Liver failure secondary to poisoning by a homemade product made of star and green anise in a 4-month-old infant.

Intoxications in pediatric age represent a frequent cause of visit to the hospital emergency unit. Herb-made products can be toxic for the infant. The neurotoxic properties of the star anise (Illicium verum) have been widely described, although it is a classic product used to treat the infantile colic. Hepatic failure due to the consumption of anise herb elaborated infusions is presented as an exceptional finding in our environment. A case of a 4-month-old infant with hypertransaminasemia, severe coagulopathy, non ketotic hypoglycemia, moderated metabolic acidosis and neurologic symptoms such as seizures and nistagmus is described. After discarding infectious, metabolic and autoimmune etiology and through a meticulous anamnesis, the family referred having administered in the last two months a daily star anise and green anise (Pimpinella anisum) infusion to the patient. It is important to emphasize the serious risk of administering homemade herb infusions to infants.

Acute alithiasic cholecystitis: a not so rare disease.

INTRODUCTION: Acute acalculous cholecystitis (AAC) occurs more frequently in critically ill patients, in the immediate postoperative period, after trauma or extensive burns. It has a high rate of morbidity and mortality. Ischemia, infection and vesicular stasis are determinants in its pathogenesis. MATERIAL AND METHOD: Retrospective study including all cases of AAC diagnosed in our pediatric intensive care unit between January 1997 and December 2012. RESULTS: We included 7 patients, all associated with viral or bacterial infection. All of them suffered from abdominal pain, mainly localized in the right upper quadrant, jaundice and dark urine. Abdominal ultrasound showed thickening and hypervascularity of the gallbladder wall in all cases. The outcome was satisfactory without surgery in all patients. CONCLUSIONS: The clinical presentation is oligosymptomatic within severe systemic diseases. The AAC should be suspected in the appearance of any abdominal pain with jaundice/dark urine and hypertransaminasemia in patients suffering from critical or serious infections.

[Lower lymphocyte response in severe cases of acute bronchiolitis due to respiratory syncytial virus]. / Menor respuesta linfocitaria en casos graves de bronquiolitis aguda por virus respiratorio sincitial.

INTRODUCTION: Acute bronchiolitis (AB) of the infant has a serious outcome in 6-16% of the hospital admitted cases. Its pathogenesis and evolution is related to the response of the T lymphocytes. The objective of the present study is to determine if the lower systemic lymphocytic response is related to a worse outcome of AB in hospitalised infants. PATIENTS AND METHOD: Retrospective observational-analytical study of cases-controls nested in a cohort of patients admitted due to RSV-AB between the period from October 2010 to March 2015. Those with a full blood count in the first 48hours of respiratory distress were included. Infants with underlying disease, bacterial superinfection, and premature infants <32 weeks of gestation were excluded. The main dichotomous variable was PICU admission. Other variables were: gender, age, post-menstrual age, gestational and post-natal tobacco exposure, admission month, type of lactation, and days of onset of respiratory distress. Lymphocyte counts were categorised by quartiles. Bivariate analysis was performed with the main variable and then by logistic regression to analyse confounding factors. RESULTS: The study included 252 infants, of whom 6.6% (17) required PICU admission. The difference in mean±SD of lymphocytes for patients admitted to and not admitted to PICU was 4,044±1755 and 5,035±1786, respectively (Student-t test, P<.05). An association was found between PICU admission and lymphocyte count <3700/ml (Chi-squared, P=.019; OR: 3.2) and it was found to be maintained in the logistic regression, regardless of age and all other studied factors (Wald 4.191 P=.041, OR: 3.8). CONCLUSIONS: A relationship was found between lymphocytosis <3700/ml in the first days of respiratory distress and a worse outcome in previously healthy infants <12 months and gestational age greater than 32 weeks with RSV-AB.

[Validation study of an acute bronchiolitis severity scale to determine admission to a Paediatric Intensive Care Unit]. / Estudio de validez de una escala de gravedad de la bronquiolitis aguda para orientar el ingreso en UCIP.

INTRODUCTION: At present, there are few validated scoring tests for assessing acute bronchiolitis (AB) severity, and limited information on their test power. The aim of the present study is to evaluate the validity of an acute bronchiolitis severity score (ABSS) to help in deciding PICU admission. PATIENTS AND METHOD: Prospective, descriptive, observational study of previously healthy infants under 1 year of age with AB, where the ABSS was used to compare severity as regards the need for PICU admission. The sample size was estimated as at least 175 patients. The research team was trained in the use of ABSS. All patients in the study were evaluated with ABSS daily, as well as in the case of clinical deterioration. The initial and maximum ABSS scores were contrasted to the need for PICU admission. A receiver operative curve was constructed, and the area under the curve was calculated, and the optimum point of sensitivity / specificity was estimated. RESULTS: The study included a total of 190 patients (male / female: 58% / 42%). PICU was required in 11 (6%). The mean± SD ABSS-maximal score for patients who required and did not require PICU was 10.55± 1.12 and 6.35± 2.3, respectively (P<.001). The AUC for ABSS-maximal was 0.94 (P<.001, 95% CI: 0.90-0.98). The optimal cut-off point was set at ≥10 points for a sensitivity of 82% and a specificity of 91%. CONCLUSIONS: ABSS estimates the severity of AB regarding the need for PICU admission, with a sensitivity and specificity of clinical usefulness.

