Detección rápida de antígenos de Streptococcus pyogenes en pacientes de 0 a 14 años asistidos en dos servicios de urgencia pediátrica (14/2/2018-13/4/2018) / Rapid detection of Streptococcus pyogenes' antigens in patients of 0 to 14 years of age, assisted in two pediatric emergency wards (2/14/2018-4/13/2018) / Detecção rápida de antígenos de Streptococcus pyogenes em pacientes de 0 a 14 anos de idade assistidos por emergência pediátrica (14/2/2018-13/4/2018)

Introducción: las infecciones estreptocócicas pueden presentarse con fiebre, inflamación faringoamigdalina con o sin exudados, petequias en el paladar, adenitis cervical, exantema escarlatiniforme y / o dolor abdominal. Resulta útil en área de urgencia disponer de pruebas de detección rápida de antígenos de S. pyogenes (DRASP) de alta especificidad y sensibilidad algo menor. Objetivos: conocer la utilidad de un test de DRASP en 2 servicios de Urgencia Pediátrica, describiendo las características clínicas y epidemiológicas de los pacientes estudiados durante el período de la investigación y su correlación con el cultivo de exudado faríngeo mediante el cálculo de sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y valor predictivo negativo (VPN). Material y métodos: estudio prospectivo, observacional, transversal en dos servicios de emergencia pediátrica. Se incluyeron niños a los que se les realizó DRASP y exudado faríngeo (EF) entre el 14 de febrero y el 13 de abril de 2018. Se registró: sexo, edad, motivo de consulta, diagnóstico, tratamiento, destino, resultado del test y de cultivo faríngeo. Se calcularon S, E, VPP y VPN. Resultados: n=241 niños. Rango 8 meses - 14 años, media 6 años. Consultaron por fiebre 103 niños (42,7%); por odinofagia 48, por erupción 11 y 47 por otros síntomas. Al 95% de los niños se le otorgó el alta. DRASP negativos 87,6% (N: 211) y positivos 12,9% (N: 31). EF negativos 80,1% (n: 193) y positivos para SßHGA en 13,7% (n: 33). La sensibilidad de la prueba fue del 52% y su especificidad del 93%. El VPP 55% y el negativo 92%. El diagnóstico más frecuente fue faringitis viral 132 (54,7%). Conclusiones: el test se aplicó fundamentalmente a escolares febriles, algunos con odinofagia. Contribuye a diferenciar en forma rápida la etiología y habilita a no usar antibióticos en caso de resultado negativo. Estos resultados avalan el uso de DRASP en la urgencia pediátrica.

Introduction: streptococcal infections can show fever, pharyngotonsillar inflammation with or without swabs, palatal petechiae, cervical adenitis, scarlatiniform rash and/or abdominal pain. Rapid detection tests for S. pyogenes antigens (DRASP) with high specificity and somewhat lower sensitivity are a useful at the Emergency Ward. Objectives: know the usefulness of a DRASP test in 2 Pediatric Emergency, describe the clinical and epidemiological characteristics of the patients studied during the research period and its correlation with the culture of pharyngeal exudates by calculating sensitivity (S) , specificity (S), positive predictive value (PPV), and negative predictive value (NPV). Material and Methods: prospective, observational, cross-sectional study carried out in two pediatric emergency wards. We included children who underwent DRASP and pharyngeal swab (PS) between February 14 and April 13, 2018. The following data were recorded: sex, age, reason for consultation, diagnosis, treatment, destination, test results and throat cultures. S, S, PPV and NPV were calculated. Results: n=241 children. Range 8 months - 14 years, average 6 years. 103 children (42.7%) consulted due to fever; 48 due to sore throat, 11 due to rash and 47 due to other symptoms. 95% of children were discharged. DRASP negative 87.6% (N: 211) and positive 12.9% (N: 31). Negative EP 80.1% (n: 193) and positive for SßHGA in 13.7% (n: 33). The test sensitivity was 52% and specificity 93%. The PPV 55% and the negative 92%. The most frequent diagnosis was viral pharyngitis 132 (54.7%). Conclusions: the test was applied mainly to febrile schoolchildren, some with odynophagia. A quick etiology differentiation is helpful, since it prevents antibiotics from being used in the event of a negative result. These results support the use of DRASP in pediatric emergency wards.

