Spontaneous Abscess of the Posterior Nasal Septum: An Unusual Cause of Nasal Obstruction in Children.

INTRODUCTION: Nasal septal abscess is a rare disorder in pediatric patients and is mostly diagnosed as a complication of trauma or secondary to dental or sinonasal infection. CASE PRESENTATION: A 10-year-old girl presented with acute nasal obstruction, otalgia, and headache. Medical history was negative; physical examination and anterior rhinoscopy did not reveal signs of acute rhinosinusitis or septal abscess. MANAGEMENT AND OUTCOME: A thorough nasal endoscopy was performed to rule out a posterior nasal infection, revealing a bilateral posterior septal bulging, in the absence of purulent discharge. CT scan and contrast-enhanced MRI were performed, confirming the diagnosis of a spontaneous posterior septal abscess. Trans-nasal endoscopic-assisted drainage was conducted under general anesthesia. Haemophilus influenzae was detected on culture. DISCUSSION: Although rare, nasal septal abscess in the pediatric age is typically anterior and secondary to local trauma or infection. Accurate medical history and anterior rhinoscopy are usually sufficient to make the diagnosis. In cases where the clinical presentation is consistent with a nasal septal abscess, with no history of recent local trauma or infection, or signs of anterior septal bulging, nasal endoscopy should be performed to rule out spontaneous posterior septal abscess. Delay in diagnosis and treatment could potentially cause the rapid onset of life-threatening complications, including intracranial abscess, meningitis, and cavernous sinus thrombosis.

Management of preseptal and orbital cellulitis for the primary care physician.

Preseptal cellulitis and postseptal (orbital) cellulitis represent a spectrum of orbital infections which a primary care provider and ophthalmologist may see during practice. Most often these conditions occur through spread from the sinuses, though there are a variety of other inciting factors. These conditions can both present with erythema and edema, but a complete and thorough exam can help a practitioner differentiate the two. Patients should be treated with targeting the most common pathogens and followed very closely by their providers. This article will discuss the anatomy, pathogenesis, risk factors, diagnosis, management and prognosis of preseptal and orbital cellulitis.

Ginsenoside Rg3 ameliorates acute exacerbation of COPD by suppressing neutrophil migration.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) is an irreversible inflammatory airways disease responsible for global health burden, involved with a complex condition of immunological change. Exacerbation-mediated neutrophilia is an important factor in the pathogenesis of cigarette smoke-induced AECOPD. Ginsenoside Rg3, a red-ginseng-derived compound, has multiple pharmacological properties such as anti-inflammatory and antitumor activities. Here, we investigated a protective role of Rg3 against AECOPD, focusing on neutrophilia. 14-week-cigarette smoke (CS) exposure and non-typeable Haemophilus inflenzae (NTHi) infection were used to establish the AECOPD murine model. Rg3 (10, 20, 40 mg/kg) was administered intragastrically from the 12th week of CS exposure before infection, and this led to improved lung function and lung morphology, and reduced neutrophilic inflammation, indicating a suppressive effect on neutrophil infiltration by Rg3. Further investigations on the mechanism of Rg3 on neutrophils were carried out using bronchial epithelial cell (BEAS-2B) and neutrophil co-culture and transepithelial migration model. Pre-treatment of neutrophils with Rg3 reduced neutrophil migration, which seemed to be the result of inhibition of phosphatidylinositol (PtdIns) 3-kinases (PI3K) activation within neutrophils. Thus, Rg3 could inhibit exacerbation-induced neutrophilia in COPD by negatively regulating PI3K activities in neutrophils. This study provides a potential natural drug against AECOPD neutrophil inflammation.

Cricoid Chondronecrosis: Case Report and Review of Literature.

