Pulmonar , Traumatismos TorácicosRESUMO
La paragonimiasis es una zoonosis parasitaria, de transmisión alimentaria, causada por especies de tremátodos del género Paragonimus, presente en áreas tropicales y subtropicales de Asia, África y América. El ser humano se infecta mediante la ingestión de crustáceos de agua dulce crudos o mal cocidos. La infección afecta principalmente los pulmones, con desarrollo de múltiples manifestaciones clínicas y radiológicas, dependiendo del momento del ciclo vital del parásito. El diagnóstico diferencial más importante de esta enfermedad es la tuberculosis pulmonar. En este artículo se describe esta enfermedad en dos niñas con diferentes manifestaciones pulmonares. La paragonimiasis se debe sospechar en pacientes con tos crónica, esputo herrumbroso, dolor torácico, con o sin compromiso cerebral, que viven o han residido en una zona endémica y que presentan una eosinofília elevada, con cambios radiológicos sugestivos del síndrome de Loeffler.
Paragonimiasis is a parasitic, food-borne zoonosis, caused by species of trematodes of the genus Paragonimus, found in tropical and subtropical areas of Asia, Africa and America. Human beings become infected by ingestion of raw or undercooked freshwater shellfish. The infection primarily affects the lungs, with the development of multiple clinical and radiological manifestations, depending on the moment in the life cycle of the parasite. The most important differential diagnosis of this disease is pulmonary tuberculosis. We report two cases of lung paragonimiasis in aboriginal Colombian girls with different pulmonary manifestations. Paragonimiasis should be suspected in patients with chronic cough, rusty sputum, chest pain, with or without brain involvement, who live or have lived in endemic areas and have a high-level eosinophilia with radiographic changes suggestive of Loeffler's syndrome.
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Feminino , Pré-Escolar , Criança , Paragonimíase , Paragonimus , Zoonoses , CrustáceosRESUMO
La fístula traqueoesofágica sin atresia esofágica es un tipo infrecuente de malformación del esófago, de etiología multifactorial, incluyendo factores ambientales y genéticos. Se manifiesta con tos y ahogo con los alimentos, cianosis y/o neumonía recurrente. El diagnóstico requiere un alto índice de sospecha clínica y su confirmación se hace por imágenes como el estudio de las vías digestivas superiores y la video-fluoroscopia, o por broncoscopia visualizando directamente la fístula, o con azul de metileno para observar el paso de este líquido. El tratamiento puede hacerse por vía endoscópica o quirúrgica, con buenos resultados.
Tracheo-esophageal fistula without esophageal atresia is a rare type of esophageal malformation. It has a multifactorial etiology including environmental and genetic factors. Common clinical manifestations are coughing and choking after meals, cyanosis and/or recurrent pneumonia. Diagnosis requires a high clinical suspicion index. Fistula confirmation is done with imaging studies including upper digestive series, video-fluoroscopy or with the use of bronchoscopy which allows direct visualization of the fistula or methylene blue passage through the abnormal communication. Fistula closure can be done endoscopically or surgically, in both cases with good results.
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Masculino , Feminino , Recém-Nascido , Doenças da Traqueia , Fístula Traqueoesofágica , Doenças do Esôfago , Trato GastrointestinalRESUMO
La aspergilosis broncopulmonar alérgica (ABPA) es la enfermedad pulmonar resultante de hipersensibilidad a Aspergillus, que lleva a alteración de la depuración mucociliar, impactación mucosa con obstrucción de la vía aérea e infiltración pulmonar. Se caracteriza clínicamente por disnea, sibilancias, fiebre, malestar general y expectoración de color marrón o negro, y por la mala respuesta clínica al tratamiento habitual instaurado para las exacerbaciones en pacientes con enfermedad pulmonar crónica. En los pacientes con fibrosis quística (FQ) puede ser difícil establecer el diagnóstico de ABPA debido a la superposición de las características clínicas, radiológicas e inmunológicas de las dos enfermedades y a la presencia frecuente de infecciones bacterianas pulmonares. Por ello, se recomienda que en el seguimiento de dichos pacientes se haga medición anual de la inmunoglobulina E (IgE) sérica total y, según su resultado y el contexto clínico, se plantee el diagnóstico de ABPA y se haga el tratamiento oportuno con esteroides con el cual mejoran los síntomas, la función pulmonar, la calidad de vida y el pronóstico. Presentamos dos pacientes pediátricos con diagnóstico de FQ de difícil control, en quienes se hizo el diagnóstico de ABPA y cuya sintomatología pulmonar mejoró con el tratamiento esteroide.
Allergic bronchopulmonary aspergillosis (ABPA) is a lung disease resulting from hypersensitivity to Aspergillus, which leads to impaired mucociliary clearance, mucus impaction with obstruction of the airway, and pulmonary infiltration. Clinically it is characterized by dyspnea, wheezing, fever, malaise, brown or black expectoration, and poor clinical response to the standard therapy for exacerbations in patients with chronic lung disease. In patients with cystic fibrosis (CF) it may be difficult to establish the diagnosis of ABPA due to the overlapping of clinical, radiological and immunological features and to the high frequency of pulmonary bacterial infections. Therefore, annual monitoring of these patients is recommended by measuring the level of total immunoglobulin E (IgE); according to its result and to the clinical context, the diagnosis and treatment of ABPA with steroids should be considered. Such treatment leads to improvement of symptoms, lung function, quality of life and prognosis. We report two pediatric patients diagnosed with CF who were difficult to control; the diagnosis of ABPA was established and their pulmonary symptoms improved with the use of steroids.