[Neopterin levels and systemic inflammatory response syndrome in pediatric critically ill patients]. / Niveles de neopterina y síndrome de respuesta inflamatoria sistémica en pacientes críticos pediátricos.

INTRODUCTION: Neopterin and biopterin are sub-products of redox reactions, which act as cofactors of enzymes responsible for nitric oxide production. The hypothesis is presented that plasma neopterin and biopterin evolve differently during the first days in a critically ill child. METHODS: A single-centre prospective observational study was conducted on patients 7 days to 14 years admitted to our Paediatric Intensive Care Unit (PICU) and that met Systemic inflammatory response syndrome (SIRS) criteria. Neopterin and biopterin levels, as well as other acute phase reactants, were collected at admission and at 24 h. RESULTS: A total of 28 patients were included, of which 78.9% were male, The median age was 5.04 years (interquartile range [IQR] 1.47-10.26), and PRISM II 2.0% (IQR 1.1-5.0). Mechanical ventilation (MV) was used in 90% of patients, with a median duration of 6.0 hrs (IQR 3.7-102.0). The median length of stay in PICU was 5.0 days (IQR 2.7-18.7), maximum VIS mean of 0 (IQR 0-14). Baseline neopterin level was 2.3±1.2 nmol/l and at 24 h it was 2.3±1.4 nmol/l. Baseline biopterin was 1.3±0.5 nmol/l and 1.4±0.4 nmol/l at 24 h. Neopterin levels were significantly higher in patients with PICU length of stay > 6 days (P=.02), patients who needed MV >24 h (P=.023), and those who developed complications (P=.05). Neopterin correlates directly and is statistically significant with the duration of MV (rho=.6, P=.011), PICU length of stay (rho=.75, P<.0001), and VIS (rho=.73, P=.001). Additionally, biopterin directly correlates with the PRISM (rho=.61, P=.008). DISCUSSION: There is a higher neopterin level when there is a longer PICU stay, higher VIS score, longer time on MV, and occurrence of complications, indicating the involvement of an activation of the cellular immune system.

[Vitamin D deficiency and morbimortality in critically ill paediatric patients]. / Déficit de vitamina D y morbimortalidad en pacientes críticos pediátricos.

OBJECTIVES: To determine the prevalence and risks factors of vitamin D deficiency, as well as its relationship with morbidity and mortality in a PICU. MATERIAL AND METHODS: An observational prospective study in a tertiary children's University Hospital PICU conducted in two phases: i: cohorts study, and ii: prevalence study. The study included 340 critically ill children with ages comprising 6 months to 16 years old. EXCLUSION CRITERIA: Chronic kidney disease, known parathyroid disorders, and vitamin D supplementation. Total 25-hydroxyvitamin D [25(OH)D] was measured in the first 48hours of admission to a PICU. Parathormone, calcium, phosphate, blood gases, blood count, C-reactive protein, and procalcitonin were also analysed. A record was also made of demographic features, characteristics of the episode, and complications during the PICU stay. RESULTS: The overall prevalence rate of vitamin D deficiency was 43.8%, with a mean of 22.28 (95% CI 21.15-23.41) ng/ml. Patients with vitamin D deficiency were older (61 vs 47 months, P=.039), had parents with a higher level of academic studies (36.5% vs 20%, P=.016), were admitted more often in winter and spring, had a higher PRISM-III (6.8 vs 5.1, P=.037), a longer PICU stay (3 vs 2 days, P=.001), and higher morbidity (61.1% vs 30.4%, P<001) than the patients with sufficient levels of 25(OH)D. Patients who died had lower levels of 25(OH)D (14±8.81ng/ml versus 22.53±10.53ng/ml, P=.012). Adjusted OR for morbidity was 5.44 (95%CI; 2.5-11.6). CONCLUSIONS: Vitamin D deficiency is frequent in critically ill children, and it is related to both morbidity and mortality, although it remains unclear whether it is a causal relationship or it is simply a marker of severity in different clinical situations.

[Prediction of Severe Course in Infants with RSV Bronchiolitis under 6 Months. Spain]. / Predicción de la evolución de la bronquiolitis por virus respiratorio sincitial en lactantes menores de 6 meses.