OBJECTIVE: Cricoid chondronecrosis is a rare entity that has significant consequences for patients. Reports of its occurrence are scattered in the literature and currently there is no comprehensive review to help guide providers. METHODS: A case report from our institution is presented. A review of available literature is then provided with assessment of risk factors, signs and symptoms at presentation, laryngeal exam findings, radiologic findings, and surgical techniques. RESULTS: Twenty-four cases of cricoid chondronecrosis were reviewed from the literature. Patient age ranged from 8 months to 76 years. A history of endotracheal intubation for various reasons was present in all but two cases, and duration of intubation ranged from 6 hours to 28 days. Patients presented with airway compromise in all but two cases-one asymptomatic patient with prior tracheostomy and another with dysphagia after radiation. Dysphonia (n = 6) and dysphagia (n = 3) were less commonly present. Subglottic stenosis (n = 19) was the most common exam finding followed by vocal fold impairment (n = 11). When CT scan findings were reported, fragmentation of the cartilage and/or hypodensity of the central lamina were described in all but one case. Interventions ranged from observation on antibiotics and steroids to surgical therapies including tracheostomy, dilation, and posterior cricoid split, with or without stent placement. CONCLUSIONS: Cricoid chondronecrosis is a serious, rare entity that can occur even after a short period of endotracheal intubation. Providers must have a high level of suspicion in patients that present with upper airway dyspnea with a history of prior intubation. LEVEL OF EVIDENCE: Level 4.

MeningiSSS: A New Predictive Score to Support Decision on Invasive Procedures to Monitor or Manage the Intracerebral Pressure in Children with Bacterial Meningitis.

BACKGROUND: Knowing the individual child's risk is highly useful when deciding on treatment strategies, especially when deciding on invasive procedures. In this study, we aimed to develop a new predictive score for children with bacterial meningitis and compare this with existing predictive scores and individual risk factors. METHODS: We developed the Meningitis Swedish Survival Score (MeningiSSS) based on a previous systematic review of risk factors. From this, we selected risk factors identified in moderate-to-high-quality studies that could be assessed at admission to the hospital. Using data acquired from medical records of 101 children with bacterial meningitis, we tested the overall capabilities of the MeningiSSS compared with four existing predictive scores using a receiver operating characteristic curve (ROC) analysis to assert the area under the curve (AUC). Finally, we tested all predictive scores at their cut-off levels using a Chi-square test. As outcome, we used a small number of predefined outcomes; in-hospital mortality, 30-day mortality, occurrence of neurological disabilities at discharge defined as Pediatric Cerebral Performance Category Scale category two to five, any type of complications occurring during the hospital stay, use of intensive care, and use of invasive procedures to monitor or manage the intracerebral pressure. RESULTS: For identifying children later undergoing invasive procedures to monitor or manage the intracerebral pressure, the MeningiSSS excelled in the ROC-analysis (AUC = 0.90) and also was the only predictive score able to identify all cases at its cut-off level (25 vs 0%, p < 0.01). For intensive care, the MeningiSSS (AUC = 0.79) and the Simple Luanda Scale (AUC = 0.75) had the best results in the ROC-analysis, whereas others performed less well (AUC ≤ 0.65). Finally, while none of the scores' results were significantly associated with complications, an elevated score on the MeningiSSS (AUC = 0.70), Niklasson Scale (AUC = 0.72), and the Herson-Todd Scale (AUC = 0.79) was all associated with death. CONCLUSIONS: The MeningiSSS outperformed existing predictive scores at identifying children later having to undergo invasive procedures to monitor or manage the intracerebral pressure in children with bacterial meningitis. Our results need further external validation before use in clinical practice. Thus, the MeningiSSS could potentially be helpful when making difficult decisions concerning intracerebral pressure management.

Streptococcus pneumoniae and Haemophilus influenzae nasopharyngeal molecular detection in children with acute respiratory tract infection in SANADOR Hospital, Romania.

Introduction. Streptococcus pneumoniae and Haemophilus influenzae are both commensals of the human nasopharynx with a high capacity to cause upper and lower respiratory tract infections.Aim. Molecular testing of nasopharyngeal samples from children at the primary care paediatric department presenting with acute respiratory tract infections (ARTIs).Methodology. From June 2016 to May 2017, 156 nasopharyngeal swabs from children diagnosed with ARTIs who had been admitted to or followed up as outpatients at the Department of Paediatrics, SANADOR Hospital (Bucharest, Romania) were tested for the presence of S. pneumoniae, H. influenzae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila, Bordetella pertussis and Bordetella parapertussis DNA.Results. S. pneumoniae had the highest detection rate (53.8 %, n=84/156), followed by H. influenzae (41 %, n=64/156) and S. pneumoniae/H. influenzae co-detection (26.2 %, n=41/156).Conclusion. A definitive laboratory diagnosis of these micro-organisms can be made for invasive disease, but there are difficulties in establishing the aetiology for mucosal infection. Molecular detection tests could complement culture-based tests by strengthening their surveillance.

