Pulmonary Mycobacterium abscessus Infection in an 11-Year-Old Child, Successfully Treated with Inhaled/Parenteral Amikacin: A Case Report and Review of Literature.

Mycobacterium abscessus appears to be increasing cause of pulmonary infection in children with underlying risk factors including cystic fibrosis, chronic lung disease and immunodeficiency syndromes. We present a case of pulmonary M. abscessus infection in a pediatric patient with primary ciliary dyskinesia and he was successfully treated with parenteral amikacin, linezolid and oral clarithromycin combined with inhaled amikacin. Clinical improvement was observed after adding inhaled amikacin to the treatment.

Antimicrobial surgical prophylaxis: Still an issue in paediatrics.

OBJECTIVES: Antimicrobial prophylaxis (AP) is an important means of reducing surgical site infections. The goal of this study was to evaluate the perioperative AP in paediatric practice and its compliance with surgical prophylaxis guidelines. METHODS: A prospective study was conducted at Gazi University Faculty of Medicine, between September 2015 and April 2016. Paediatric patients who underwent surgical procedures were included in the study. Surgical AP was evaluated. RESULTS: During the entire study period, 466 children underwent surgery at our centre; 433 (92.7%) received antimicrobial prophylaxis. Overall adherence to the guidelines regarding surgical prophylaxis was 22.1%. The rate of administration of surgical prophylaxis was significantly lower, and the duration was shorter when the surgical procedure was clean (P = 0.002). When the duration of the procedure was longer, the rate of administration of prophylaxis was higher (P = 0.000). The duration of postoperative prophylaxis was longer than recommended in 72.2% of the patients. In the multivariate analysis, application errors increased with longer surgical time (P = 0.01, OR 2.18, 95% CI 1.19-4.03). CONCLUSIONS: High rates of misapplication of antimicrobial surgical prophylaxis were observed in this study. Awareness and usage of guidelines should be encouraged. The education of clinicians should be supported by studies regarding surgical prophylaxis in children.

Infections in Pediatric Burn Patients: An Analysis of One Hundred Eighty-One Patients.

Background: Infectious complications are one of the most life-threatening complications and result in substantial mortality and morbidity in children who have been burned. The goal of the study is to assess the risk factors for sepsis in pediatric burn patients in a referral hospital. Methods: This study was performed at the Pediatric Burn Unit of Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital during the period between January 2014 and June 2017. The patients were evaluated for age, sex, burn etiology, burned body surface area (BSA), the presence of inhalation injury, sepsis, positive cultures, the micro-organisms cultured samples, and septic focus. Results: A total of 181 patients were included in the study. The most common cause of burns was scalds in 120 patients (66.3%). Forty-one patients (22.7%) developed health-care-associated infection and sepsis. Gram-negative micro-organisms were isolated in 40 (97.6%) patients (Acinetobacter spp., Pseudomonas aeruginosa, Klebsiella pneumonia) with sepsis. Carbapenem resistance was detected in 31 (93.8%) of 40 patients. Mortality was observed in 11 patients (6.1%) in the group with sepsis. Burn surface area, burn depth, C-reactive protein (CRP) values, mortality, Garcés index, and Baux index were higher in the group with sepsis (p < 0.05). Multiple regression analysis revealed that mechanism of injury (flame), burned BSA ≥25%, C-reactive protein ≥6 mg/dL (area under the curve [AUC]: 0.76 p < 0.001 and AUC: 0.90, p < 0.001, respectively) at admission were independent parameters for development of sepsis in pediatric burn patients. Conclusion: Multi-drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii were important agents of blood stream infection in burned children. Burned BSA ≥25% and CRP ≥6 mg/dL were risk factors for developing sepsis in pediatric burn patients.

Passive Smoking and Disease Severity in Childhood Pneumonia Under 5 Years of Age.

