Epidemiological and bacterial profile of childhood meningitis in Tunisia.

The worldwide burden of disease of bacterial meningitis remains high, despite the decreasing incidence following introduction of routine vaccination campaigns.The aim of our study was to evaluate the epidemiological and bacteriological profile of paediatric bacterial meningitis (BM) in Tunisian children, during the period 2003-2019, following the implementation of Haemophilus influenzae type b (Hib) vaccine (April 2011) and before 10-valent pneumoccocal conjugate vaccine (PCV10) introduction to the childhood immunization program.All bacteriologically confirmed cases of BM admitted to children's hospital of Tunis were recorded (January 2003 to April 2019). Serogroups of Neisseria meningitidis (Nm) and serotypes of Streptococcus pneumoniae (Sp) and H. influenzae (Hi) and antibiotic resistance were determined using conventional and molecular methods.Among 388 cases, the most frequent species were Sp (51.3%), followed by Nm (27.5%) and Hi (16.8%). We observed a significant decrease in Hi BM rate during the conjugated Hib vaccine use period (P < 0.0001). The main pneumococcal serotypes were 14, 19F, 6B, 23F and 19A and the serotype coverage of PCV10, PCV13, PCV15 and PCV20 was 71.3 and 78.8%, 79.4 and 81.9% respectively. The most frequent Nm serogroup was B (83.1%). Most Hi strains were of serotype b (86.9%). High levels of resistance were found: Sp and Nm to penicillin (respectively 60.1 and 80%) and Hi to ampicillin (42.6%). All meningococcal and Hi isolates were susceptible to third-generation cephalosporins and 7.2% of pneumococcal strains had decreased susceptibility to these antibiotics.The Hib conjugate vaccine decreased the rate of BM. Sp dominated the aetiology of BM in children in Tunisia. Conjugate vaccines introducing decreases not only BM cases but also antimicrobial resistance.

Influenza A/H1N1 pdm 09 in children's Hospital Bechir Hamza of Tunis.

BACKGROUND: Influenza A (H1N1) is a contagious acute respiratory infection caused a pandemic in 2009. The outcome was variable among populations. AIM: To describe a clinical spectrum and the outcome of Tunisian children with pandemic H1N1/09 influenza virus. METHODS: This is a retrospective, descriptive study of children with pandemic H1N1/09 influenza virus hospitalized in the children's hospital of tunis, between November 2009 and February 2010. The diagnosis was made on positive rapid test or PCR. RESULTS: thirty two children were included. The median age was 12 months. The most frequently symptoms were: fever (87,5%), digestive disorders ( 59,4%) and dyspnea (15,6%). The mean length of stay was 3,8 days. The outcome was complicated by a bacterial infection (56,3%), and one death. CONCLUSION: Mild form of H1N1/influenza virus is the most common presentation; however severe forms can be observed especially in infants.

Perforated Meckel's diverticulum in a very preterm baby revealed at birth.

Perforated Meckel's diverticulum (MD) in a preterm baby is very rare. We report a case of a very preterm baby, born at 29-week gestation, with a birth weight of 1400 g, admitted in the third hour of life to our intensive care unit (ICU) for respiratory distress syndrome with abdominal distention. An abdominal radiograph showed a pneumoperitoneum. Laparotomy revealed Meckel's perforation. The baby was discharged healthy at the age of 16 days. MD should be kept in mind as one cause of an acute abdomen in preterm neonates mimicking necrotizing enterocolitis. To our knowledge, our patient is the third reported case described in the literature and the first one revealed at birth.

Retrospective Analysis of Clinical Characteristics and Disease Outcomes in Children and Adolescents Hospitalized Due to COVID-19 Infection in Tunisia.