Introdução: as infecções estreptocócicas manifestam-se com febre, inflamação faringotonsilar com ou sem exsudado, petéquias palatinas, adenite cervical, erupção cutânea escarlatiniforme e/ou dor abdominal. Nos serviços de emergência é útil realizar testes de detecção rápida para antígenos de S. pyogenes (DRASP) com alta especificidade e sensibilidade um pouco mais baixa Objetivos: conhecer a utilidade do teste DRASP em 2 Emergências Pediátricas, descrever as características clínicas e epidemiológicas dos pacientes estudados durante o período da pesquisa e sua correlação com a cultura de exsudatos faríngeos por meio do cálculo de sensibilidade (S) , especificidade (S), positivo valor preditivo (VPP) e valor preditivo negativo (VPN). Material e métodos: estudo prospectivo, observacional, transversal, realizado em duas unidades de emergência pediátrica. Foram incluídas crianças que realizaram DRASP e swab faríngeo (PS) entre 14 de fevereiro e 13 de abril de 2018. Foram registrados os seguintes dados: sexo, idade, motivo da consulta, diagnóstico, tratamento, destino, resultados de exames e culturas de garganta. S, S, VPP e VPN foram calculados. Resultados: n=241 crianças. Faixa 8 meses - 14 anos, média 6 anos. 103 crianças (42,7%) consultadas por febre; 48 por dor de garganta, 11 por erupção cutânea e 47 por outros sintomas. 95% das crianças receberam alta. DRASP negativo 87,6% (N: 211) e positivo 12,9% (N: 31). EP negativo 80,1% (n: 193) e positivo para SßHGA em 13,7% (n: 33). A sensibilidade do teste foi de 52% e a especificidade de 93%. O PPV 55% e o negativo 92%. O diagnóstico mais frequente foi faringite viral 132 (54,7%). Conclusões: o teste foi aplicado principalmente em escolares febris, alguns com odinofagia. A rápida diferenciação etiológica é útil, pois evita o uso de antibióticos em caso de resultado negativo. Esses resultados apoiam o uso do DRASP em enfermarias de emergência pediátrica.

Prevalence and antibiotic susceptibility of group A beta-haemolytic streptococcal isolates in children presenting with acute pharyngitis in Lusaka, Zambia

Background. Group A beta-haemolytic streptococci (GABHS)-associated pharyngitis can complicate into rheumatic fever and rheumatic heart disease (RHD).Objectives. To determine the prevalence and antibiotic susceptibility of GABHS isolates in children presenting with acute pharyngitis and assess the utility of Zambian Treatment Guideline (ZTG) criteria as a local clinical scoring system.Methods. This descriptive cross-sectional study was conducted at the paediatric outpatient department of the University Teaching Hospital in Lusaka, Zambia. The study cohort, comprising children aged 3 - 15 years (n=146), were recruited as presenting with symptoms of pharyngitis. The children underwent a clinical assessment that included a detailed case history, presenting symptoms and a throat swab that was subsequently cultured. Microbial isolates were typed and the antibiotic sensitivity of cultured GABHS to penicillin and erythromycin determined.Results. GABHS were cultured from 22 (15.1%) children within this study. All the GABHS isolates (n=22) were susceptible to penicillin G; however, 19% of isolates displayed reduced susceptibility to erythromycin. None of the ZTG criteria, when used individually, was sufficiently sensitive to detect GABHS pharyngitis among this cohort.Conclusion. The prevalence of GABHS pharyngitis is similar that been described elsewhere. While GABHS remains highly susceptible to penicillin, which is used in the local RHD control programmes, concern remains for children treated with erythromycin owing to the resistance noted in some of the isolates. The ZTG clinical criteria displayed poor sensitivity in identifying GABHS pharyngitis. This has significant implications for effective diagnosis and treatment of pharyngitis and associated complications within this high RHD endemic area

Fiebre periódica con estomatitis aftosa, faringitis, y adenitis / Periodical fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)

RESUMEN Se presenta un caso de fiebre periódica con estomatitis aftosa, faringitis, y adenitis síndrome de fiebre periódica con estomatitis aftosa, faringitis, y adenitis, entidad aparentemente infrecuente de la cual no se recoge reporte en el país. La etiología no es todavía bien comprendida, se observa con mayor frecuencia entre los 2 y 5 años, aunque se han descrito casos en adultos. Se caracteriza por fiebre periódica con estomatitis aftosa, faringitis, y adenitis de carácter periódica con una dramática respuesta al uso de esteroide en la mayoría de los casos. El caso que se presenta es un paciente de 5 años de edad, sexo masculino, con cuadros de fiebre periódica asociado a amigdalitis con exudado, adenitis y lesiones aftosas, con respuesta en la fase aguda a la prednisona y con respuesta al tratamiento de mantenimiento con cimetidina. En la actualidad lleva 11 meses en remisión (AU).