OBJECTIVE: To objectively investigate the effect of passive smoking on pneumonia and disease severity in children aged less than 5 years by using cotinine as an indicator of passive smoking. METHODS: Between December 2015 and April 2016, children aged less than 5 years with pneumonia and age-matched healthy controls were included in this study, which was conducted at three tertiary pediatric pulmonology centers. A questionnaire was given to the parents regarding demographic data and smoking status at home. Urinary cotinine/creatinine ratio (CCR) was measured. The data from the pneumonia and control groups, as well as children with mild and severe pneumonia within the pneumonia group, were compared. RESULTS: A total of 227 subjects were included in the study; there were 74 children in the pneumonia group and 153 in the control group. The mean age of all the children was 33.4 ± 1.28 months. Of all subjects, 140 were male and 102 were exposed to passive smoking by their parents at home. There were statistically significant differences in age, number of people in the home, and mother's and father's age between the control and pneumonia groups (p < 0.05). No difference was found in the CCR in the control and pneumonia group (p > 0.05). Age and urinary CCR were significantly different between children with mild and severe pneumonia (p < 0.05). CONCLUSION: We showed that passive smoking exposure was associated with the development of severe pneumonia in children. Further studies are needed to examine the underlying cause in detail.

Risk factors for bacteremia in children with febrile neutropenia

Background/aim: Bacteremia remains an important cause of morbidity and mortality during febrile neutropenia (FN) episodes. We aimed to define the risk factors for bacteremia in febrile neutropenic children with hemato-oncological malignancies. Materials and methods: The records of 150 patients aged ≤18 years who developed FN in hematology and oncology clinics were retrospectively evaluated. Patients with bacteremia were compared to patients with negative blood cultures. Results: The mean age of the patients was 7.5 ± 4.8 years. Leukemia was more prevalent than solid tumors (61.3% vs. 38.7%). Bacteremia was present in 23.3% of the patients. Coagulase-negative staphylococci were the most frequently isolated microorganism. Leukopenia, severe neutropenia, positive peripheral blood and central line cultures during the previous 3 months, presence of a central line, previous FN episode(s), hypotension, tachycardia, and tachypnea were found to be risk factors for bacteremia. Positive central line cultures during the previous 3 months and presence of previous FN episode(s) were shown to increase bacteremia risk by 2.4-fold and 2.5-fold, respectively. Conclusion: Presence of a bacterial growth in central line cultures during the previous 3 months and presence of any previous FN episode(s) were shown to increase bacteremia risk by 2.4-fold and 2.5-fold, respectively. These factors can predict bacteremia in children with FN.

Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey.

OBJECTIVES: The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey. METHODS: A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed. RESULTS: A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies. CONCLUSION: The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.

Comparison of prophylactic use of intravenous immunoglobulin versus Pentaglobin® in pediatric patients after hematopoietic stem cell transplantation.

There are few studies evaluating the use of IgM-enriched IVIG (Pentaglobin(®) ) in HSCT recipients. This study aimed to compare the efficacy of prophylactic use of IVIG versus prophylactic use of Pentaglobin(®) within the first 100 days after allogeneic HSCT. We performed a prospective, randomized study of the use of prophylactic IVIG versus prophylactic use of Pentaglobin(®) in patients after allogeneic HSCT. The first dose of IVIG or Pentaglobin(®) was given before conditioning regimen and after transplant was given on day +1, +8, +15, and +22. And then, it was given if IgG level was below 400 mg/dL. Twenty-seven patients in IVIG group and 32 patients in Pentaglobin(®) group were included in the study. There were no significant differences in the duration of neutropenia, hospitalization, fever, and in the number of pyrexial episode, septicemia, bacteremia, local infection, CMV infection, acute GVHD, VOD, and adverse events between the IVIG group and Pentaglobin(®) group. Randomized placebo-controlled trials are needed to conclude that utilization of IVIG or Pentaglobin(®) has no beneficial effect in HSCT.