Due to low susceptibility of coronavirus disease of 2019 (COVID-19) in children, limited studies are available regarding COVID-19 in the pediatric population in Tunisia. The current study evaluated the incidence, clinical characteristics, and outcomes of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection among children hospitalized at Béchir Hamza Children's Hospital. A retrospective cohort analysis was conducted using the hospital database between March 2020 and February 2022 with children aged ≤15 years with SARS-CoV-2 infection (confirmed by RT-PCR). A total of 327 COVID-19 hospitalized patients with a mean age of 3.3 years were included; the majority were male. Neurological disease (20%) was the most common comorbidity, while fever (95.3%) followed by cough (43.7%) and dyspnea (39.6%) were the most frequent symptoms reported. Severe disease with oxygen requirement occurred in 30% of the patients; 13% were admitted in the Intensive Care Unit. The overall incidence rate of COVID-19 hospitalization (in Tunis governorates) was 77.02 per 100,000 while the inpatient case fatality rate was 5% in the study population. The most prevalent circulating variant during our study period was Delta (48.8%), followed by Omicron (26%). More than 45% of the study population were <6 months and one-fourth (n = 25, 26.5%) had at least one comorbidity. Thus, the study findings highlight the high disease burden of COVID-19 in infants.

Critically ill infants with SARS-COV-2 delta variant infection.

BACKGROUND: SARS-CoV-2 is described to cause mild to moderate symptoms in children. To date, clinical data and symptoms of the Delta variant in pediatric patients are lacking. AIM: To describe clinical characteristics and outcomes of infants admitted in the pediatric intensive care unit (PICU) during the period of Delta variant predominance. METHODS: We performed a retrospective study, between June 23, 2021 and August 16, 2021. We included children aged under 15 years, admitted to PICU with severe and critical form of SARS-CoV-2 infection as confirmed by RT-PCR. We reviewed medical records for all patients. RESULTS: During the study period, 20 infants were included. The median age was 47 days (IQR: 26.5-77). The sex ratio was 0.8 (9 males). No underlying medical conditions were noted. Parents were not vaccinated. Respiratory involvement was the main feature to be observed in our cohort. Eleven patients had pediatric acute respiratory distress (PARDS) with a median oxygen saturation index (OSI) of 9 (IQR: 7-11). PARDS was mild in 4 cases, moderate in 5 cases and severe in 2 cases. Hemodynamic instability was observed in 4 cases. The main radiological finding was ground glass opacities in 11 cases. Seventeen patients were mechanically ventilated and 3 of them were escalated to high-frequency oscillatory ventilation. The median duration of mechanical ventilation was 6 days (IQR 2.5-12.5). The remaining patients were managed with high flow nasal cannula. Four patients died. CONCLUSION: We report herein a case series of very young infants, with no comorbidities, and with a life-threatening illness due to SARS-CoV-2 Delta variant.

Pseudotumoral cutaneous aspergillosis in chronic granulomatous disease, report of a pediatric case.

Invasive aspergillosis is a life-threatening condition in patients with chronic granulomatous disease (CGD). Skin invasion by Aspergillus occurs most commonly by contiguity to a neighboring cavity. We describe an unusual case of invasive cutaneous aspergillosis presented as a large burgeoning tumor in a 4-year-old girl with CGD who underwent surgical treatment for bifocal osteomyelitis of the left leg. The skin invasion occurred 4 months after a "successful" treatment of invasive pulmonary aspergillosis. Atypical presentation and diagnostic difficulties are discussed. Invasive cutaneous aspergillosis may be polymorphic. The diagnosis should be considered early in the etiological investigation of any suspicious skin lesions in CGD even in uncommon aspects such as burgeoning tumors.

Severe and critical SARS-COV-2 delta variant infection in infants without underlying medical conditions.