ABSTRACT We present a case of periodical fever with aphthous stomatitis, pharyngitis and adenitis (PFAPA syndrome), entity that is apparently infrequent and its report in the country was not found. Its etiology is not still clearly understood. It appears with higher frequency in the ages between 2 and 5 years, though it has been described in adult population. It is characterized by periodical fever with aphthous stomatitis, pharyngitis and adenitis of periodical character, with a dramatic answer to the use of steroids in most of the cases. The case that is presented is the one of a male patient aged 5 years with reiterative periodical fever associated to tonsillitis with exudate, adenitis and aphthous lesions, with answer, in the acute phase, to prednisone, and to cimetidine at the maintenance therapy. Nowadays, he is already 11 months in remission (AU).

Peritonsillar and deep neck infections: a review of 330 cases / Infecções peritonsilares e cervicais profundas: revisão de 330 casos

Abstract Introduction: Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck. Objective: The aim of this study is to review different factors that may influence peritonsillar and deep neck infections and may play a role as bad prognosis predictors. Methods: We present a retrospective study of 330 patients with deep neck infections and peritonsillar infections who were admitted between January 2005 and December 2015 in a tertiary referral hospital. Statistical analysis of comorbidities, diagnostic and therapeutic aspects was performed with Excel and SPSS. Results: There has been an increase in incidence of peritonsilar and deep neck infections. Systemic comorbidities such as diabetes or hepatopathy are bad prognosis factors. The most common pathogen was S. viridans (32.1% of positive cultures). 100% of the patients received antibiotics and corticosteroids, 74.24% needed surgical treatment. The most common complications were mediastinitis (1.2%) and airway obstruction (0.9%). Conclusion: Systemic comorbidities are bad prognosis predictors. Nowadays mortality has decreased thanks to multidisciplinary attention and improvements in diagnosis and treatment.

Resumo Introdução: Infecções cervicais profundas são definidas como processos infecciosos supurativos dos espaços viscerais profundos do pescoço. Objetivo: Analisar diferentes fatores que podem influenciar as infecções peritonsilares e cervicais profundas que podem desempenhar um papel como preditores de mau prognóstico. Método: Apresentamos um estudo retrospectivo de 330 pacientes portadores de infecções cervicais profundas e de infecções peritonsilares admitidos entre janeiro de 2005 e dezembro de 2015 em um hospital terciário de referência. A análise estatística de comorbidades, aspectos diagnósticos e terapêuticos foi realizada utilizando-se os programas Excel e o SPSS. Resultados: Houve um aumento na incidência de infecções peritonsilares e infecções cervicais profundas. Comorbidades sistêmicas como diabetes ou doença hepática são fatores de mau prognóstico. O patógeno mais comum foi S. viridans (32,1% das culturas positivas). 100% dos pacientes receberam antibióticos e corticosteroides, e 74,24% necessitaram de tratamento cirúrgico. As complicações mais comuns foram mediastinite (1,2%) e obstrução das vias aéreas (0,9%). Conclusão: Comorbidades sistêmicas são preditores de mau prognóstico. Atualmente, a mortalidade diminuiu graças ao cuidado multidisciplinar e melhorias no diagnóstico e tratamento.

Una regla de predicción clínica ¿anticipa el diagnóstico de la faringitis estreptocóccica en niños de 2 a 15 años? / Does a clinical prediction rule anticipate the diagnosis for streptococcal pharyngitis in children aged 2 to 15?

Resumen Introducción: La etiología estreptocóccica de una faringitis debe ser confirmada con métodos de laboratorio para evitar un sobre-tratamiento antimicrobiano, exámenes que agregan costo a la atención del paciente. Los scores diseñados para aplicar en niños y adultos son imperfectos. Objetivo: Desarrollar una regla de predicción clínica para contribuir al diagnóstico de la faringitis estreptocóccica (FE) en niños. Pacientes y Métodos: Se incluyeron 318 pacientes de 2 a 15 años que fueron evaluados por sospecha de FE en el Servicio de Urgencias Pediátricas y la Unidad de Pediatría Ambulatoria de la Red Salud UC-Christus. Se obtuvo un cultivo faríngeo y una prueba rápida de detección de antígeno para Streptococcus pyogenes de cada paciente. Los datos se analizaron para posibles predictores clínicos de FE con análisis de regresión múltiple. Resultados. Setenta y tres casos de FE fueron diagnosticados (23,9%). En el análisis univariado, la fiebre se asoció inversamente con FE (p = 0,002). La odinofagia, las petequias palatinas y la estación del año (otoño e invierno) se asociaron positivamente con FE (p = 0,007, p < 0,001 y p = 0,03 respectivamente). En el análisis de regresión múltiple, los modelos no tuvieron suficiente poder para predecir etiología por S. pyogenes. Conclusión: Los predictores clínicos analizados, incluso los incluidos sistemáticamente en reglas de predicción clínica, no mostraron suficiente poder predictor para incluir o excluir de forma segura la FE en este contexto y, por lo tanto, sería necesario mejorar el acceso a las pruebas de confirmación.

