Deep Vein Thrombosis after a Supracondylar Fracture of the Humerus in a Child - A Rare Complication.

Deep vein thrombosis in the upper extremities is uncommon, especially in the pediatric population and in the trauma setting. The diagnosis is challenging, due to its rarity, requiring a high degree of suspicion. We describe a rare case of humeral vein thrombosis after a displaced supracondylar fracture of the humerus in a 7-year-old girl. The risk factors for thromboembolism and sequelae are also discussed. The early detection and treatment are mandatory to prevent poor outcomes, such as fatal thromboembolism.

Deep Vein Thrombosis after a Supracondylar Fracture of the Humerus in a Child - A Rare Complication / Trombose venosa profunda após uma fratura supracondilar do úmero em uma criança - Uma complicação rara

Abstract Deep vein thrombosis in the upper extremities is uncommon, especially in the pediatric population and in the trauma setting. The diagnosis is challenging, due to its rarity, requiring a high degree of suspicion. We describe a rare case of humeral vein thrombosis after a displaced supracondylar fracture of the humerus in a 7-year-old girl. The risk factors for thromboembolism and sequelae are also discussed. The early detection and treatment are mandatory to prevent poor outcomes, such as fatal thromboembolism.

Resumo Trombose venosa profunda nas extremidades superiores é incomum, especialmente na população pediátrica e no ambiente do trauma. O diagnóstico é desafiador, devido a sua raridade, exigindo alto grau de suspeita. Descrevemos um caso raro de trombose venosa úmera após uma fratura supracondilar deslocada do úmero em uma menina de 7 anos. Os fatores de risco para tromboembolismo e sequelas também são discutidos. A detecção e o tratamento precoces são obrigatórios para evitar desfechos ruins, como tromboembolismo fatal.

Osteomielitis hematógena aguda en Lisboa: asociación con miositis y artritis inesperadamente alta / Acute haematogenous osteomyelitis in Lisbon: An unexpectedly high association with myositis and arthritis

Introducción: Aunque actualmente se tiende a un abordaje terapéutico menos agresivo, la osteomielitis hematógena aguda (OHA) sigue suponiendo un reto, con una morbilidad significativa a nivel mundial. El objetivo del estudio fue evaluar si se alcanzó una adherencia del 80% con el protocolo vigente, identificar las complicaciones y riesgos asociados y analizar las tendencias en la etiología y el manejo de la OHA en la población pediátrica. Métodos: Estudio observacional longitudinal unicéntrico en pacientes menores de 18 años con OHA ingresados en un hospital pediátrico entre 2008 y 2018 divididos en 2 cohortes (antes y después de 2014). Se analizaron datos demográficos, clínicos y concernientes a la evolución de la enfermedad. Resultados: El estudio incluyó a 71 niños con OHA, 56% varones, con una edad mediana de 3 años (rango intercuartílico, 1-11). Se observó una incidencia 1,8 veces mayor en los últimos 5 años. El agente causal se identificó en el 37% de los casos: SASM (54%), SARM (4%), Streptococcus pyogenes (19%), Kingella kingae (12%), Streptococcus pneumoniae (8%) y Neisseria meningitidis (4%). Se identificaron complicaciones en el 45% y secuelas en 3,6% de los pacientes. En los últimos años aumentó la incidencia de miositis (30% vs. 7%; p=0,02) y de artritis séptica (después de 2015, 68% vs. 37,2%, p=0,012), así como la proporción de pacientes con tratamiento inferior a 4 semanas (37% vs. 3,5%; p=0,012), con tasas de secuelas similares. Los factores de riesgo de complicaciones fueron la edad ≥3 años, nivel de PCR≥20mg/l, duración de los síntomas al ingreso de 5 o más días y cultivo positivo, aunque en el análisis multivariado solo se validó el cultivo positivo. La presencia de complicaciones se identificó como factor de riesgo de secuelas a los 6 meses. Conclusiones: El presente estudio confirma que la OHA puede ser agresiva. La identificación de los factores de riesgo es fundamental para su abordaje. (AU)

Introduction: Despite the current trend towards less aggressive therapeutic approaches, acute haematogenous osteomyelitis (AHO) continues to be a challenge and is associated with significant morbidity worldwide. Our aim was to determine if 80% compliance with current protocol was achieved, identify complications and associated risk factors and analyse trends in aetiology and management of AHO in children. Methods: We conducted a longitudinal, observational, single-centre study in patients with AHO aged less than 18 years admitted to a paediatric hospital, between 2008 and 2018, divided into 2 cohorts (before and after 2014). Demographic, clinical data and disease progression were analysed. Results: The study included 71 children with AHO, 56% male, with a median age of 3 years (interquartile range, 1–11). We found a 1.8-fold increase of cases in the last 5 years. The causative agent was identified in 37% of cases: MSSA (54%), MRSA (4%), Streptococcus pyogenes (19%), Kingella kingae (12%), Streptococcus pneumoniae (8%), and Neisseria meningitidis (4%). Complications were identified in 45% of patients and sequelae in 3.6%. In recent years, there was an increase in myositis (30% vs. 7%; p=0.02), septic arthritis (68% vs. 37.2%; p=0.012) and in the proportion of patients treated for less than 4 weeks (37% vs. 3.5%; p=0.012), with a similar sequelae rates. The risk factors for complications were age 3 or more years, CRP levels of 20mg/l or higher, time elapsed between onset and admission of 5 or more days and positive culture, although on multivariate analysis only positive culture was significant. The presence of complications was a risk factor for sequelae at 6 months. Conclusions: Our study confirms that AHO can be aggressive. The identification of risk factors for complications may be fundamental for management. (AU)

Sacroileítis piógena: Lecciones aprendidas de una serie de casos atípicos / Pyogenic sacroiliitis: Lessons learned from an atypical case series

Introducción: La sacroileítis piógena (SIP) es una entidad infrecuente que representa del 1 al 2% del total de las infecciones articulares en la edad pediátrica. Su diagnóstico a menudo se complica y retrasa debido a la inespecificidad de sus síntomas, signos y exploración física. Además, la identificación microbiológica puede resultar difícil debido a la alta proporción de hemocultivos negativos y los riesgos implicados en la aspiración de líquido articular en esta localización. Pacientes y métodos: Revisión retrospectiva de las historias clínicas de todos los pacientes menores de 18 años ingresados en un hospital infantil terciario con SIP en el período 2008-2016. Resultados: Se identificaron 6 casos de SIP en niños. Los hemocultivos fueron negativos, y la identificación del agente etiológico requirió aspiración de líquido sinovial en un paciente con infección por Aggregatibacter aphrophilus y pruebas específicas para la detección de agentes menos frecuentes en los pacientes restantes: Kingella kingae (n = 2), Brucella melitensis (n = 1) y Bartonella henselae (n = 1). Los pacientes recibieron regímenes de antibioterapia específica, y todos presentaron una evolución favorable y libre de secuelas durante el seguimiento. Conclusiones: A pesar del reducido tamaño muestral, nuestro estudio puso de relieve la baja efectividad del hemocultivo en el diagnóstico de la SIP pediátrica. También evidenció la necesidad de mantener un elevado índice de sospecha de los agentes atípicos y de emplear precozmente métodos diagnósticos apropiados, como las pruebas de imagen y la reacción en cadena de la polimerasa (PCR) en muestras de sangre, así como la prescripción de antibioterapia efectiva

Introduction: Pyogenic sacroiliitis (PSI) is a rare condition that amounts to 1% to 2% of all joint infections in the paediatric age group. Its diagnosis is often difficult and delayed due to its nonspecific signs, symptoms and physical findings. Also, the identification of the causative microorganism is frequently challenging due to a high proportion of negative blood cultures and the risks involved in joint aspiration in this site. Patients and methods: We performed a retrospective review of the health records of all patients aged less than 18 years admitted to a tertiary children's hospital due to PSI between 2008 and 2016. Results: We identified 6 cases of paediatric PSI. The blood cultures were negative, and the identification of the causative agent required joint fluid aspiration in one patient with infection by Aggregatibacter aphrophilus, and specific screening tests for less frequent agents in the other patients: Kingella kingae (n = 2), Brucella melitensis (n = 1) and Bartonella henselae (n = 1). The patients were treated with specific antimicrobial regimens, and all had favourable clinical outcomes and were free from sequelae during the follow-up. Conclusions: Despite the small sample size, our study evinced the low effectiveness of blood cultures for diagnosis of paediatric PSI. It also highlights the need for a high level of suspicion for atypical agents and the early use of adequate diagnostic methods, including imaging and serological testing or polymerase chain-reaction (PCR) analysis of blood samples, as well as prescription of effective antimicrobial therapy