Antimicrobial Resistance and Diagnostic Imaging in Infants Younger Than 2 Months Old Hospitalized With a First Febrile Urinary Tract Infection: A Population-based Comparative Study.

BACKGROUND: Data on urinary tract infection (UTI) in infants ≤2 months of age are limited. We examined clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes in infants ≤2 months of age and children 2-24 months of age hospitalized with the first febrile UTI. METHODS: Children ≤24 months of age hospitalized with their first-diagnosed febrile UTI were prospectively studied. Renal ultrasonography, Tc-dimercaptosuccinic acid scanning and voiding cystourethrography were performed in all children. RESULTS: Of the 388 children analyzed (255 boys and 133 girls), 61 patients were ≤2 months of age, representing 15.7% of the whole population, whereas 327 patients were 2-24 months of age. Escherichia coli was the predominant bacterium, with similar antimicrobial resistance in the 2 groups, and associated E. coli bacteremia occurred in 9 patients (2.3%). Renal ultrasonography showed abnormal findings in 130 patients (33.5%), but there was no difference in the rate of abnormal findings between the groups. Vesicoureteral reflux (VUR) was present in 130 children (33.5%), including 93 (24%) with grades III-V VUR. VUR was more prevalent in the infants ≤2 months of age (P = 0.007), but there was no difference in the prevalence of grades III-V VUR between the groups. The incidence of renal scarring was 28.6% (111/388), and it did not differ between the groups. CONCLUSIONS: There are similarities in clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes after a first UTI between the young infants ≤2 months and children 2-24 months of age. The same guidelines for the diagnosis and management after the first febrile UTI can be applied to children who are ≤24 months of age.

Necrotizing pneumonia and acute purulent pericarditis caused by Streptococcus pneumoniae serotype 19A in a healthy 4-year-old girl after one catch-up dose of 13-valent pneumococcal conjugate vaccine.

Streptococcus pneumoniae is a common cause of infectious diseases in children that may lead to life-threatening complications. Acute purulent pericarditis is an uncommon complication of S. pneumoniae in the antibiotic era. A healthy 4-year-old girl was admitted with pneumonia and pleural effusion. She had received one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age. She rapidly developed necrotizing pneumonia, complicated by bronchopleural fistula presenting as subcutaneous emphysema and pneumothorax and acute purulent pericarditis. S. pneumoniae serotype 19A was subsequently identified from blood, empyema and pericardial fluid cultures. After appropriate antibiotic therapy and a right lower lobectomy, her condition stabilized and she promptly recovered. This case highlights two rare potential clinical complications of pneumococcal disease in a child: necrotizing pneumonia and acute purulent pericarditis. This is the first report of a child who received just one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age, as per the United States' Advisory Committee on Immunization Practice's recommendations, but who still developed severe invasive pneumococcal disease with life-threatening complications caused by S. pneumoniae serotype 19A.

Role of Renal Ultrasonography in Predicting Vesicoureteral Reflux and Renal Scarring in Children Hospitalized with a First Febrile Urinary Tract Infection.

BACKGROUND: This study was designed to examine the capability of renal ultrasonography (US) for predicting vesicoureteral reflux (VUR) and renal scarring (RS), and to assess, using initial US, the significant urologic abnormalities that impact on management of children hospitalized with a first febrile urinary tract infection (UTI). METHODS: Hospitalized children aged ≤ 2 years with a first febrile UTI were prospectively evaluated using imaging studies, including (99m)Tc dimercaptosuccinic acid (DMSA) scan, US, and voiding cystourethrography. RESULTS: Of the 310 children analyzed (195 boys and 115 girls), 105 (33.9%) had abnormal US. Acute DMSA scans were abnormal in 194 children (62.6%), including 89 (45.9%) with concomitant abnormal US. There was VUR in 107 children (34.5%), including 79 (25.5%) with Grades III-V VUR. The sensitivity and negative predictive values of US were 52.3% and 75.1%, respectively, for Grades I-V VUR and 68.4% and 87.8%, respectively, for Grades III-V VUR. Eighty-five children (27.4%) had RS, including 55 (64.7%) with abnormal US. Of the 105 children with abnormal US, 33 (31.4%) needed subsequent management (surgical intervention, parental counseling, or follow up of renal function). Nephromegaly on initial US and Grades III-V VUR were risk factors of RS. CONCLUSION: Abnormal US may carry a higher probability of Grades III-V VUR and RS, and can affect subsequent management in a significant number of children. Nephromegaly on initial US and Grades III-V VUR are strongly associated with an increased risk for RS. Thus, US should be performed on children after a first febrile UTI and children with normal US may not require voiding cystourethrography.