Background: The etiology of a streptococcal pharyngitis must be documented by laboratory techniques to avoid unnecessary antimicrobial treatment, but this strategy increases cost for the patient. Available scores applied in children or adults are imperfect. Aim: To develop a clinical prediction rule to aid the diagnostic process of streptococcal pharyngitis (SP) in children in a low-resource setting. Methods: Three hundred and eighteen patients aged 2 to 15 years who were evaluated for suspected SP at the Pediatric Emergency Department and the Pediatric Ambulatory Unit of Red Salud UC-Christus entered the study. A throat culture and a rapid antigen detection test for Streptococcus pyogenes were obtained from each patient. Data were analyzed for possible clinical predictors of SP with univariate and multiple regression analyses. Results: Seventy-three cases of SP were diagnosed (23.9%). In the univariate analysis, fever was inversely associated with SP (p = 0.002). Odynophagia, palatal petechiae, and season of the year (autumn and winter) were positively associated with SP (p = 0.007, p < 0.001 and p = 0.03 respectively). In multiple regression analysis the models did not have sufficient power to predict streptococcal etiology. Conclusion: Clinical predictors, even those systematically included in clinical prediction rules, did not show sufficient predictive power to safely include or exclude SP in this setting, and thus, it is necessary to improve access to confirmatory tests.

Diretrizes de conduta e tratamento de síndromes febris periódicas: síndrome de febre periódica, estomatite aftosa, faringite e adenite / Guidelines for the management and treatment of periodic fever syndromes: periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome

Resumo Objetivo: Estabelecer diretrizes baseadas em evidências científicas para manejo da síndrome de febre periódica, estomatite aftosa, faringite e adenite (PFAPA). Descrição do método de coleta de evidência: A Diretriz foi elaborada a partir de cinco questões clínicas que foram estruturadas por meio do Pico (Paciente, Intervenção ou Indicador, Comparação e Outcome), com busca nas principais bases primárias de informação científica. Após definir os estudos potenciais para sustento das recomendações, esses foram graduados pela força da evidência e pelo grau de recomendação. Resultados: Foram recuperados e avaliados pelo título e resumo 806 trabalhos e selecionados 32 artigos, para sustentar as recomendações. Recomendações: 1. O diagnóstico da PFAPA é clínico e de exclusão, deve a suspeita ser considerada em crianças que apresentam episódios febris de origem indeterminada recorrentes e periódicos ou amidalites de repetição, intercalados com períodos assintomáticos, sobretudo em crianças em bom estado geral e com desenvolvimento pondero-estatural mantido; 2. Os achados laboratoriais são inespecíficos. Não existem alterações patognomônicas nos exames complementares; 3. A evidência que sustenta a indicação do tratamento cirúrgico (tonsilectomia com ou sem adenoidectomia) é baseada em dois ensaios clínicos randomizados não cegos que incluíram pequeno número de pacientes; 4. O uso de prednisona no início do quadro febril em pacientes com PFAPA mostrou ser eficaz. Melhores evidências ainda são necessárias para apoiar seu uso na PFAPA; 5. Apesar de os resultados obtidos de estudos com inibidores de IL-1ß serem promissores, esses são limitados a poucos relatos de casos.

Abstract Objective: To establish guidelines based on scientific evidence for the management of periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome. Description of the evidence collection method: The Guideline was prepared from 5 clinical questions that were structured through PICO (Patient, Intervention or indicator, Comparison and Outcome), to search in key primary scientific information databases. After defining the potential studies to support the recommendations, these were graduated considering their strength of evidence and grade of recommendation. Results: 806 articles were retrieved and evaluated by title and abstract; from these, 32 articles were selected to support the recommendations. Recommendations: 1. PFAPA is a diagnosis of exclusion established on clinical grounds, and one must suspect of this problem in children with recurrent and periodic febrile episodes of unknown origin, or with recurrent tonsillitis interspersed with asymptomatic periods, especially in children in good general condition and with preservation of weight and height development. 2. Laboratory findings are nonspecific. Additional tests do not reveal pathognomonic changes. 3. The evidence supporting an indication for surgical treatment (tonsillectomy with or without adenoidectomy), is based on two non-blinded randomized clinical trials with small numbers of patients. 4. The use of prednisone at the onset of fever in patients with PFAPA proved to be an effective strategy. There is still need for more qualified evidence to support its use in patients with PFAPA. 5. Despite promising results obtained in studies with IL-1β inhibitors, such studies are limited to a few case reports.

