Clinical Presentation and Outcomes of Kawasaki Disease in Children from Latin America: A Multicenter Observational Study from the REKAMLATINA Network.

OBJECTIVES: To describe the clinical presentation, management, and outcomes of Kawasaki disease (KD) in Latin America and to evaluate early prognostic indicators of coronary artery aneurysm (CAA). STUDY DESIGN: An observational KD registry-based study was conducted in 64 participating pediatric centers across 19 Latin American countries retrospectively between January 1, 2009, and December 31, 2013, and prospectively from June 1, 2014, to May 31, 2017. Demographic and initial clinical and laboratory data were collected. Logistic regression incorporating clinical factors and maximum coronary artery z-score at initial presentation (between 10 days before and 5 days after intravenous immunoglobulin [IVIG]) was used to develop a prognostic model for CAA during follow-up (>5 days after IVIG). RESULTS: Of 1853 patients with KD, delayed admission (>10 days after fever onset) occurred in 16%, 25% had incomplete KD, and 11% were resistant to IVIG. Among 671 subjects with reported coronary artery z-score during follow-up (median: 79 days; IQR: 36, 186), 21% had CAA, including 4% with giant aneurysms. A simple prognostic model utilizing only a maximum coronary artery z-score ≥2.5 at initial presentation was optimal to predict CAA during follow-up (area under the curve: 0.84; 95% CI: 0.80, 0.88). CONCLUSION: From our Latin American population, coronary artery z-score ≥2.5 at initial presentation was the most important prognostic factor preceding CAA during follow-up. These results highlight the importance of early echocardiography during the initial presentation of KD.

Deep immunophenotyping reveals biomarkers of multisystemic inflammatory syndrome in children in a Latin American cohort.

BACKGROUND: Multisystemic inflammatory syndrome in children (MIS-C) is a life-threatening disease that occurs 2-5 weeks after severe acute respiratory syndrome coronavirus 2 exposure and is characterized by severe multisystemic inflammation. Early recognition of MIS-C is key to prognosis; therefore, establishing clinical and laboratory biomarkers that predict complications is urgently needed. OBJECTIVE: We characterized the immune response and clinical features of patients with acute MIS-C and determined biomarkers of disease in a cohort of 42 Latin American patients. METHODS: Immune characterization was performed using flow cytometry from peripheral mononuclear cells and severe acute respiratory syndrome coronavirus 2-specific humoral and cellular response was performed using flow cytometry, enzyme-linked immunospot, enzyme-linked immunosorbent assay, and neutralizing antibody assays. RESULTS: MIS-C is characterized by robust T-cell activation and cytokine storm. We uncovered that while C-X-C motif chemokine ligand (CXCL) 9, IL-10, CXCL8, CXCL10, IL-6, and IL-18 are significantly elevated in patients with shock, while CCL5 was increased in milder disease. Monocyte dysregulation was specifically associated with KD-like MIS-C. Interestingly, MIS-C patients show a natural killer cell degranulation defect that is persistent after 6 months of disease presentation, suggesting it could underlie disease susceptibility. Most MIS-C had gastrointestinal involvement, and higher levels of neopterin were identified in their stools, potentially representing a biomarker of intestinal inflammation in MIS-C. Severe acute respiratory syndrome coronavirus 2-specific cellular response and neutralizing antibodies were identifiable in convalescent MIS-C patients, suggesting sustained immunity. CONCLUSION: Clinical characterization and comprehensive immunophenotyping of Chilean MIS-C cohort provide valuable insights in understanding immune dysregulation in MIS-C and identify relevant biomarkers of disease that could be used to predict severity and organ involvement.

Kawasaki disease presenting with hoarseness: A multinational study of the REKAMLATINA network.

BACKGROUND: Recently, hoarseness affecting the supraglottic structure has been reported in Kawasaki disease (KD). The objective of this study was to characterize the frequency of hoarseness in acute KD patients in Latin America. METHODS: We used prospective data from the multinational Red de Enfermedad de Kawasaki en America Latina (REKAMLATINA) network. A total of 865 patients from 20 countries were enrolled during the 3 year study period. Data on hoarseness were available in 858 (99.2%) patients. The clinical and laboratory characteristics between hoarse and non-hoarse KD were compared. RESULTS: Hoarseness was documented in 100 (11.6%) patients. Hoarse patients were younger than those with KD without hoarseness (median age 18 vs 26 months; P = 0.002) and presented with lower hemoglobin (10.7 g/dL vs 11.3 g/dL; P = 0.040) and hematocrit levels (32% vs 33%, P = 0.048). CONCLUSIONS: Hoarseness was found to be prevalent as a presenting sign of acute KD in younger children. Anemia may indicate the presence of active inflammation.

[Etiologic diagnosis in meningitis and encephalitis molecular biology techniques]. / Diagnóstico etiológico en meningitis y encefalitis por técnicas de biología molecular.