Childhood pneumonia in low-and-middle-income countries: An update.

OBJECTIVES: To review epidemiology, aetiology and management of childhood pneumonia in low-and-middle-income countries. DESIGN: Review of published English literature between 2013 and 2019. RESULTS: Pneumonia remains a major cause of morbidity and mortality. Risk factors include young age, malnutrition, immunosuppression, tobacco smoke or air pollution exposure. Better methods for specimen collection and molecular diagnostics have improved microbiological diagnosis, indicating that pneumonia results from several organisms interacting. Induced sputum increases microbiologic yield for Bordetella pertussis or Mycobacterium tuberculosis, which has been associated with pneumonia in high TB prevalence areas. The proportion of cases due to Streptococcus pneumoniae and Haemophilus influenzae b has declined with new conjugate vaccines; Staphylococcus aureus and H. influenzae non-type b are the commonest bacterial pathogens; viruses are the most common pathogens. Effective interventions comprise antibiotics, oxygen and non-invasive ventilation. New vaccines have reduced severity and incidence of disease, but disparities exist in uptake. CONCLUSION: Morbidity and mortality from childhood pneumonia has decreased but a considerable preventable burden remains. Widespread implementation of available, effective interventions and development of novel strategies are needed.

The challenges of treating tracheobronchitis in a laryngectomee due to nontypeable Haemophilus influenzae: a case report.

BACKGROUND: Laryngectomees run the risk of developing severe respiratory tract infections especially during the winter and when they do not wear a stoma cover. A case of severe tracheobronchitis in a laryngectomee is presented that illustrates the risks and difficulties encountered in managing this infection in a neck breather. CASE PRESENTATION: A 76-year-old Caucasian man, a laryngectomee, presented with bacterial tracheobronchitis and conjunctivitis due to beta-lactamase-producing nontypeable Haemophilus influenzae. He was febrile (38.9 °C; 102.0 F), and had repeated episodes of hypertension. He was treated with levofloxacin 500 mg/day, ciprofloxacin eye drops, acetaminophen, and guaifenesin. Humidification of his trachea and the airway was sustained by insertions of saline into the stoma as well as breathing humidified air. The main challenge was to maintain the patency of his airway as the mucus was very dry and viscous and tended to stick to the walls of his trachea and the stoma. His condition improved within 7 days and he had a complete recovery. CONCLUSIONS: Maintaining the patency of the airway in laryngectomees who suffer from lower respiratory tract infection is of utmost importance as the mucus can be very dry and viscous and can stick to the walls of the trachea and the stoma.

Management of paediatric periorbital cellulitis: Our experience of 243 children managed according to a standardised protocol 2012-2015.

INTRODUCTION: Paediatric periorbital cellulitis is a common condition. Accurate assessment can be challenging and appropriate use of CT imaging is essential. We audited admissions to our unit over a four year period, with reference to CT scanning and adherence to our protocol. METHODS: Retrospective audit of paediatric patients admitted with periorbital cellulitis, 2012-2015. RESULTS: Total of 243 patients included, mean age 4.7 years with slight male predominance, the median length of admission was 2 days. 48/243 (20%) underwent CT during admission, 25 (52%) of these underwent surgical drainage. As per protocol, CT brain performed with all orbital scans; no positive intracranial findings on any initial scan. Three children developed intracranial complications subsequently; all treated with antibiotics. Our re-admission rate within 30 days was 2.5%. CONCLUSIONS: Our audit demonstrates benefit of standardising practice and the low CT rate, with high percentage taken to theatre and no missed abscesses, supports the protocol. There may be an argument to avoid CT brain routinely in all initial imaging sequences in those children without neurological signs or symptoms.

Defining the Binding Region in Factor H to Develop a Therapeutic Factor H-Fc Fusion Protein against Non-Typeable Haemophilus influenzae.

