[Spondylodiscitis in children: a review. A propos of two cases]. / La spondylodiscite chez l'enfant: a propos de deux observations.

Spondylodiscitis is defined as an infection of the intervertebral disc and the adjacent vertebral bodies. It represents, at the most, 2-4% of osteoarticular infections in children and its clinical presentation is often insidious. The specific condition of the young child (isolated discitis) is explained by some anatomical peculiarities. We report two cases of spondylodiscitis in children of different ages and review the pediatric characteristics, the role of imaging, the bacteriological diagnosis and the management of this disease.

[Clinical case of the month. Left recurrent neck abscess revealing a fourth branchial cleft fistula]. / Le cas clinique du mois. Abcès cervical gauche récidivant révélateur d'une fistule de la quatrième fente branchiale.

The fourth branchial cleft fistula, which can be the origin of a recurrent left neck abscess, is a rare congenital malformation. Its diagnosis can be difficult. A ten-year-old girl presented with a left painful swelling of the neck. At ultrasonography and tomodensitometry, the diagnosis of thyroglossal cyst was suspected. Antibiotics were prescribed before surgical resection. The intervention was successful and the peroperative macroscopic aspect of the lesion suggested a dermoid cyst. Four months later, the same symptoms reappeared with fever. An intravenous antibiotic therapy was started while a magnetic resonance imaging demonstrated a possible aero-digestive tract fistula. Two days later, the patient developed an aero-cutaneous fistula. Oral antibiotics were started. Five months later, the girl came back for a second recurrence. A few days after her admission, she developed again an aero-cutaneous fistula. The diagnosis of surinfected fourth cleft fistula was made. An antibiotic therapy was started until the second intervention. After discussion about embryology, we describe the physiopathology, the differential diagnosis and the management of a fourth branchial cleft fistula causing recurrent left neck abscess.

[A clinical case of spontaneous involution of systemic cat scratch disease]. / Involution spontanée d'une forme systémique de maladie par griffade de chat: à propos d'un cas.

Typical Cat-scratch disease (CSD) manifests as regional lymphadenopathy following cat scratch and sometimes associated with mild fever. There is a lot of atypical manifestations and some of those have systemic involvement. Hepatosplenic CSD is a systemic presentation associating fever of unknown origin with nodules in the liver and/or the spleen. Ultrasound abdominal examination shows nodules (3-30 mm) in the spleen and/or in the liver. Diagnostic is based on serology for B henselae (always IgG + and sometimes IgM +), or polymerase chain reaction (PCR) on the liver to test for the presence of B henselae. Hepatosplenic CSD is rare and therefore underdiagnosed. There is no consensus about the treatment but most of the authors suggest to treat with rifampicine. We report a case of a 4-years-old girl presenting with fever of unknown origin (FUO), high inflammatory markers with normal leukocytosis and hepatosplenic nodules. The diagnosis of CSD was made retrospectively. Evolution was favourable even though no specific antibiotic treatment for Bartonella henselae was administrated.

[Dengue shock syndrome]. / Le cas clinique du mois. A propos d' une fièvre "importée.

Célia, 21 month-old child, presented to our pediatric clinic a few months ago with a fever of unknown origin after a stay in St-Domingue with her parents. Complementary investigations led to a diagnosis of Dengue Fever. The condition, not very frequent and thus not well known in our countries, represents a major world health problem especially because of the global failure of prophylactic measures. If the disease is self-limited in most cases, severe form can occur, with significant mortality and morbidity. Delay in diagnosis and treatment of these severe cases is often fatal.

Early skin sensitization to aeroallergens.

BACKGROUND: Early detection of aeroallergen sensitization is important as a prognosis factor but may be more difficult in young children. OBJECTIVE: We sought to demonstrate that skin sensitization to aeroallergens was present in a selected group of 0-2-year-old children and that it was associated with environmental exposure and a family history of allergic disease. METHODS: Data on exposure and history were extracted from the files of 824 children seen in the asthma clinic and who were skin tested to a panel of aero- and food allergens. RESULTS: Forty percent of our children demonstrated atopy, 28% were sensitized to aeroallergens, the majority of which to house dust mite. Higher sensitization rates were found in children with large weals to histamine (P<0.001) and in those who slept with soft toys [odds ratio (OR) 1.45, 95% confidence interval (CI) 1.02-2.08]. With a definition of sensitization including the size of the weal to histamine, there was a negative association with a personal history of eczema only (OR 0.66, 95% CI 0.45-0.99). There was no gender-dependent effect and no association with day-care attendance. CONCLUSION: This is one of the largest studies to evaluate skin testing in a selected population of young children. We found a high prevalence of sensitization to aeroallergens, which was associated with exposure to soft toys. Further follow-up of this population will allow assessment of the predictive value of this sensitization.

