Detection of immunoglobulin M and immunoglobulin G antibodies to Mycoplasma pneumoniae in children with community-acquired lower respiratory tract infections.

CONTEXT: Mycoplasma pneumoniae (M. pneumoniae) causes up to 40% of community-acquired pneumonia in children. It is impossible to identify M. pneumoniae infection on the basis of clinical signs, symptoms, and radiological features. Therefore, correct etiological diagnosis strongly depends on laboratory diagnosis. AIMS: This study aims to investigate the role of M. pneumonia e in pediatric lower respiratory tract infections (LRTIs) employing enzyme-linked immunosorbent assays (ELISA) and particle agglutination (PA) test. SETTINGS AND DESIGN: Two hundred and eighty children, age 6 months to 12 years with community-acquired LRTIs were investigated for M. pneumoniae etiology. MATERIALS AND METHODS: We investigated 280 children hospitalized for community-acquired LRTIs, using ELISA and PA test for detecting M. pneumoniae immunoglobulin M (IgM) and immunoglobulin G antibodies. STATISTICAL ANALYSIS USED: The difference of proportion between the qualitative variables was tested using the Chi-square test and Fischer exact test. P ≤ 0.05 was considered as statistically significant. Kappa value was used to assess agreement between ELISA and PA test. RESULTS: M. pneumoniae was positive in 51 (23.2%) <5 years and 33 (54.0%) children in ≥5 years of age group, and this difference was statistically significant (P < 0.001). Clinical and radiological findings in M. pneumoniae positive and negative groups were comparable. ELISA detected M. pneumoniae in 78 (27.8%) and PA test 39 (13.9%) patients; 33 (84.6%) ELISA positive and 6 (15.4%) ELISA negative. ELISA/PA test together detected M. pneumoniae infection in 84 (30%) children. CONCLUSIONS: Our data underline that M. pneumoniae plays an important role in children with community-acquired LRTIs and more particularly in children >5 years of age.

Rapid detection of respiratory syncytial virus in community-acquired lower respiratory tract infections in children by chromatographic assay.

Respiratory syncytial virus (RSV) is the single most important viral agent causing pediatric lower respiratory tract infections (LRTIs) worldwide. To evaluate the role of RSV in pediatric LRTIs, we studied 85 children <2 years of age hospitalized for community-acquired LRTIs. Nasopharyngeal aspirates were obtained on admission for the detection of RSV antigen by immunochromatographic assay. Demographic, clinical, and radiological findings for RSV antigen were compared. Data analysis was performed by Chi-square test. A relatively higher number of RSV-infected children 32 (60.4%) were below 6 months of age. Clinical and radiological findings in both RSV-positive and RSV-negative groups were comparable. RSV antigen was positive in 53 (62.4%) with immunochromatography. Our study confirms that RSV plays a significant role in community-acquired LRTIs in children.

Mycoplasma pneumoniae in Community-Acquired Lower Respiratory Tract Infections.

OBJECTIVE: To determine the role of Mycoplasma pneumoniae (M. pneumoniae) in pediatric lower respiratory tract infections (LRTIs) employing serological tests and polymerase chain reaction (PCR) analysis. METHODS: In this prospective study, 200 children aged 6 mo to 12 y hospitalized with acute LRTIs were investigated for M. pneumoniae. Serum samples were collected for serological analysis of M. pneumoniae. Throat swab samples were obtained on admission to amplify 277-base pair region of 16S rDNA gene of M. pneumoniae by PCR. RESULTS: In the present study, 40(26.1%) children <5 y and 28(59.5%) children ≥5 y age group were positive for M. pneumoniae infection and this difference was statistically significant (P < 0.001). M. pneumoniae was positive in 32(41%) female and 36(29.5%) male children though this difference was statistically insignificant (P = 0.12). The clinical profile across M. pneumoniae positive and negative cases were comparable except for presence of chest pain which was statistically significant (P = 0.023). None of the radiological findings was statistically associated with incidence of M. pneumoniae infection. Serological evidence of acute M. pneumoniae infection was observed in 64(32%) patients with sensitivity 66.6% and specificity 70.1% while PCR positivity in 12(6%) patients with sensitivity 12.5% and specificity 97%. Together, serology and PCR detected M.pneumoniae infection in 68(34%) patients. CONCLUSIONS: The present study underlines the role of M. pneumoniae in children with community- acquired LRTIs and more particularly in ≥5 y of age.