Non-typeable Haemophilus influenzae (NTHi) cause a range of illnesses including otitis media, sinusitis, and exacerbation of chronic obstructive pulmonary disease, infections that contribute to the problem of antibiotic resistance and are themselves often intractable to standard antibiotic treatment regimens. We investigated a strategy to exploit binding of the complement inhibitor Factor H (FH) to NTHi as a functional target for an immunotherapeutic containing the NTHi binding domain of FH fused to the Fc domain of IgG1. Chimeric proteins containing the regions that most FH-binding bacteria use to engage human FH, domains 6 and 7 (FH6,7/Fc) and/or 18 through 20 (FH18-20/Fc), were evaluated for binding to NTHi. FH6,7/Fc bound strongly to each of seven NTHi clinical isolates tested and efficiently promoted complement-mediated killing by normal human serum. FH18-20/Fc bound weakly to three of the strains but did not promote complement dependent killing. Outer-membrane protein P5 has been implicated in FH binding by NTHi, and FH6,7/Fc binding was greatly diminished in five of seven P5 deficient isogenic mutant strains tested, implicating an alternative FH binding protein in some strains. Binding of FH18-20/Fc was decreased in the P5 mutant of one strain. A murine model was used to evaluate potential therapeutic application of FH6,7/Fc. FH6,7/Fc efficiently promoted binding of C3 to NTHi exposed to mouse serum, and intranasal delivery of FH6,7/Fc resulted in significantly enhanced clearance of NTHi from the lung. Moreover, a P5 deficient mutant was attenuated for survival in the lung model, suggesting that escape mutants lacking P5 would be less likely to replace strains susceptible to FH6,7/Fc. These results provide evidence for the potential utility of FH6,7/Fc as a therapeutic against NTHi lung infection. FH binding is a common property of many respiratory tract pathogens and FH/Fc chimeras may represent promising alternative or adjunctive therapeutics against such infections, which are often polymicrobial.

Bilateral Portal Percutaneous Endoscopic Debridement and Lavage for Lumbar Pyogenic Spondylitis.

Common management approaches for spinal infections include conservative administration of antibiotics and aggressive surgical debridement. Minimally invasive endoscopic treatment has been reported and is gaining widespread attention because of its simplicity and effectiveness. This study retrospectively evaluated the clinical outcomes of bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution in the treatment of patients with lumbar pyogenic spondylitis. From January 2007 to December 2011, a total of 22 patients diagnosed with single-level lumbar pyogenic spondylitis underwent bilateral portal percutaneous endoscopic debridement and lavage with dilute povidone-iodine solution at the authors' institution. Clinical outcomes were assessed by careful physical examination, visual analog scale pain score, modified MacNab criteria functional score, regular serologic testing, and imaging studies to determine whether percutaneous endoscopic debridement and lavage treatment was successful or if surgical intervention was required. Causative bacteria were identified in 19 (86.4%) of 22 biopsy specimens. Eighteen patients had satisfactory relief of back pain and uneventful recovery after this treatment. The success rate was 81.8% (18 of 22). Both visual analog scale and modified MacNab criteria scores improved significantly in successfully treated patients. No major surgical complications were noted, except for 3 patients who had residual or subsequent paresthesia in the affected lumbar segment. Percutaneous endoscopic debridement and lavage is a minimally invasive procedure that can yield a higher bacterial diagnosis, relieve back pain, and help to eradicate lumbar pyogenic spondylitis. It is an effective alternative treatment for patients with spinal infection before extensive open surgery.

Therapeutic Transcutaneous Immunization with a Band-Aid Vaccine Resolves Experimental Otitis Media.

Transcutaneous immunization (TCI) is a noninvasive strategy to induce protective immune responses. We describe TCI with a band-aid vaccine placed on the postauricular skin to exploit the unique organization of the stratum corneum and to promote the development of immune responses to resolve active experimental otitis media due to nontypeable Haemophilus influenzae (NTHI). This therapeutic immunization strategy induced significantly earlier resolution of middle ear fluid and rapid eradication of both planktonic and mucosal biofilm-resident NTHI within 7 days after receipt of the first immunizing band-aid vaccine. Efficacy was ascribed to the homing of immunogen-bearing cutaneous dendritic cells to the nasal-associated lymphoid tissue, induction of polyfunctional CD4(+) T cells, and the presence of immunogen-specific IgM and IgG within the middle ear. TCI using band-aid vaccines could expand the use of traditional parenteral preventative vaccines to include treatment of active otitis media, in addition to other diseases of the respiratory tract due to NTHI.