OBJECTIVE: The need for mechanical ventilation (MV) in acute bronchiolitis (AB) by respiratory syncytial virus (RSV) varies depending on the series (6-18%). Our goal is to determine the admissions to PICU for MV in patients under 6 months with AB and define the risk factors for building a prediction model. METHODS: Retrospective study of patients younger than 6 months admitted by BA-VRS between the periods April 1, 2010 and March 31, 2015 was made. The primary variable was the admission to PICU for MV. Related addition, to find risk factors in a model of binary logistic regression clinical variables were collected. A ROC curve model was developed and optimal cutoff point was identified. RESULTS: In 695 cases, the need of MV in the PICU (Y) was 56 (8.1%). Risk factors (Xi) included in the equation were: 1. male sex (OR 4.27) 2. postmenstrual age (OR: 0.76) 3. Weight income less than p3 (OR: 5.53) 4. intake lees than 50% (OR: 12.4) 5. Severity by scale (OR: 1.58) 6. apneas before admission (OR: 25.5) 7. bacterial superinfection (OR 5.03) and 8. gestational age more than 37 weeks OR (0.32). The area under the curve, sensitivity and specificity were 0.943, 0.84 and 0.93 respectively. CONCLUSIONS: The PICU admission for MV was 8.1 in every 100 healthy infants hospitalized for AB and year. The prediction model equation can help to predict patients at increased risk of severe evolution.

OBJETIVO: La necesidad de ventilación mecánica (VM) en la bronquiolitis aguda por el virus respiratorio sincitial (VRS) varía según las series entre el 6 y el 18 %. Nuestro objetivo fue conocer los ingresos en la unidad de cuidados intensivos para VM de pacientes con bronquiolitis aguda menores de 6 meses y definir los factores de riesgo con el fin de construir un modelo de predicción. METODOS: Estudio retrospectivo de pacientes menores de 6 meses ingresados por bronquiolitis aguda por VRS entre los periodos 1 de abril de 2010 y 31 de marzo de 2015. La variable principal fue el ingreso en la unidad de cuidados intensivos pediátricos para ventilación mecánica. Además, se recogieron variables clínicas relacionadas para hallar factores de riesgo en un modelo de regresión logística binaria. Con el modelo se elaboró una curva ROC y se identificó un punto óptimo de corte. RESULTADOS: De 695 casos, precisaron VM 56 (8,1%). Los factores de riesgo (Xi) incluidos en la ecuación fueron: 1. Sexo varón (OR: 4,27) 2. Edad postmenstrual (OR:0,76) 3. Peso al ingreso inferior a p3(OR: 5,53) 4. Ingesta inferior a 50% (OR:12,4), 5. Gravedad por escala (OR:1,58), 6. Apneas antes del ingreso (OR:25,5) 7. Sobreinfección bacteriana (OR: 5,03) y 8. Edad gestacional superior a 37 semanas OR (0,32). El área bajo la curva, sensibilidad y especificidad fueron 0,943; 0,84 y 0,93 respectivamente. CONCLUSIONES: Los ingresos en UCIP para VM fueron 8,1 por cada 100 lactantes sanos hospitalizados por BA y año. La ecuación elaborada del modelo de predicción puede ser de ayuda para predecir los pacientes con mayor riesgo de evolución grave.

A new prognostic scoring system for meningococcal septic shock in children. Comparison with three other scoring systems.

OBJECTIVE: To develop a quick and sensitive method for identification of children with presumed meningococcal septic shock at risk of death at admission to the pediatric intensive care unit (PICU) and to compare its performance with three other prognostic systems: Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS), Malley score and the Paediatric Index of Mortality (PIM). DESIGN: Multicenter retrospective cohort study. SETTING: PICUs of 14 tertiary hospitals. PATIENTS: The developmental sample included 192 children consecutively admitted to the PICUs with presumed or confirmed meningococcal septic shock from 1983 to 1995. The validation sample included 158 children consecutively admitted from 1996 to 1998. INTERVENTIONS: Clinical and laboratory data gathered during the first 2 h after admission were used to develop the new score and to compute the other scoring systems. Logistic regression was applied to identify the independent predictors of death. MEASUREMENTS AND RESULTS: Overall mortality was 31.5%. The new score included seven variables: cyanosis (2 points), Glasgow coma scale less than 8 (2 points), refractory hypotension (2 points), oliguria (1 point), leukocytes less than 4000/mm(3) (1 point), partial thromboplastin time more than 150% of control value (1 point) and base deficit more than 10 mmol/l (1 point). The new score provided the best discriminative capability, as measured by the area under the ROC curve (SEM) in the validation sample =0.88 (0.03), PIM =0.82 (0.04), Malley I =0.80 (0.04), GMSPS =0.79 (0.04) and Malley II =0.76 (0.04). CONCLUSIONS: A new prognostic score is proposed for therapeutic stratification of children with presumed meningococcal septic shock.