Application of serology and nested polymerase chain reaction for identifying Chlamydophila pneumoniae in community-acquired lower respiratory tract infections in children.

CONTEXT: Chlamydophila pneumoniae is a common cause of community-acquired respiratory infections, including pneumonia, bronchitis, and upper respiratory tract infections. Since it is difficult to detect C. pneumoniae in clinical practice, specific etiological diagnosis is established only in a minority of cases. AIMS: To investigate the role of C. pneumoniae in community-acquired lower respiratory tract infections (LRTIs) in children, with the use of serological tests and nested polymerase chain reaction (PCR) analysis. SETTINGS AND DESIGN: One hundred children, age of 2 months to 12 years, hospitalized for community-acquired LRTIs were investigated for C. pneumoniae etiology. MATERIALS AND METHODS: We investigated 100 children hospitalized for community-acquired LRTIs, using enzyme-linked immunosorbent assay for detecting anti-C. pneumoniae immunoglobulin M, and immunoglobulin G antibodies and nasopharyngeal aspirates for analysis of C. pneumoniae PCR. The demographic, clinical, and radiological findings for C. pneumoniae antibody positive and C. pneumoniae antibody negative cases were compared. STATISTICAL ANALYSIS USED: Data analysis was performed by Chi-square test and Fisher's exact tests using Epi Info (2002). RESULTS: Clinical and radiological findings in both the groups were comparable. A relatively higher rate of C. pneumoniae infection in children was observed below 5 years of age. Serological evidence of C. pneumoniae infection was observed in 12 (12%) patients and nested PCR was positive in 5 (5%) children. Thirteen (13%) patients were diagnosed with C. pneumoniae infection by serology and/or nested PCR. CONCLUSIONS: Our study confirms that C. pneumoniae plays a significant role in community-acquired LRTIs in children of all ages, even in children aged <5 years.

Acute kidney injury in a child: A case of Munchausen syndrome by proxy.

Renal and urologic problems in pediatric condition falsification (PCF) or Munchausen by proxy (MSP) can result in serious diagnostic dilemma. Symptoms of hematuria, pyuria and recurrent urinary tract infections have occasionally been described. However, MSP presenting as azotemia has not been previously reported. We describe the case of an unfortunate boy who had to undergo unnecessary hemodialysis for persistent hyperkalemia and azotemia before a final diagnosis of the falsification of investigations by the parents was made.

Piloting Upfront Xpert MTB/RIF Testing on Various Specimens under Programmatic Conditions for Diagnosis of TB & DR-TB in Paediatric Population.

BACKGROUND: India accounts for one-fifth of the global TB incidence. While the exact burden of childhood TB is not known, TB remains one of the leading causes of childhood mortality in India. Bacteriological confirmation of TB in children is challenging due to difficulty in obtaining quality specimens, in the absence of which diagnosis is largely based on clinical judgement. While testing multiple specimens can potentially contribute to higher proportion of laboratory confirmed paediatric TB cases, lack of high sensitivity tests adds to the diagnostic challenge. We describe here our experiences in piloting upfront Xpert MTB/RIF testing, for diagnosis of TB in paediatric population in respiratory and extra pulmonary specimens, as recently recommended by WHO. METHOD: Xpert MTB/RIF testing was offered to all paediatric (0-14 years) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities in the project areas covering 4 cities of India. RESULTS: Under this pilot project, 8,370 paediatric presumptive TB & presumptive DR-TB cases were tested between April and-November 2014. Overall, 9,149 specimens were tested, of which 4,445 (48.6%) were non-sputum specimens. Xpert MTB/RIF gave 9,083 (99.2%, CI 99.0-99.4) valid results. Of the 8,143 presumptive TB cases enrolled, 517 (6.3%, CI 5.8-6.9) were bacteriologically confirmed. TB detection rates were two fold higher with Xpert MTB/RIF as compared to smear microscopy. Further, a total of 60 rifampicin resistant TB cases were detected, of which 38 were detected among 512 presumptive TB cases while 22 were detected amongst 227 presumptive DR-TB cases tested under the project. CONCLUSION: Xpert MTB/RIF with advantages of quick turnaround testing-time, high proportion of interpretable results and feasibility of rapid rollout, substantially improved the diagnosis of bacteriologically confirmed TB in children, while simultaneously detecting rifampicin resistance.