We report herein a case series of infants, with no comorbidities, who developed a life-threatening illness due to the SARS-CoV-2 Delta variant. We retrospectively reviewed the medical records of children, aged under 15 years, admitted to PICU, during the peak of Delta infection, between June 23 and August 16 2021, with severe and critical forms of SARS-CoV-2 infection, confirmed by RT-PCR. Twenty infants were included, the median age was 47 days (IQR: 26.5-77) and sex ratio was 0.8. No underlying medical conditions were noted. Parents were not vaccinated. Respiratory involvement was the main feature observed. Eleven patients had paediatric acute respiratory distress (PARDS) with a median oxygen saturation index (OSI) of 9 (IQR: 7-11). PARDS was mild in four, moderate in five, and severe in two cases. Hemodynamic instability was observed in 4 cases. The main radiological finding was ground glass opacities in 11 cases. Seventeen patients were mechanically ventilated, and three of them were escalated to high-frequency oscillatory ventilation. The median duration of mechanical ventilation was 6 days (IQR 2.5-12.5). The remaining patients were managed with high-flow nasal cannula. Four patients died.

Community acquired methicillin-resistant Staphylococcus aureus preseptal cellulitis complicated by zygomatic osteomylitis, cavernous sinus thrombosis and meningitis in a healthy child.

We report a case of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA) preseptal cellulitis complicated by zygomatic osteomyelitis, cavernous sinus thrombosis, meningitis, and necroziting pneumonia in a previously healthy two and half month old girl. This case exemplifies an aggressive and disseminated CA-MRSA infection with deep venous thrombosis in an infant without predisposing risk factors. The literature is reviewed and recommendations for management are provided.

[Early neonatal infection caused by Streptococcus pneumonias: report of 3 cases]. / Infection neonatale precoce a streptococcus pneumoniae: a propos de 3 observations.

BACKGROUND: S pneumoniae is a rare cause (1-8 %) of maternofetal infection causing an important morbi-mortality in the newborn and the mother. AIM: To report 3 cases of early neonatal infection due to S pneumonia. CASES REPORT: Three cases of early neonatal infection due to S pneumoniae are reported. The three newborns were at term or near term babies with a vaginal delivery in two cases and a caesarean section in one case. They presented severe symptoms, with a progressive onset after birth, leading to hypoxemic pneumonia in one case and to septic shock in two newborns associated with meningitis in one case. S pneumoniae was isolated in the blood culture in two patients with positive soluble antigens in the cerebrospinal fluid in one case and positive peripheral bacteriological swabs in the other case. In the third case, S pneumoniae was isolated in the tracheal sample of the newborn and his mother. S pneumoniae was sensitive to ampicillin in two patients and of decreased sensitivity to ampicillin in one patient. The clinical course was favourable in the three patients after hospitalization in the intensive care unit. CONCLUSION: Early neonatal infections caused by S pneumonia are rare and are an important cause of morbi-mortality in the newborn and the mother.

Community-acquired methicillin-resistant Staphylococcus aureus infections requiring admission to a Tunisian pediatric intensive care unit.

BACKGROUND: There is limited literature describing severe community acquired methicillin-resistant S aureus (CA-MRSA) in children admitted to an intensive care unit. AIM: To review clinical features and outcome of children admitted in a Tunisian pediatric intensive care with CA-MRSA. METHODS: Retrospective chart review of patients coded for CAMRSA over 10 years. RESULTS: There were 14 (0.32% of all admissions) patients identified with severe CA-MRSA. The median age was 3 months (range,0.5-156 months). All patients had pulmonary involvement. Six children (42.8%) developed septic shock. Two (14.3%) patients had multifocal infection with deep venous thrombosis. Two (14.3%) patients died. CONCLUSION: Severe CA-MRSA pneumonia dominated presentation. The mortality of CA-MRSA infection in our series is lower than reported in the literature.

Multifocal atrial tachycardia: an unusual cause of cardiogenic shock in a newborn.

BACKGROUND: Chaotic or multifocal atrial tachycardia (MAT) is a rare tachyarrhythmia in children, accounting for less than 1% of supraventricular tachycardia seen in childhood. The majority of children with MAT are healthy; a few may exhibit mild to life threatening cardiorespiratory disease. AIM: To report a new case of MAT revealed by a severe respiratory distress and cardiogenic shock. CASE REPORT: We report a rare case of MAT revealed by a severe respiratory distress and cardiogenic shock in a 12-day-old newborn. The echocardiogram demonstrated an isolated secundum-type atrial septal defect with a decreased left ventricular function. He was successfully treated with intravenous amiodarone. A relay by oral amiodarone and digoxine was made. Four months later, he had no recurrence of arrhythmia and left ventricular function returned to normal. CONCLUSION: Our case is original by its association to an isolated ostium secondum-type atrial septal defect and by the occurrence of a congestive heart failure revealing the arrhythmia and the structural heart disease during the neonatal period.

First Tunisian Cluster Admissions of Critically Ill Patients with Multisystem Inflammatory Syndrome in Children (MIS-C).

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a new emerging severe disease that is temporally related to previous exposure to coronavirus infection disease (COVID-19). AIM: To describe the clinical features, laboratory findings, therapies, and outcomes for the first Tunisian cluster admissions of critically ill children with severe MIS-C. METHODS: Retrospective study conducted from November 01 to November 30, 2020According to the WHO definition case, we included eight children aged less than 15 years who were admitted to our pediatric intensive care and met MIS-C criteria. We reviewed all patients' medical records to collect demographic and clinical data, severity scores, laboratory test results, echocardiographic findings, treatment, and outcomes. RESULTS: The median age was 8 years (IQR: 4-10years). All children were previously fit and well. Seven patients were boys. Known exposure to COVID-19 was reported in 4 cases. Fever and gastrointestinal symptoms were reported in all cases. Five patients had marked abdominal pain and were examined by the surgeon for possible appendicitis. Seven patients had diarrhea. On examination, we found rash (n=7), conjunctivitis (n=7), cheilitis (n=5), and meningism (n=3). We reported cardiac dysfunction in 7 cases and shock with hypotension in 3 cases. All patients received immunoglobulins, methylprednisolone, and a low dose of aspirin. No deaths occurred. CONCLUSION: We reported here the first Tunisian cluster admissions of 8 critically ill children with MIS-C to highlight the increase of a new severe emerging disease with evidence of prior COVID-19 infection in older children.

High flow nasal cannula therapy versus continuous positive airway pressure and nasal positive pressure ventilation in infants with severe bronchiolitis: a randomized controlled trial.

INTRODUCTION: non-invasive ventilation is widely used in the respiratory management of severe bronchiolitis. METHODS: a randomized controlled trial was carried out in a tertiary pediatric university hospital´s PICU over 3 years to compare between continuous positive airway pressure/nasal positive pressure ventilation (CPAP/NPPV) and high flow nasal cannula (HFNC) devices for severe bronchiolitis. The trial was recorded in the national library of medicine registry (NCT04650230). Patients aged from 7 days to 6 months, admitted for severe bronchiolitis were enrolled. Eligible patients were randomly chosen to receive either HFNC or CPAP/NPPV. If HFNC failed, the switch to CPAP/NPPV was allowed. Mechanical ventilation was the last resort in case of CPAP/NPPV device failure. The primary outcome was the success of the treatment defined by no need of care escalation. The secondary outcomes were failure predictors, intubation rate, stay length, serious adverse events, and mortality. RESULTS: a total of 268 patients were enrolled. The data of 255 participants were analyzed. The mean age was 51.13 ± 34.43 days. Participants were randomized into two groups; HFNC group (n=130) and CPAP/NPPV group (n=125). The success of the treatment was significantly higher in the CPAP/NPPV group (70.4% [61.6%- 78.2%) comparing to HFNC group (50.7% [41.9%- 59.6%])- (p=0.001). For secondary outcomes, lower baseline pH was the only significant failure predictor in the CPAP/NPPV group (p=0.035). There were no differences in intubation rate or serious adverse events between the groups. CONCLUSION: high flow nasal cannula was safe and efficient, but CPAP/ NPPV was better in preventing treatment failure. The switch to CPAP/NPPV if HFNC failed, avoided intubation in 54% of the cases.

[Tuberculosis in childhood: clinical features and problems in diagnosis. Report of 30 cases]. / La tuberculose de l'enfant: aspects cliniques et problèmes diagnostiques, a propos de 30 observations.

BACKGROUND: The clinical polymorphism and the low yield bacteriological tests make the diagnosis of tuberculosis (TBC) in children often difficult. THE AIM of this report is to specify hospital incidence of childhood TBC and to discuss problems in diagnosis. METHODS: We reviewed retrospectively cases of TBC enrolled at Medicine A Department in Children's Hospital of Tunis during the last ten years (1998-2007). Diagnosis of TB was supported according to bacteriological or histological confirmation or regarding the association of epidemiological data (TB contagium), clinical and radiological findings and favourable outcome with anti tuberculous drugs. RESULTS: thirty children had TBC. They were 18 girls and 12 boys. The main age at diagnosis was 8.6 years (3 months-14 years). All children were vaccinated with BCG. Thirteen patients had definite familial history of TBC contact. Tuberculin-skin test was positive in 15 patients. The diagnosis was supported within a mean period of 44 days (8, 240 days). Pulmonary TBC occurred in five patients and extra-pulmonary TBC in 25. Four patients had more than two TBC localizations. Miliary and TBC meningitis occurred in seven patients. The rate of diagnosis confirmation was 40%. Clinical outcome improved in 29 children with anti tuberculosis therapy while one infant died with miliary TBC. Five patients developed pleural, neurological or bone sequelaes and another patient presented autoimmune bicytopenia, diffuse bronchectasis and pulmonary aspergillosis. CONCLUSION: TBC occurs in 0.91/year/1000 hospitalized children in our institution. Low diagnosis confirmation rate was observed with infants and in pleural and primary TBC. Although all patients received BCG vaccine, 23.3% of them developed a life-threatening form of TBC.

Rabies encephalitis in a child: a failure of rabies post exposure prophylaxis?

Rabies remains a serious public health problem in many developing countries. The diagnosis is easy when a non-immunised patient presents with hydrophobia and hypersalivation after a bite by a known rabid animal but more difficult when a patient presents atypical symptoms after having received rabies postexposure prophylaxis. Rabies postexposure prophylaxis failure is rare. We report a case of a 6-year-old boy who presented febrile seizure with agitation and cerebellar signs, without hydrophobia or hypersalivation, 17 days after a dog bite. Despite four doses of rabies vaccine and immunoglobulin, he died. Diagnostic confirmation of rabies encephalitis was made in post mortem on brain biopsies by fluorescent antibody technique.

Predictors of Mortality in Mechanically Ventilated Critical Pertussis in a low Income Country.

BACKGROUND: Critical pertussis is characterized by severe respiratory failure, important leukocytosis, pulmonary hypertension, septic shock and encephalopathy. AIM: To describe the clinical course of critical pertussis, and identify predictors of death at the time of presentation for medical care. METHODOLOGY: Retrospective study conducted in children's hospital Tunisian PICU between 01 January and 31 October 2013. Patients with critical pertussis confirmed by RT-PCR and requiring mechanical ventilation were included. Predictors of death were studied. RESULTS: A total of 17 patients was studied. Median age was 50 days. Mortality was 23%. Predictors risk of mortality were : high PRISM score (Pediatric Risk of Mortality Score) (p=0,007), shock (p=0,002), tachycardia (p=0,005), seizures (p=0,006), altered mental status (p=0,006), elevated WBC count (p=0,003) and hemodynamic support (p=0022). However, the difference did not reach statistical significance in comorbidity, pneumoniae, high pulmonary hypertension or exchange transfusion. Concomitant viral or bacterial co-infection was not related to poor outcome. CONCLUSION: Young infants are at high risk to have critical pertussis. Despite advances in life support and the treatment of organ failure in childhood critical illness, critical pertussis remains difficult to treat.