[Limp with fever in adolescent: about 2 cases of pyomyositis]. / Boiterie fébrile chez l'adolescent: à propos de 2 observations de pyomyosite.

The authors report on 2 cases of limp with fever in adolescents, which developed after vigorous physical activity and were due to pyomyositis. Clinical, biological and radiological findings of the disorder are reviewed. Treatment is discussed. Early diagnosis and treatment are crucial for good prognosis.

Partial interferon-gamma receptor 1 deficiency in a child with tuberculoid bacillus Calmette-Guérin infection and a sibling with clinical tuberculosis.

Complete interferon-gamma receptor 1 (IFNgammaR1) deficiency has been identified previously as a cause of fatal bacillus Calmette-Guérin (BCG) infection with lepromatoid granulomas, and of disseminated nontuberculous mycobacterial (NTM) infection in children who had not been inoculated with BCG. We report here a kindred with partial IFNgammaR1 deficiency: one child afflicted by disseminated BCG infection with tuberculoid granulomas, and a sibling, who had not been inoculated previously with BCG, with clinical tuberculosis. Both responded to antimicrobials and are currently well without prophylactic therapy. Impaired response to IFN-gamma was documented in B cells by signal transducer and activator of transcription 1 nuclear translocation, in fibroblasts by cell surface HLA class II induction, and in monocytes by cell surface CD64 induction and TNF-alpha secretion. Whereas cells from healthy children responded to even low IFN-gamma concentrations (10 IU/ml), and cells from a child with complete IFNgammaR1 deficiency did not respond to even high IFN-gamma concentrations (10,000 IU/ml), cells from the two siblings did not respond to low or intermediate concentrations, yet responded to high IFN-gamma concentrations. A homozygous missense IFNgR1 mutation was identified, and its pathogenic role was ascertained by molecular complementation. Thus, whereas complete IFNgammaR1 deficiency in previously identified kindreds caused fatal lepromatoid BCG infection and disseminated NTM infection, partial IFNgammaR1 deficiency in this kindred caused curable tuberculoid BCG infection and clinical tuberculosis.

[Necrotizing pneumonia in children: apropos of 4 cases]. / Pneumonie nécrosante de l'enfant: à propos de 4 cas.

OBJECTIVES: To describe the necrotizing pneumonia in children, a severe affection which prevalence seems to increase; to review literature. PATIENTS AND METHODS: We report 4 cases of necrotizing pneumonia: symptoms, agents, diagnostic tools, treatment and long term evolution. RESULTS: In 2 cases, pneumatoceles could be seen at chest X-ray. Two patients presented a deficiency of anti-pneumococcal antibodies. Three needed insertion of a pleural chest tube of whom 1 had a resection of a small piece of necrotic lung. Duration of hospitalisation is longer than in uncomplicated pneumonias. CONCLUSION: Necrotizing pneumonia is a severe affection. Diagnosis has to be made by lung CT. Long term evolution is excellent in pediatric population with serious management at hospital.

[Pleural effusion in childhood: management algorithm]. / Epanchement pleural de l'enfant: Proposition d'un algorithme de prise en charge.

Based on an increased prevalence of empyema in children,we reviewed the literature on the diagnosis and management of this affection. A retrospective study of 11 children admitted to our hospital in 2003 shows a prolonged hospitalisation (median 18 days) even with adequate treatment. Based on our experience and data from the literature, we propose a management algorithm to allow treatment of children admitted ith pleural effusion.

Chronic respiratory failure due to toxic epidermal necrosis in a 10 year old girl.