Complications of long-standing foreign body in the airway and their outcomes after endoscopic management: an experience of 20 cases.

AIM: To study the outcomes after endoscopic treatment of chronic foreign bodies (FBs) in the airway. MATERIALS AND METHODS: A retrospective study (2008-2013) of 20 cases with chronic airway FBs (>2 weeks) was done with emphasis on endoscopic management. All cases were initially evaluated by the pediatric pulmonologist. Flexible and rigid bronchoscopy was done for diagnosis and retrieval, respectively. The techniques of FB retrieval, problems encountered, and their solutions were analyzed. Follow-up flexible bronchoscopy was done in symptomatic cases. Outcomes were assessed in terms of successful removal of the FB, clinical recovery, lung expansion, and need for further procedures. RESULTS: Twenty cases (16 boys, 4 girls) with a mean age of 7 years had a chronic airway FB diagnosed on chest X-ray (n=6) and flexible bronchoscopy (n=14). Six cases had computed tomography evaluation. On rigid bronchoscopy, the FB was successfully retrieved in 16 cases. Two cases required open surgery for FB-induced tracheoesophageal fistula. One case required pneumonectomy because of a battery eroding into the lung parenchyma. One patient died. Of the 16 who had successful retrieval, 11 recovered with full lung expansion. Four recovered after additional bronchoscopic procedures (cauterization of granulation [n=2] and balloon dilatation of bronchial stenoses [n=2]). One case required pneumonectomy for persistent collapse despite multiple dilatations. CONCLUSIONS: An airway FB producing chronic respiratory symptoms may be missed because of lack of definite history of an inhaled FB. Clinical suspicion and flexible bronchoscopy are instrumental in diagnosis. Treatment is challenging because of chronicity-related complications and requires innovative ideas to make best use of the available urologic and bronchoscopic equipment. Addition of tracheotomy provides safety in difficult cases. Bronchoscopic removal leads to clinical and radiological recovery in most cases.

Multi-detector computed tomography imaging of large airway pathology: A pictorial review.

The tracheobronchial tree is a musculo-cartilagenous framework which acts as a conduit to aerate the lungs and consequently the entire body. A large spectrum of pathological conditions can involve the trachea and bronchial airways. These may be congenital anomalies, infections, post-intubation airway injuries, foreign body aspiration or neoplasms involving the airway. Appropriate management of airway disease requires an early and accurate diagnosis. In this pictorial essay review, we will comprehensively describe the various airway pathologies and their imaging findings by multi-detector computed tomography.

Empyema thoracis in children: a short term outcome study.

This study prospectively evaluates clinical course of pyogenic empyema thoracis in 25 children (2 mo to 12 y) treated with injectable antibiotics and chest tube drainage, and followed for 6 weeks. The median (range) age at presentation was 3 y (4 mo to 11 y). The pleural fluid culture was positive in 24% of patients. Staphylococcus aureus was the most commonly isolated organism. The median (range) duration of injectable antibiotics was 14(14-52) d; median duration of total antibiotics (injectable and oral) was 4 weeks. The median (range) duration of chest tube insertion and hospital stay was 8(5-45) and 14(14-56) days, respectively. All patients were discharged without any surgical intervention besides chest tube drainage. At discharge, pleural thickening was present in 84% and crowding of ribs was seen in 60% of the subjects on radiological examination. All these patients were asymptomatic at discharge. Chest deformity was present in 20% of the patients at 6-weeks follow up. Antibiotics and chest tube drainage is an effective method of treating pyogenic empyema thoracis in children in resource-poor settings.