Extra-adrenal paraganglioma presenting as acute chest pain mimicking acute myocardial infarction in a 10-year-old boy.

Extraadrenal paragangliomas are rare pediatric tumors with variable symptoms that cause difficultly in diagnosis and delayed treatment. We report the case of a 10-year-old boy who presented to the pediatric emergency department with acute chest pain and dyspnea mimicking a non-ST-segment elevation acute myocardial infarction. He was subsequently found to have an extraadrenal paraganglioma after a series of imaging and laboratory examinations. The mass was subsequently removed, and the diagnosis of extraadrenal paraganglioma was confirmed histologically. Acute coronary syndrome as the presenting feature of extraadrenal paragangliomas in pediatric population is an even rarer clinical entity.

Comparison of procalcitonin and different guidelines for first febrile urinary tract infection in children by imaging.

BACKGROUND: We examined the ability of a procalcitonin (PCT) protocol to detect vesicoureteral reflux (VUR) and renal scarring (RS), evaluated procedural costs and radiation burden, and compared four representative guidelines for children with their first febrile urinary tract infection (UTI). METHODS: Children aged ≤2 years with their first febrile UTI who underwent renal ultrasonography (US), acute and late technetium-99m ((99m)Tc)-dimercaptosuccinic acid scan, and voiding cystourethrography were prospectively studied. The representative guidelines applied in a retrospective simulation included the American Academy of Pediatrics (AAP), National Institute of Clinical Excellence, top-down approach (TDA), and Italian Society of Pediatric Nephrology (ISPN). These were compared in terms of ability to detect abnormalities, procedural costs and radiation. RESULTS: Of 278 children analyzed, 172 (61.9%) had acute pyelonephritis. There was VUR in 101 (36.3%) children, including 73 (26.3%) with grades III-V VUR. RS was identified in 75 (27.0%) children. To detect VUR, TDA and PCT had the highest sensitivity for grades I-V VUR (80.2%) and III-V VUR (94.5%), respectively, whereas AAP had the highest specificity for I-V VUR (77.4%) and III-V VUR (78.0%), respectively. TDA and PCT had the highest sensitivity (100%) for detecting RS. The highest cost and radiation dose was associated with TDA, whereas AAP had the least expenditure and radiation exposure. By multivariate analysis, PCT and VUR, especially grades III-V, were independent predictors of RS. CONCLUSIONS: There is no perfect guideline for first febrile UTI children. The PCT protocol has good ability for detecting high-grade VUR and RS. If based on available imaging modalities and reducing cost and radiation burden, clinical suggestions in the AAP guidelines represent a considerable protocol.

Association of a lymphotoxin-alpha gene polymorphism and atopic asthma in Taiwanese children.

BACKGROUND: The lymphotoxin-alpha (LT-alpha) gene is located on chromosome 6 (6p21.1-6p21.3) and it may regulate tumor necrosis factor (TNF) production. TNF is a potent cytokine in the airway inflammatory response. Polymorphisms of TNF-associated genes have been related to asthma. This study investigated an LT-alpha-Ncol polymorphism in the first intron of the LT-alpha gene (LT-alpha-Ncol*1 allele, as a variant type; and LT-alpha-Ncol*2 allele), which may predispose individuals to asthma and atopy. METHODS: Polymerase chain reaction-based assays were performed to determine LT-alpha-Ncol genotypes among our subjects. A genetic case control analysis was then performed on 114 atopic asthmatic and 155 non-asthmatic unrelated children. RESULTS: There was a statistically higher frequency of LT-alpha-Ncol*1 allele carriers (1/1+1/2) in the subjects with atopic asthma than in controls (OR=1.923; 95% CI = 1.061-3.484; p = 0.031). CONCLUSION: The results indicate that LT-alpha-Ncol*1 may be a risk factor for atopic asthma in Taiwanese children.

Anterior mediastinal immature teratoma with precocious puberty in a child with Klinefelter syndrome.

Klinefelter syndrome occurs in approximately 1 in 1000 males. A 4-year-old boy presented with precocious puberty and an anterior mediastinal mass. Serum alpha-fetoprotein and human chorionic gonadotropin levels were mildly increased. Computed tomography revealed a germ cell tumor (GCT) of the mediastinum. Complete resection of the tumor was performed. Histologic analysis revealed an immature teratoma. Males with Klinefelter syndrome develop GCTs at a rate 50 times higher than unaffected males. This case report calls attention to the need to rule out Klinefelter syndrome in boys who present with precocious puberty and a mediastinal GCT.