Toxic epidermal necrosis is a severe mucocutaneous disease with a high mortality rate. A third of the patients surviving the acute phase will develop pulmonary complications. The most frequent complication is bronchiolitis obliterans. Despite well-conducted treatment, in most cases, lung injury often leads to chronic respiratory failure. We describe here the case of a young patient that presented a toxic epidermal necrosis at the age of 3 years. Poor therapeutic compliance result in chronic respiratory failure and after 7 years of follow-up, pulmonary transplant remains the only long-term alternative. Close monitoring of respiratory symptoms in the course of toxic epidermal necrosis, intense treatment as soon as they appear and a long-term follow-up are essential to postpone chronic respiratory failure.

Cutaneous lesions of disseminated cryptococcosis as the presenting manifestation of human immunodeficiency virus infection in a twenty-two-month-old child.

We report the case of a 22-month-old African boy with cutaneous lesions as the predominant feature of disseminated cryptococcosis (positive blood and cerebrospinal fluid cultures) and as the presenting manifestation of severe vertically acquired HIV infection (CDC C3 category). To our knowledge these cutaneous lesions have never been reported as the initial manifestation of AIDS in children.

Foreign body aspiration in childhood: management algorithm.

Foreign body inhalation is still a major cause of morbidity and even mortality in the under-fives. To reduce its frequency, more severe preventative measures must be imposed and to allow for early diagnosis, a low threshold for bronchoscopy is necessary. This retrospective study is based on 33 children referred to us for suspicion of inhaled foreign body. Symptomatology, clinical and paraclinical data are reviewed. Based on our practice and on the experience gained from the literature, we propose a management algorithm which will need to be further assessed by a prospective study.

[Laryngitis revealing bacterial tracheitis in a five-year-old child]. / Laryngite révélatrice d'une trachéite bactérienne chez un enfant âgé de cinq ans.

CASE REPORT: We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. COMMENTS: We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. CONCLUSION: Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.

[Quality of the care of the pediatric patient admitted to the emergency room]. / Qualité de la prise en charge de l'enfant admis en salle d'urgence polyvalente.

AIM: By a prospective study, authors tried to analyse the quality of management of the pediatric patient admitted in the emergency department. POPULATION AND METHODS: One hundred admission files were prospectively analysed for characteristics of age (mean age: 70 months), effectiveness of measurement of physiological parameters, evaluation of appropriateness of nursing management according to recorded parameters, length of stay in the emergency department according to the need for hospitalization, blood tests, X-rays and the seniority of the attending medical staff. RESULTS: Parameters were not, or only incompletely, recorded in 65 files. . Although all were recorded in the remaining 35 files, subsequent management was inadequate in seven cases. Mean length of stay in the emergency department was 116 minutes, influenced by the need for hospitalization (145 minutes compared to 102 minutes for the non-hospitalized children), timing of admission (mean: 125 minutes from 8 am to 6 pm, compared to 94 minutes from 6 pm to 8 am), need for blood tests, X-rays or both (mean: 122, 107 and 170 minutes respectively, compared to 55 minutes when no complementary exam was asked) and seniority of attending medical staff (mean: 65 minutes for permanent staff compared to 116 minutes for fellows). CONCLUSIONS: Measurement of physiological parameters must be standard practise in the management of pediatric patients admitted to the emergency department and must lead to appropriate management without undue delay. In order to reach this goal, emergency departments should be more adequately staffed with nurses and senior doctors specifically trained in the care of the pediatric patient. Blood tests and X-rays should be more readily available.

[Spontaneous pneumomediastinum in an adolescent: an underestimated cause of chest pain]. / Pneumomédiastin spontané chez un adolescent: une cause sous-estimée de douleurs thoraciques.

CASE REPORT: A case of mediastinal emphysema occurring without etiologic factor except a Valsalva's manoeuvre a few hours before admission in a 15-year-old boy is reported. Symptoms were cervical and chest pain with moderate dysphagia. Diagnosis was confirmed by palpating subcutaneous air in the neck region and mediastinal air on a chest roentgenogram. A CT scan was performed to exclude a concurrent pneumothorax. The patient recovered with bed rest. CONCLUSION: Spontaneous pneumomediastinum results from nontraumatic, mediastinal air leakage without underlying lung disease. It should be considered in the differential diagnosis of chest pain, especially in healthy adolescents and young adults; it is certainly underdiagnosed in this population.

[Lyme disease and facial paralysis in children]. / Maladie de Lyme et paralysie faciale de l'enfant.

Lyme disease is one of the most common cause of acute peripheral facial palsy in children. Overall nervous system involvement is also the predominant manifestation of Lyme disease in children, chiefly as facial palsy and/or aseptic meningitis. The medical records of ten patients with discharge diagnosis of facial palsy associated to borreliosis were retrospectively reviewed. The diagnostic criteria for borreliosis included acute peripheral facial palsy associated with erythema migrans (1/10) and/or positive Lyme serology in serum (10/10) or CSF (6/10). Facial palsy was associated with a high rate (9/10) of occult meningitis. Cerebrospinal fluid findings showed lymphocytic pleocytosis associated to moderate increased protein level. PCR assays displayed a very low sensitivity. All patients with meningitis were treated with intravenous ceftriaxone for 3 weeks and received their treatment as outpatients with an heparinised venous catheter. Our study confirm that borreliosis should be considered in every case of peripheral facial palsy and based on the high rate of occult meningitis, we also advocate to perform a lumbar puncture. Although long term prognosis of facial palsy associated with Lyme disease in children appears excellent, current treatment recommendations advocate prolonged antibiotic therapy.

[Urinary infection in the child: diagnosis, treatment, and prognosis]. / Infection urinaire de l'enfant: diagnostic, traitement et pronostic.

Urinary tract infection is a common paediatric disease. Pyelonephritis may lead to severe renal damage (renal scarring), with possible arterial hypertension and renal insufficiency. Treatment and prognosis are closely related to a number of risk factors such as clinical, biological, radiological and scintigraphic data. The aim of the management is to give the most appropriate treatment and follow-up to avoid renal scarring.

[Nontuberculous mycobacterial epitrochlear adenitis]. / Adénite épitrochléenne à mycobactérie non tuberculeuse.

We report the case of a 2-year-old girl referred for unilateral epitrochlear lymphadenitis caused by Mycobacterium avium. Adenitis is the most frequent presentation of non tuberculous mycobacteria in children. Typical locations are the cervical, submandibular, axillar, inguinal, mediastinal, and parotid regions. To our knowledge, this is the first observation of an epitrochlear location. The diagnosis was made by evidencing the causal bacterium but also by the exclusion of other causes such as Bartonella henselae and Mycobacterium tuberculosis infections. Treatment is based on surgical excision, which provides a cure rate of 90%. Macrolides are reserved for extended lesions and/or relapsing lesions despite surgical management.

External validation of the bacterial meningitis score in children hospitalized with meningitis.

UNLABELLED: The Bacterial Meningitis Score (BMS) is considered as the rule with the highest sensitivity to safely distinguish between aseptic and bacterial meningitis (BM). OBJECTIVE: The objective of our study was to evaluate the performance of the score and its usefulness for the clinician. METHOD: Retrospective analysis of two Belgian academic hospitals-based cohort studies. All consecutive children aged 29 days to 18 years admitted for acute meningitis between January 1996 and December 2008 was eligible. The BMS (risk of bacterial meningitis if seizure, positive cerebrospinal fluid (CSF) Gram staining, CSF protein level (3) 80 mg/dl, CSF neutrophil count 1,000/ mm3 or blood neutrophil count > or = 10,000/mm3) was applied to all patients with meningitis defined by CSF pleocytosis > 8 WBC/mm3. RESULTS: 174 patients were included in the final analysis of whom 26 (15%) had BM. Of the 93 patients categorized as having with no risk for BM (BMS score = 0), 2 patients had BM, one of which had petechial rash (negative predictive value 97.8%). BMS had a sensitivity of 92.3%. Risk of BM was significantly related to the BMS score: 6/147 (4%) patients with BMS < or = 1 had BM compared to 20/27 (74%) patients with BMS > 1. CONCLUSIONS: Our study reports a lower sensitivity of the BMS than observed in previous validation studies. We suggest to include the BMS in a decision tree aiming to optimize the ordering of laboratory investigations including viral and bacterial PCR testing in any child with CSF pleocytosis.