Seroprotection for hepatitis B in children with nephrotic syndrome.

BACKGROUND: Children with nephrotic syndrome have been shown to have lower seroconversion to various vaccines due to immune dysregulation, prolonged immunosuppressive treatment and recurrent prolonged proteinuria.The primary aim of this study was to determine hepatitis B surface antibody (anti-HBs) titers in children with nephrotic syndrome who had been previously vaccinated against hepatitis B. The secondary aim was to study the association of anti-HBs titers with type of disease, schedule and dose of vaccination, and type of immunosuppressive therapy. METHODS: This cross-sectional study was conducted in the Department of Pediatrics in a tertiary care hospital between January 2011 and January 2012). All children (aged 1-18 years) with nephrotic syndrome who tested negative for hepatitis B surface antigen and who had previously been vaccinated against hepatitis B, with the last dose being at least 1 month prior to being included in the study. A form consisting of history and clinical details was filled in, and the schedule and dose of vaccination(s) received was noted. A blood sample was taken from all patients for biochemical assessment and determination of anti-HBs titer. RESULTS: The patient cohort comprised 75 children (51 males; 24 females) of whom 42 (56%) had steroid-resistant nephrotic syndrome (SRNS) and 33 (44%) had steroid-sensitive nephrotic syndrome (SSNS). Most patients enrolled in the study (96%) were in remission at the time of the biochemical and serological assessment. Twenty-one (28%) patients had received only steroids, while 72 % also received other immunosuppressants. Forty-six (61.3%) patients had received a double dose of vaccine. Of the 75 children enrolled, 36 (48%) and 39 (52%) had an anti-HBs titer of ≥10 mIU/mL (seroprotected) and <10 mIU/mL (unprotected), respectively. The mean titer among all patients was 143.58 mIU/mL. The seroprotection rates were 63.6% in SSNS patients and 35.7% in SRNS subjects (P = 0.016). CONCLUSIONS: Based on our results, we conclude that children with SRNS are less likely to seroconvert with vaccination. A higher dose (double) of hepatitis B vaccine should be used for vaccinating such patients. Anti-HBs titers should be monitored in SRNS patients post-vaccination, and a booster should be given if titers fall to <10 mIU/mL.

Acute renal failure in children in a tertiary care center.

In this retrospective study, records of all patients aged one month to 12 years who presented with acute renal failure (ARF) between May 2005 and August 2010 were retrieved. Clinical details, biochemistry, need for renal replacement therapy (RRT), cause of ARF and outcome at discharge were recorded. During this period, 230 children presented with ARF; their median age at presentation was 30 months (range: five-144 months); 120 (52.2%) were males. The causes of ARF were acute tubular necrosis (ATN) in 121 (52.6%), glomerular disorders in 5.7%, structural anomalies of the urinary tract in 9.6% and hemolytic uremic syndrome in 27 (11.7%). The mean duration of hospital stay was 17.8 ± 7.6 days. RRT was required for 54 patients (23.6%); peritoneal dialysis in 49 and hemodialysis in five patients. Complete recovery was noted in 99 study patients (43.2%) and sequelae remained in 84 patients (36.7%). Forty-six patients (20.1%) with ARF died. ATN secondary to septicemia was the most common cause of ARF in our study.

Unusual presentation of celiac disease presenting with renal complications.

Celiac disease is a chronic inflammatory condition of small intestine resulting due to sensitivity to wheat protein gluten. Most patients in the childhood present with primary gastrointestinal complaints. The authors present here two young girls with renal complaints later diagnosed to have celiac disease.

Case report: Isolated unilateral pulmonary vein atresia diagnosed on 128-slice multidetector CT.