Myocarditis in a Child with Crimean-Congo Hemorrhagic Fever.

Crimean-Congo hemorrhagic fever (CCHF) is a viral, tick-borne disease that can be fatal, especially in the adult patient population. CCHF involves multiple organ systems. Pericardial effusion, cardiac hypokinesia, T-wave changes, bundle branch block, and myocardial involvement can be seen as a cardiac complication of CCHF. Several different viruses like Coxsackie A/B and adenovirus may cause myocarditis and cardiomyopathy, but myocardial involvement of CCHF in children was rarely reported. We report a 13-year-old boy patient with myocarditis during the course of CCHF who has completely resolved after convalescent period of the disease.

Dissecting the heterogeneity of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis.

OBJECTIVE: To seek insights into the heterogeneity of macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (sJIA) through the analysis of a large patient sample collected in a multinational survey. METHODS: International pediatric rheumatologists and hemato-oncologists entered their patient data, collected retrospectively, in a Web-based database. The demographic, clinical, laboratory, histopathologic, therapeutic, and outcome data were analyzed in relation to (1) geographic location of caring hospital, (2) subspecialty of attending physician, (3) demonstration of hemophagocytosis, and (4) severity of clinical course. RESULTS: A total of 362 patients were included by 95 investigators from 33 countries. Demographic, clinical, laboratory, and histopathologic features were comparable among patients seen in diverse geographic areas or by different pediatric specialists. Patients seen in North America were given biologics more frequently. Patients entered by pediatric hemato-oncologists were treated more commonly with biologics and etoposide, whereas patients seen by pediatric rheumatologists more frequently received cyclosporine. Patients with demonstration of hemophagocytosis had shorter duration of sJIA at MAS onset, higher prevalence of hepatosplenomegaly, lower levels of platelets and fibrinogen, and were more frequently administered cyclosporine, intravenous immunoglobulin (IVIG), and etoposide. Patients with severe course were older, had longer duration of sJIA at MAS onset, had more full-blown clinical picture, and were more commonly given cyclosporine, IVIG, and etoposide. CONCLUSION: The clinical spectrum of MAS is comparable across patients seen in different geographic settings or by diverse pediatric subspecialists. There was a disparity in the therapeutic choices among physicians that underscores the need to establish uniform therapeutic protocols.

Secondary antifungal prophylaxis in pediatric hematopoietic stem cell transplants.

Invasive fungal infections (IFIs) constitute a leading cause of morbidity and infection-related mortality among hematopoietic stem cell transplant (HSCT) recipients. With the use of secondary prophylaxis, a history of IFI is not an absolute contraindication to allo-HSCT. However, still, IFI recurrence remains a risk factor for transplant-related mortality. In this study, of the 105 children undergoing HSCT between April 2010 and February 2013, 10 patients who had IFI history before transplantation and had undergone allo-HSCT were evaluated retrospectively to investigate results of secondary prophylaxis. In conclusion, our study shows that amphotericin B and caspofungin was successful as secondary antifungal prophylaxis agents with no relapse of IFI. In addition, after engraftment, secondary prophylaxis was continued with voriconazole orally in 4 patients that yielded good results.

Cytokine concentrations in pediatric patients with Crimean-Congo hemorrhagic fever.

Crimean-Congo hemorrhagic fever is a zoonotic disease that can be a severe illness in humans. We investigated concentrations of interleukin (IL)-6, tumor necrosis factor-α and IL-10 in serum samples obtained from 25 pediatric Crimean-Congo hemorrhagic fever cases and 35 control children with no signs of infection. Lower cytokine values in our patients could be a good prognostic factor to for a better outcome.

Severe iron deficiency anemia and marked eosinophilia in adolescent girls with the diagnosis of human fascioliasis.