Eleven-year-old-girl with membranous sore throat

Diphtheria is caused by Corynebacterium diphtheriae primarily affecting mucous membrane of upper airways. Global incidence of diphtheria has reduced due to worldwide immunization programs. Yet cases of diphtheria are reported across the world because of poor vaccine coverage, large population and low socio economic status. We report here a case of diphtheria in an 11-year-old girl who presented with fever, sore throat, difficulty in swallowing and hoarseness of voice for 3 days. Hematological analysis showed neutrophit leukocytosis with normal lymphocytes, CRP was raised, cardiac profile, renal function test, hepatic functions and chest x-ray were normal. Microscopy of throat swab revealed rods containing metachromatic granules .on Albert stain. Intramuscular penicillin was started and diphtheria antioxin was administered. The child recovered uneventfully and was kept on follow up

Diagnosis of streptococcal pharyngotonsillitis in children and adolescents: clinical picture limitations / Diagnóstico da faringoamigdalite estreptocócica em crianças e adolescentes: limitações do quadro clínico

OBJECTIVE: To assess the utility of clinical features for diagnosis of streptococcal pharyngotonsillitis in pediatrics. METHODS: A total of 335 children aged 1-18 years old and presenting clinical manifestations of acute pharyngotonsillitis (APT) were subjected to clinical interviews, physical examinations, and throat swab specimen collection to perform cultures and latex particle agglutination tests (LPATs) for group A streptococcus (GAS) detection. Signs and symptoms of patients were compared to their throat cultures and LPATs results. A clinical score was designed based on the multivariate logistic regression analysis and also was compared to throat cultures and LPATs results. Positive throat cultures and/or LPATs results were used as a reference standard to establish definitive streptococcal APT diagnosis. RESULTS: 78 children (23.4%) showed positivity for GAS in at least one of the two diagnostic tests. Coryza absence (odds ratio [OR]=1.80; p=0.040), conjunctivitis absence (OR=2.47; p=0.029), pharyngeal erythema (OR=3.99; p=0.006), pharyngeal exudate (OR=2.02; p=0.011), and tonsillar swelling (OR=2.60; p=0.007) were significantly associated with streptococcal pharyngotonsilitis. The highest clinical score, characterized by coryza absense, pharyngeal exudate, and pharyngeal erythema had a 45.6% sensitivity, a 74.5% especificity, and a likelihood ratio of 1.79 for streptococcal pharyngotonsilitis. CONCLUSIONS: Clinical presentation should not be used to confirm streptococcal pharyngotonsilitis, because its performance as a diagnostic test is low. Thus, it is necessary to enhance laboratory test availability, especially of LPATs that allow an acurate and fast diagnosis of streptococcal pharyngotonsilitis...

OBJETIVO: Avaliar a utilidade do quadro clínico para o diagnóstico da faringoamigdalite estreptocócica na faixa pediátrica. MÉTODOS: 335 indivíduos de 1 a 18 anos com quadro clínico de faringoamigdalite foram submetidos a anamnese, exame clínico, cultura e teste de aglutinação de partículas do látex (TAPL) para o estreptoco β-hemolítico do grupo A (EBHGA) em swab orofaríngeo. Os sinais e sintomas foram comparados ao resultado da cultura e do TAPL e, em seguida, também o foi o agrupamento de sinais e sintomas definido por regressão logística multivariada, utilizado para gerar um escore clínico. Para o diagnóstico definitivo de faringoamigdalite estreptocócica, o padrão de referência foi a cultura e o TAPL, em paralelo. RESULTADOS: 78 indivíduos (23,4%) apresentaram resultados positivos para EBHGA em pelo menos um dos testes. Ausência de coriza (OR=1,80; p=0,04); ausência de conjuntivite (OR=2,44; p=0,029); hiperemia de orofaringe (OR=3,99; p=0,006); exsudato de orofaringe (OR=2,02; p=0,011) e hipertrofia de amígdalas (OR=2,60; p=0,007) apresentaram associação significante com a faringoamigdalite estreptocócica. A pontuação máxima no escore clínico, no qual figuram três características (ausência de coriza, exsudato de orofaringe e hiperemia de orofaringe) correspondeu a uma sensibilidade de 45,6%, uma especificidade de 74,5% e uma likelihood ratio de 1,79 para a presença de faringoamigdalite estreptocócica. CONCLUSÃO: O quadro clínico não deve ser usado isoladamente para confirmar o episódio de faringoamigdalite estreptocócica por apresentar um baixo desempenho diagnóstico. É necessário aumentar a disponibilidade de testes laboratoriais, em especial o TALP, que permite o diagnóstico rápido...

Streptococcal acute pharyngitis

Acute pharyngitis/tonsillitis, which is characterized by inflammation of the posterior pharynx and tonsils, is a common disease. Several viruses and bacteria can cause acute pharyngitis; however, Streptococcus pyogenes (also known as Lancefield group A β-hemolytic streptococci) is the only agent that requires an etiologic diagnosis and specific treatment. S. pyogenes is of major clinical importance because it can trigger post-infection systemic complications, acute rheumatic fever, and post-streptococcal glomerulonephritis. Symptom onset in streptococcal infection is usually abrupt and includes intense sore throat, fever, chills, malaise, headache, tender enlarged anterior cervical lymph nodes, and pharyngeal or tonsillar exudate. Cough, coryza, conjunctivitis, and diarrhea are uncommon, and their presence suggests a viral cause. A diagnosis of pharyngitis is supported by the patient's history and by the physical examination. Throat culture is the gold standard for diagnosing streptococcus pharyngitis. However, it has been underused in public health services because of its low availability and because of the 1- to 2-day delay in obtaining results. Rapid antigen detection tests have been used to detect S. pyogenes directly from throat swabs within minutes. Clinical scoring systems have been developed to predict the risk of S. pyogenes infection. The most commonly used scoring system is the modified Centor score. Acute S. pyogenes pharyngitis is often a self-limiting disease. Penicillins are the first-choice treatment. For patients with penicillin allergy, cephalosporins can be an acceptable alternative, although primary hypersensitivity to cephalosporins can occur. Another drug option is the macrolides. Future perspectives to prevent streptococcal pharyngitis and post-infection systemic complications include the development of an anti-Streptococcus pyogenes vaccine.

Impacto do uso da prova rápida para estreptococo beta-hemolítico do grupo A no diagnóstico e tratamento da faringotonsilite aguda em pronto-socorro de Pediatria / Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a Pediatric emergency room / Impacto del uso de la prueba rápida para estreptococos beta-hemolíticos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis en emergencia de Pediatría

OBJETIVO: Avaliar o impacto da realização rotineira da prova rápida para pesquisa de estreptococo do grupo A no diagnóstico e tratamento da faringotonsilite aguda em crianças. MÉTODOS: Estudo prospectivo e observacional que contou com a utilização de protocolo de pesquisa estabelecido na Unidade de Emergência do Hospital Universitário da Universidade de São Paulo para o atendimento de crianças e adolescentes com faringotonsilite aguda. RESULTADOS: Com base na avaliação clínica, dos 650 pacientes estudados, antimicrobianos seriam prescritos para 389 indivíduos (59,8%) e, com o uso da pesquisa de estreptococo do grupo A, foram prescritos em 286 pacientes (44,0%). Das 261 crianças que não receberiam antibiótico pelo quadro clínico, 111 (42,5%) tiveram pesquisa de estreptococo do grupo A positiva. O diagnóstico baseado no quadro clínico apresentou sensibilidade de 61,1%, especificidade de 47,7%, valor preditivo positivo de 44,9% e valor preditivo negativo de 57,5%. CONCLUSÕES: O diagnóstico clínico da faringotonsilite estreptocócica mostrou baixa sensibilidade e especificidade. O uso rotineiro da prova rápida para pesquisa de estreptococo permitiu a redução do uso de antibióticos e a identificação de um grupo de risco para as complicações da infecção estreptocócica, pois 42,5% dos pacientes com prova rápida positiva não receberiam antibióticos, se levado em consideração apenas o diagnóstico clínico.

OBJECTIVE: To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS: This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS: 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS: The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

OBJETIVO: Evaluar el impacto de la realización de rutina de la prueba rápida para investigación de estreptococos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis aguda en niños. MÉTODOS: Estudio prospectivo y observacional que contó con el uso de protocolo de investigación establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atención a niños y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluación crítica, de los 650 pacientes estudiados, antimicrobianos serían prescritos a 389 individuos (59,8%) y, con el uso de la investigación de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 niños que no recibirían antibióticos por el cuadro clínico, 111 (42,5%) tuvieron investigación de estreptococos del grupo A positiva. El diagnóstico basado en el cuadro clínico presentó sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnóstico clínico de la faringotonsilitis estreptocócica mostró baja sensibilidad y especificidad. El uso de rutina de la prueba rápida para investigación de estreptococos permitió la reducción del uso de antibióticos y la identificación de un grupo de riesgo para las complicaciones de la infección estreptocócica, pues el 42,5% de los pacientes con prueba rápida positiva no recibirían antibióticos si se llevara en consideración solamente el diagnóstico clínico.

Regras validadas para faringite estreptocócica / Validated rules for strep throat

Duas escalas de pontuação comumente utilizadas são efetivas para determinar crianças e adultos com baixa probabilidade de ter estreptococos como causa para sua faringite aguda.1 Seu uso adequado, recomendado nos Estados Unidos pelos Centros para o Controle e Prevenção de Doenças (Centers for Disease Control and Prevention, CDC),2 pode evitar exames desnecessários.

Rinovirus: Frecuencia en niños con infección respiratoria aguda, no internados / Rhinoviruses: Frequency in nonhospitalized children with acute respiratory infection

Los métodos moleculares para diagnosticar rinovirus humanos (RVH) han aumentado la sensibilidad de detección. Esto ha permitido documentar la asociación entre los RVH y las infecciones respiratorias agudas (IRA) altas y bajas. La infección por RVH durante la infancia se asoció con posterior desarrollo de asma. Se estudió la frecuencia de RVH en 186 niños menores de 6 años ambulatorios con IRA (alta o baja), durante 2 años consecutivos (1/6/2008 - 31/5/2010). Se correlacionó la presencia de RVH con los antecedentes y características clínico-epidemiológicas. La detección de RVH se realizó con una RT-PCR en tiempo real que amplifica parte de la región 5' no codificante del genoma. Los virus respiratorios clásicos se estudiaron por inmunofluorescencia. En el 61% de los niños se detectó etiología viral. Las frecuencias fueron: RVH 27%, virus sincicial respiratorio (VSR) 16%, influenza A y B 9%, parainfluenza 8%, metapneumovirus 7% y adenovirus 0.5%. Se observaron coinfecciones duales en 8 casos, siendo RVH el más frecuente (en 4 de ellos). Los RVH circularon durante todo el período estudiado, con picos en invierno y primavera. No se observaron diferencias clínico-epidemiológicas significativas entre pacientes con o sin RVH, excepto un mayor porcentaje de niños afebriles con RVH. Los RVH fueron los virus más detectados en niños ambulatorios, principalmente en menores de 2 años, los segundos virus asociados a bronquiolitis, luego del VSR, y detectados tres veces más en los niños expuestos a tabaquismo pasivo (OR: 2,91; p = 0.012) que en el resto. Fueron identificados como único agente en el 28% de las bronquiolitis.

Molecular methods for human rhinoviruses (HRV) have increased the sensitivity in their diagnosis. HRV may cause acute respiratory infections (ARI) of the upper and lower respiratory tract. HRV infection during childhood is a predictor of asthma development. In this study, the HRV frequency in outpatient children with ARI was determined, and their clinical features and previous conditions were evaluated. A total of 186 respiratory samples of children under 6 year old attending the CEMIC pediatric emergency room from June 1, 2008 to May 31, 2010, were studied. Classical respiratory viruses were detected by immunofluorescence. A real time RT-PCR that amplifies part of the 5' non coding genomic region was used for HRV detection. Viral detection was obtained in 61% of children. The frequency was: 27% for HRV, 16% for respiratory syncytial virus (RSV), 9% for influenza, 8% for parainfluenza, 7% for metapneumovirus and 0.5% for adenovirus. Dual coinfection was detected in 8 children and HRV were the most frequent, detected in 4 of them. HRV circulated during the two year period of the study, with peaks during winter and spring. No clinical difference was observed between patients with or without HRV, except an increase percent of children with HRV without fever. HRV were the most frequent viruses detected in this population, mainly in children under 2 year old, the second cause of bronchiolitis after RSV and more frequently detected in children exposed to passive smoking (OR = 2.91; p = 0.012), and were detected as the sole etiologic agent in 28% of bronchiolitis.

Immunoasssay chromatographic antigen test for rapid diagnosis of Group A beta hemolytic Streptococcus pharyngitis in children: a cross/ sectional study

Group A beta-hemolytic streptococcus [GABHS] is an important pharyngotonsillitis etiologic agent in children. The objective of this study was diagnosis of streptococcal pharyngitis based on rapid antigen detection test and conventional pharyngeal culture. The rapid GABHS antigen detection test was compared to culture on blood agar, the gold standard for the diagnosis of this etiologic agent. Streptococcal antigen was detected in pharyngeal specimens of 34.5% of cases by rapid strip test. We detected group A Streptococcus in 17.2% of pharyngeal culture. There was no agreement between two methods [PV < 0.1]. The negative pharyngeal culture results are probably due to antibiotic usage in 43.2% of patients. Positive rapid test results in pharyngeal swab was age dependent [P < 0.05]. There was good correlation between observing the [petechia in pharynx of patients] and positive rapid test in pharyngeal swab [P < 0.004]. Throat culture results were relatated to previous antibiotic usage [P < 0.03]. The rapid test in pharyngeal swab is helpful for rapid diagnosis and treatment of GABHS pharyngitis. Diagnosis of GABHS pharyngitis based on soley clinical findings is misleading in the majority of cases. Petechia observed in pharynx of the cases was highly predictive of streptococcal pharyngitis

Faringoamigdalitis estreptocócica / Streptococcal pharyngitis

Streptococcal pharyngitis is common in children and adolescents. It is strongly suggested by the presence of fever, tonsillar exudate, tender enlarged anterior cervical lymph nodes and absence of cough (Centor criteria). Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly. The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy. Treatment of acute streptococcal pharyngitis is important for preventing acute rheumatic fever and suppurative complications, hastening illness resolution, and preventing transmission. Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness. Amoxicillin is equally effective and more palatable. Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy.

Síndrome de Lemierre: relato de caso / Lemierre syndrome: case report

A síndrome de Lemierre é uma doença rara, mais comum em jovens, causada frequentemente pelo Fusobacterium necrophorum. Inicia-se com faringite e propaga-se até a veia jugular interna, promovendo uma fonte de bacteremia contínua e êmbolos sépticos pulmonares. Manifestações clínicas incluem febre, alterações respiratórias e massa cervical. O diagnóstico é realizado por tomografia computadorizada e duplex scan, além de hemocultura ou cultura direta. O tratamento é realizado com antibióticos beta-lactâmicos resistentes a beta-lactamases, sendo a cirurgia raramente necessária. Paciente do sexo feminino, 34 anos, com quadro de orofaringite, evoluiu em 48 horas com queda do estado geral, febre, aumento de volume e dor em região cervical esquerda...

Lemierre syndrome is a rare disease. It often affects young adults and is most frequently caused by Fusobacterium necrophorum. The initial event is pharyngitis, which extends to the internal jugular vein, serving as source of continuous bacteremia and septic pulmonary emboli. Clinical manifestations include fever, respiratory distress, and swollen cervical lymph nodes. Diagnosis is established based on blood culture or direct blood culture and confirmed by computed tomography and/or duplex scan. Treatment consists of administration of beta-lactamase resistant beta-lactam antibiotics...

El tratamiento antibiótico dos veces por día es tan eficaz como la dosificación más frecuente en la faringitis aguda estreptocóccica / Antibiotic treatment twice a day is as effective as more frequent dosing in acute streptococcal pharyngitis

A partir de la descripción de un caso clínico sobre la necesidad de administrar un tratamiento antibiótico a una niña con faringitis aguda estreptocóccica, se plantea la posible diferencia de eficacia entre dosis administradas cada seis u ocho horas, comparadas con la administración cada 12 o 24 horas. Se concluye que la indicación de penicilina o amoxicilina oral cada doce horas tiene eficacia similar a la indicación cada seis u ocho, para producir la resolución clínica y bacteriológica de la faringitis estreptocóccica en niños, con las ventajas de una mayor probabilidad de adherencia al tratamiento en la población infantil. No se evidenció el mismo efecto en el caso de la dosis única de penicilina, que disminuye su eficacia, sin embargo la amoxicilina así podría indicarse en una dosis única diaria.

Faringoamidalite estreptocócica: comparação entre diagnóstico clínico e microbiológico / Streptococcal pharyngitis: comparison between the clinical and microbiological diagnosis

Introdução: Faringoamidalite é queixa frequente nos pronto-socorros pediátricos, com presença do Streptococcus pyogenes em 20 por cento dos casos. Os sinais e sintomas clínicos são insuficientes para diferenciar quadros virais dos bacterianos. Os métodos microbiológicos, teste rápido(TR) e cultura orofaringe(CO) são indispensáveis para diagnóstico e redução de antibióticos...

Introductions: Pharyngitis is a common complaint in the emergency room for children, with the presence of Streptococcus pyogenes in 20 per cent of the cases. The clinical signs and symptoms are insufficient to differentiate viral from bacterial infections. The microbiological methods, rapid test (RT) and oropharynx cultura (OC), are essential for diagnosis and for reducing the use of antibiotics...