Unilateral pulmonary venous atresia is an uncommon entity that is generally believed to be congenital. Most patients present in infancy or childhood with recurrent chest infections or hemoptysis. Pulmonary angiography is usually used for definitive diagnosis. However, the current multislice CT scanners may obviate the need for pulmonary angiography. We report two cases diagnosed using 128-slice CT angiography. On the CT angiography images both these cases demonstrated absent pulmonary veins on the affected side, with a small pulmonary artery and prominent bronchial or other systemic arterial supply.

Pyrazinamide blood concentrations in children suffering from tuberculosis: a comparative study at two doses.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Pyrazinamide is recommended in doses varying from 15 to 40 mg kg(-1). The most commonly used average daily dose is 25 mg kg(-1). Its use is associated with dose dependent hepatotoxicity. Lower doses are not used because of lack of pharmacokinetic data especially in children. There is only one detailed study of pyrazinamide in children at a dose of 35 mg kg(-1). WHAT THIS STUDY ADDS: This is the first study evaluating serum concentrations of pyrazinamide in children at a dose of 15 mg kg(-1) which is on the lower side of the recommended dose. The study also compared the serum concentrations and pharmacokinetics achieved with this dose with the widely used dose of 25 mg kg(-1) in children suffering from tuberculosis. The pharmacokinetics and pharmacodynamic indices of pyrazinamide were comparable with the 25 and 15 mg kg(-1) doses. AIMS: To evaluate the pharmacokinetics and pharmacodynamic indices of pyrazinamide at doses of 15 and 25 mg kg(-1) in children suffering from tuberculosis. METHODS: Twenty children with tuberculosis received pyrazinamide at a single dose of 25 mg kg(-1) (group I) and 15 mg kg(-1) (group II). Serial blood samples were collected and the drug concentrations were analyzed spectrophotometrically. The pharmacokinetic parameters were calculated and the duration of time for which pyrazinamide concentrations in serum remained above the pyrazinamide inhibitory concentrations of 20 microg ml(-1) and 25 microg ml(-1) was studied. RESULTS: The mean peak serum concentration was 42.4 +/- 3.3 microg ml(-1) (95% CI +/- 6.5) and 38.6 +/- 3.9 microg ml(-1) (95% CI +/- 7.7) in groups I and II, respectively. The elimination half-life was 9.3 +/- 1.3 h and 10.5 +/- 2.3 h (P = 0.6) and clearance was 0.06 +/- 0.01 l h(-1) kg(-1) and 0.04 +/- 0.01 l h(-1) kg(-1) (P = 0.08) in groups I and II, respectively. Pharmacokinetic parameters and PKPD indices were comparable with both the doses. CONCLUSIONS: The study indicates that comparable serum concentrations of pyrazinamide are attained with 25 mg kg(-1) and 15 mg kg(-1) doses in children. The elimination half-life was longer and volume of distribution greater in children than in the adult population.

Study of pulmonary function tests in thalassemic children.

The present study aimed to investigate pulmonary function tests (PFTs) in children with thalassemia and to assess the relation between the degree respiratory impairment with the body iron status. High resolution computed tomography of chest (CHRCT) and bronchoalveolar lavage (BAL) was performed to study the cause of pulmonary dysfunction. Thirty-one children with thalassemia over 8 years were included. PFTs were studied including lung volumes and carbon monoxide diffusion capacity (DLco). Patients with abnormal PFTs and/or impaired DLco were further subjected to CHRCT and BAL. Total cell count was measured; differential count was performed on Giemsa and PAP smears. Iron laden macrophages were identified on Perl's stain. PFTs were normal in 51.61%, diffusion capacity impaired in 41.16%, restriction in 16.12%, while obstruction in 3.22% of cases, respectively. There was significant inverse correlation between DLco and serum ferritin. Through multivariate regression analysis, ferritin was found to be a strong predictor for forced vital capacity and total lung capacity. Bronchial dilatation and areas of air trapping were the predominant CHRCT findings. Iron laden macrophages were demonstrated in 14 of 15 patients in BAL. A significant correlation between serum ferritin and DLco, forced vital capacity, total lung capacity, and the presence of iron laden macrophages in BAL indicates that iron plays a major role in the etiopathogenesis of these abnormalities.