INTRODUCTION: The aetiological study of infections of the central nervous system has traditionally been performed using bacterial cultures and, more recently, using polymerase chain reaction (PCR) for herpes simplex virus (HSV). Bacterial cultures may not have good performance, especially in the context of patients who have received antibiotics prior to sampling, and a request for HSV only by PCR reduces the information to only one aetiological agent. The aim of this study is to determine the infectious causes of meningitis and encephalitis, using traditional microbiology and molecular biology to improve the aetiological diagnosis of these diseases. PATIENTS AND METHOD: A prospective study was conducted on 19 patients with suspected meningitis, admitted to the Luis Calvo Mackenna Hospital in Santiago, Chile, from March 1, 2011 to March 30, 2012. After obtaining informed consent, the CSF samples underwent cytochemical study, conventional culture, multiplex PCR for the major producing bacterial meningitis (N. meningitidis, S. pneumoniae, H. influenzae), real-time single PCR for HSV-1 and 2, VZV, EBV, CMV, HHV-6 and enterovirus. Clinical and epidemiological data were also collected from the clinical records. RESULTS: Of the 19 patients analysed, 2 were diagnosed by conventional methods and 7 by adding molecular biology (increase to 37%). Three patients had meningitis due to S. pneumoniae, one due to Enterobacter cloacae, 2 patients meningoencephalitis HSV-1, and one VZV meningitis. CONCLUSIONS: The addition of PCR to conventional diagnostic methods in CNS infections increases the probability of finding the causal agent. This allows a more adequate, timely and rational management of the disease.

[Successful treatment of a persistent rhino-cerebral mucormycosis in a pediatric patient with a debut of acute lymphoblastic leukemia]. / Tratamiento exitoso de una mucormicosis rinocerebral persistente en un paciente pediátrico durante el debut de una leucemia aguda.

The fungi of the order Mucorales cause mucormycosis, which usually presents as an invasive fungal disease with rapid angioinvasion in immunocompromised patients. Rhinocerebral is the most common presentation. The lipid formulations of amphotericin B are used as primary treatment in invasive mucormycosis; the combined use of posaconazole could allow a reduction in the dose of amphotericin B improving tolerance and adherence to treatment. Caspofungin and amphotericin B association has been shown to be synergistic in vitro and effective in murine models. We present the case of a preschool patient that during the debut of acute lymphoblastic leukemia developed a rhinocerebral mucormycosis successfully responding to antifungal treatment with the combination of liposomal amphotericin and caspofungin.

[Reinstating cloxacilin for empiric antibiotic in late-onset sepsis]. / Reposicionando la cloxacilina como antibioticoterapia empírica inicial de la sepsis tardía neonatal.

Vancomycin has been used for more than 50 years in neonatal intensive care units (NICUs) as the therapy of choice for late-onset sepsis, mainly because Coagulase negative Staphylococci (CoNS) are common and mostly resistant to oxacyllin despitelow virulence and unusual association with fulminant sepsis. CUs due to several factors including its high pharmacokinetic variability, difficulty in reaching therapeutic plasmatic drug concentrations and progressively increasing minimum inhibitory concentrations (MIC). The increase of CoNS with higher MICs as well as the rise of infections caused by resistant gram-negative bacilli and candida should move to reconsider Vancomycin as first line treatment. Infections in neonates have a different behavior than in other populations and we consoder of utmost importance to consider the use of oxacyllin as first line antimicrobial therapy for late-onset sepsis.

[Children with asplenia or hyposplenia: Preventing overwhelming post splenectomy infection]. / Asplenia e hiposplenia en pediatría: Prevención de sepsis bacteriana fulminante.

The spleen's ability to prevent overwhelming post-splenectomy infection (OPSI) is mainly given by its capacity to filter and phagocyte bacterial elements from the blood, remove foreign elements from it, and the early production of opsonins. The anatomic absence of the spleen is usually secondary to a surgical resection, but it could also be congenital. Streptococcus pneumoniae has been identified as the main agent of OPSI in asplenic patients with an extremely high global mortality associated. This article is an exhaustive review of the current evidence and recommendations available for prevention of invasive infections in asplenic patients.

Hematologic parameters and biomarkers predictors of severity in Multisystem Inflammatory Syndrome in children associated with SARS-CoV-2. / Parámetros hematológicos y biomarcadores predictores de gravedad en Síndrome Inflamatorio Pediátrico Multisistémico asociado a SARS-CoV-2.

INTRODUCTION: The multisystem inflammatory syndrome in children associated with SARS-CoV-2 (MIS-C) is cha racterized by a hyperinflammatory state resulting from a cytokine storm, evidenced by alterations in laboratory blood testing and acute-phase proteins. OBJECTIVE: to describe the clinical and labora tory characteristics of patients hospitalized due to MIS-C and identify predictive markers of severity. PATIENTS AND METHOD: Retrospective study of 32 patients. The group was divided into critical and non-critical according to clinical presentation and therapy used. Clinical and laboratory aspects were studied, including complete blood count, coagulation tests, and biomarkers. RESULTS: 18/32 were males, with a median age of 6.8 years. The most frequent manifestations were cardiovascular (84.3%), digestive (84%), and mucocutaneous (59%). The group of critical patients included 15 patients, 12 were males with a median age of 8.9 years, and the non-critical group included 17 patients, 6 were males with a median age of 5.4 years. The laboratory parameters at the admission in the global group showed increased C-reactive protein, D-dimer, leukocytes, neutrophils, ferritin, and fibrinogen. In contrast, albumin and blood sodium levels were decreased. At admission, the critical group was cha racterized by presenting thrombocytopenia, hypoalbuminemia, prolonged prothrombin time, and elevated ferritin. At the time of deterioration, there was an intensification of thrombocytopenia, in creased C-reactive protein together with increased neutrophils level. CONCLUSION: The blood count, C-reactive protein, and albuminemia at admission proved to be significantly important in the identi fication of patients at risk of clinical deterioration.

[Recommendations for the suspected diagnosis and management of Multisystemic Inflammatory Syndrome (MIS-C) in the context of a SARS-CoV-2 pandemic. April 2021]. / Recomendaciones para la sospecha diagnóstica y manejo del Síndrome Inflamatorio Multisistémico (SIM-COVID-19) en contexto pandemia SARS-CoV-2. Abril 2021.

Multisystem inflammatory syndrome temporally associated with COVID-19 (MIS-C) is a post-infectious complication described in children and adolescents with previous exposure to SARS-CoV-2. Because of its potential to evolve to severe disease -including cardiovascular impairment and multiple organ failure it requires a prompt diagnosis and appropriate management, including intensive care for most cases. These guidelines compile recent information from scientific literature, from our local clinical experiences during the past pandemic year, and have been discussed by experts. The recommendations provided are meant to help the clinical work of health teams attending the pediatric population.

[Recommendations for the diagnosis and management of cytomegalovirus infection in pregnant woman and newborn infant]. / Recomendaciones para el diagnóstico y manejo de la infección por citomegalovirus en la mujer embarazada y el recién nacido.

The Chilean Society of Infectology, through its Neonatal Infections Committee in conjunction with the Chilean Society of Obstetrics and Gynecology, propose a document for the Diagnosis and Management of Cytomegalovirus Infection in Pregnant Woman and Newborn Infant. This guideline suggests the management of mother and child infection, its diagnostic and therapeutic options. Considers the global and Latin American epidemiology, with recommendations for clinical and laboratory evaluation; diagnostic criteria, therapeutic approaches according to the clinical situation, analyzes prevention measures and establishes a national proposal for monitoring this disease.

[Tuberculosis: a challenge in newborn care and how to deal with it. Update document]. / Tuberculosis: un reto en la atención del recién nacido y cómo enfrentarlo. Documento de Actualización.

Tuberculosis in the neonatal stage has a high morbidity and mortality, is difficult to diagnose and involves the mother-child binomial and their environment. The particular characteristics of the immune system in pregnant women and the newborn, impact the clinical presentation of this disease. Its diagnosis is complex and the establishment of treatment must be timely and cannot be postponed. Relevant aspects for the diagnosis and management of the newborn exposes to the tuberculosis are covered.

[Clinical manifestations of SARS-CoV-2 infection in children in the middle of pandemic season in a pediatric tertiary center. Report of local COVID Clinical Committee, Hospital de Niños Roberto del Río, Santiago Chile]. / Espectro clínico de la infección en niños por virus SARS-CoV-2 en un centro de referencia pediátrico en plena pandemia. Reporte del Comité Clínico COVID, Hospital de Niños Roberto del Río, Santiago Chile.

BACKGROUND: SARS-CoV-2 virus infection responsible for de pandemic in course, is a new clinical and physiopathological entity, whose control is still uncertain till we can provide an effective and universal vaccine. In the beginning it was described as a respiratory disease which affects mainly adults, children can have the disease too and in this group the disease can be different than the adult disease. Acute infection in children is mostly mild and when it requires hospital assistance it resolves with support therapy and without complications most of the time. However, in the Pediatric Inflammatory Multisystemic Syndrome is vital the early clinical suspect and refers to a tertiary center to bring support and properly treatment. AIM: To describe the clinical spectrum of SARS-CoV-2 virus disease in a pediatric referral center with the pandemic still in development. METHOD: A case series of 537 patients with SARS-CoV-2 infection treated between March 1 and July 15, 2020 is presented with a description of those who were hospitalized. RESULTS: 127 (23%) of them were hospitalized and of these 69% were symptomatic. Twenty-six patients (20%) of those hospitalized presented PIMS, only one died for complications of his chronic diseases.

Presentation and Outcomes of Kawasaki Disease in Latin American Infants Younger Than 6 Months of Age: A Multinational Multicenter Study of the REKAMLATINA Network.

Objective: To characterize the clinical presentation and outcomes of Kawasaki disease (KD) in infants <6 months of age as compared to those ≥6 months in Latin America. Methods: We evaluated 36 infants <6 months old and 940 infants ≥6 months old diagnosed with KD in Latin America. We compared differences in laboratory data, clinical presentation, treatment response, and coronary artery outcomes between the two cohorts. Results: The majority (78.1%) of infants and children ