Non-coronary cardiac events, younger age, and IVIG unresponsiveness increase the risk for coronary aneurysms in Italian children with Kawasaki disease.

OBJECTIVES: Kawasaki disease (KD) is the most frequent cause of acquired heart disease in children in high-income countries because of coronary artery involvement. Risk factors for coronary lesions can vary in consideration of different genetic background and environmental factors. METHODS: Multicenter retrospective and prospective study including 372 consecutive children (58% boys; mean age 34.3 ± 30.3 months, Caucasian 85%) was diagnosed with KD. We divided the cohort into 2 groups according to the presence of coronary anomalies (CAA) and aneurysms. We compared the groups and studied the risk factors for CAA and for aneurysms, the most severe lesions. RESULTS: Children with CAA were 91/372 (24.46%, aneurysms 20/372, 5.37%). Children with CAA were more likely to have a longer duration of fever (p < 0.001), later day of treatment (p < 0.001), to be IVIG non-responders and late treated (p < 0.001), while age, clinical presentation, and seasonality were not different. They also had significantly higher WBC and neutrophils, lower lymphocytes, Hb and Na during the acute stage, and slower resolution of inflammation. Age, IVIG unresponsiveness, and presence of non-coronary cardiac findings were independent risk factors for CAA and for aneurysms, while neutrophils just for CAA. Age under 6 months was a risk factor for the aneurysm. Aneurysms occurred more frequently in the first quartile of the age of KD onset (under 14 months). CONCLUSION: Very young children with non-coronary cardiac findings are at increased risk for a more severe form of KD with aneurysms. These children could benefit from adjunctive therapy beside IVIG, especially if they have higher markers of inflammation, particularly neutrophils. Key points • Risk factors for coronary lesions can vary in consideration of different genetic background and environmental factors. • Risk factors for coronary involvement have been extensively studied in the Asian population, and others have been validated in cohorts with mixed ethnicities. • In our predominantly Caucasian population, non-coronary cardiac findings, age younger than 6 months, and IVIG unresponsiveness are independent risk factors for a more severe form of KD with aneurysms.

Dural sinus mechanical thrombectomy and continuous local rt-PA infusion in a child with refractory intracranial hypertension and progressive visual loss: A case report.

BACKGROUND: Children with intracranial hypertension are at risk for visual loss and their visual function must be closely monitored. Surgery with the insertion of a ventriculoperitoneal shunt is imperative when vision is threatened. CASE DESCRIPTION: Herein, we report a case of a 5-year-old boy whose refractory intracranial hypertension and severe, progressive visual loss (secondary to a chronic, otogenic, right sigmoid sinus thrombosis, and a contralateral sinus tight stenosis) were resolved by a combination of continuous (6 h), locoregional, infusion of recombinant tissue plasminogen activator (rt-PA), and mechanical thrombectomy. CONCLUSION: The association of in loco and continuous infusion of recombinant tissue plasminogen activator (rt- PA) with mechanical thrombectomy resulted in effective in partially reopening the occluded sinus and facilitating a good clinical recovery. This combined endovascular approach may represent an alternative, less invasive, therapeutic option to surgery in children with intracranial hypertension caused by chronic cerebral venous sinus thrombosis.

[Infective endocarditis as predisposing factor to recurrence]. / Le endocarditi infettive come fattore predisponente a successive recidive.

In this paper we communicate our experience with 60 patients who suffered two or more episodes of infectious endocarditis (IE), selected from 1053 cases of IE defined in accordance with Duke's Hospital criteria. Relapsing IE was diagnosed when episodes occurred with at least a 6 month interval between them or when, even if the time distance was shorter, they were caused by different microorganisms. Sixty-four cases of relapsing IE were observed. In each patient we considered age, sex, presence of risk-factors for IE, time laps from the onset of symptomatic disease to diagnosis, time interval between the two or more IE episodes, aetiology, endocarditic location, echocardiographic elements, therapy, complications and final outcome were considered. We conclude, agreeing with other authors, that infectious endocarditis may rightfully be considered a risk factor for further IE episodes and that, for this reason, an adequate prophylactic therapy must be given.

[Streptococcus bovis infectious endocarditis: clinical and epidemiological characteristics]. / Le endocarditi infettive da Streptococcus bovis: caratteristiche cliniche ed epidemiologiche.

This paper shows our experience concerning the study of Streptococcus bovis infectious endocarditis (EI): 47 patients, with no prior history of IV drug abuse (NTD), who suffered EI caused by Streptococcus bovis were excerpted from a case record of 1053 cases with diagnosis of EI defined in accordance with Duke's Hospital criteria. For each patient we considered age, sex, complications, echocardiographic findings, antibiotic therapy, eventual heart-surgery and final outcome of the disease. We then compared the parameters of our patients, with the ones of 216 NTD patients suffering non Streptococcus bovis EI, selected according to age correspondence and concomitant onset of the disease. The characteristics of Streptococcus bovis EI are analogous to the ones of EIs caused by other micro-organisms in NTD patients, except for a non statistically significant trend of higher frequency in old age and in males. Concerning possible predisposing conditions, we considered the association extensively described in the literature between Streptococcus bovis EI and gastroenteric pathology (above all colon neoplasms): this association was not frequently observed in our study because appropriate instrumental investigations of the digestive tract were carried out only in a minority of patients.

[Factors associated with the time to clinical diagnosis of infectious endocarditis. Analysis of a multicentre case-record]. / Fattori associati ai tempi di diagnosi dell'endocardite infettiva. Analisi di una casistica multicentrica.

The authors demonstrate that time necessary for diagnosis in 902 patients with validated infectious endocarditis was significantly shorter in 249 drug addicts confronted with 653 non-addicted patients. With regard to the latter category we noticed a significant tendency in diagnostic time reduction in the last five years of observation and this is probably due to the improved knowledge on infectivologists regarding the clinical presentation of infectious endocarditis rather than the application of validating protocols

[Signs and symptoms that lead to clinical hypothesis of infective endocarditis]. / Segni e sintomi propiziatori di ipotesi clinica di endocardite infettiva.

We studied clinical presentations on admission in Infectious Disease Wards of 1053 patients (308 i.v. drug abusers and 745 non drug abusers) with IE validated according to the Duke Hospitals' criteria, from a total of 1164 patients observed from 1984 to 1999. We divided the patients in three five-year span groups (1984-89, 1990-94 and 1995-99) and we examined signs and symptoms on presentation that led us to suspect I.E. (sepsis, valvulopathy, peripheric vascular damage and predisposing conditions including i.v. drug abuse). Our study confirms that clinical diagnosis of I-E. nowadays is reliable if history and physical examination are carried out correctly.

[Polymicrobial infective endocarditis in Italy]. / Endocarditi infettive polimicrobiche in Italia.

In our series, including 1053 cases of infective endocarditis (IE) collected from 86 Infectious Diseases Centres in Italy between 1984 and 1999, we identified 34 cases (3.2%) with a polymicrobial etiology. Intravenous drug abuse was the most important risk factor for the development of polymicrobial IE. Twenty three patients had a left sided-IE and 6 patients had a right-sided IE. The most commonly encountered microorganisms were Staphylococci and Streptococci and the most frequently observed associations of microorganisms were those between Staphylococci and Gram-negative bacteria and between Staphylococci and fungi. Twelve patients (35.3%) underwent surgery, and 5 patients (16.7%) died. Polymicrobial endocarditis did not differ clinically from IE caused by a single microorganism, and the prognosis seems to be related to the site of infection and to some specific pathogens.