Human fascioliasis (HF), caused by the common liver fluke Fasciola hepatica, is an endemic infection in many parts of tropical countries. HF can also be seen in some of the non-tropical countries. This report describes two girls with severe iron deficiency anemia and eosinophilia, who were diagnosed as HF. The infection was successfully eliminated with the administration of triclabendazole. No side effects or recurrence was observed after the treatment. It should be kept in mind that marked eosinophilia with severe iron deficiency anemia should alert pediatricians to the possibility of F. hepatica infection.

Prophylactic acyclovir and preemptive ganciclovir to prevent cytomegalovirus disease in children after hematopoietic stem cell transplant.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of acyclovir prophylaxis and preemptive ganciclovir treatment in preventing cytomegalovirus disease in children who underwent hematopoietic stem cell transplant. MATERIALS AND METHODS: We reviewed the clinical records of 66 children (36 boys, 30 girls; mean age, 9 ± 5 y; age range, 2-20 y) who underwent hematopoietic stem cell transplant at Ankara Children's Hematology and Oncology Hospital, Bone Marrow Transplantation Unit, between April 2010 and March 2012. RESULTS: In these 66 children, 61 children (92.4%) received allogeneic transplant; 50 children (76.9%) received a myeloablative regimen; and 14 children (21.2%) received anti-thymocyte globulin as part of the conditioning regimen. All children received acyclovir prophylaxis from the beginning of conditioning regimen until 100 days after transplant, and children received preemptive treatment with ganciclovir when cytomegalovirus DNAemia ≥ 400 copies/mL on 2 tests or ≥ 1000 copies/mL on 1 test. There were 19 children (28.8%) who had cytomegalovirus reactivation during median follow-up 381 days (range, 100-720 d). Cytomegalovirus disease was observed in only 2 patients (10.5%); 1 patient had cytomegalovirus hepatitis and 1 patient had cytomegalovirus gastrointestinal disease. Both patients were cured of cytomegalovirus with treatment for 1 month. There was no death attributable to cytomegalovirus reactivation and/or disease. Febrile neutropenia, acute graft-versus-host disease, and steroid use were more frequent in patients who had cytomegalovirus than did not have cytomegalovirus reactivation. The risk of cytomegalovirus reactivation was increased 5-fold in patients who used steroids. CONCLUSIONS: Acyclovir prophylaxis and preemptive treatment with ganciclovir may be effective in preventing cytomegalovirus disease in most children who have hematopoietic stem cell transplant.

A rare cause of abdominal lymphadenopathy--tularemia: report of two pediatric cases.

Tularemia caused by Francisella tularensis occurs worldwide in the northern hemisphere, with great variation in geographic and temporal occurrence. It generally presents as an acute febrile disease with the major clinical presentations including the six classic forms of tularemia: ulceroglandular, glandular, oculoglandular, oropharyngeal, typhoidal, and pneumonic. In contrast to European countries, where the ulceroglandular form is more prominent, the oropharyngeal form is the most common presentation in Turkey. We present rare cases of oropharyngeal tularemia in a 16-year-old boy and nine-year-old girl. To the best of our knowledge, these are the firstly described abdominal lymphadenopathy cases from Turkey. The second case was admitted with erythema nodosum, and abdominal lymphadenopathy was detected during the investigation. Excisional lymph node biopsy revealed abdominal tularemia. It is necessary to consider tularemia in the differential diagnosis of abdominal lymphadenopathy in tularemia regions. We also conclude that oropharyngeal tularemia can cause lymphadenopathy in any part of the gastrointestinal tract.

Life-threatening agranulocytosis, anemia, and plasmacytosis after dipyrone use for fever in a child.

Dipyrone or metamizole Na (Novalgin) is commonly used as an antipyretic, analgesic, and spasmolytic agent in some parts of the world; however, it is banned in developed countries because of severe side effects. Here we present a case of a 4-year-old boy who developed life-threatening agranulocytosis, anemia, and marked plasmacytosis in his bone marrow after dipyrone use for fever, which resolved with steroid therapy.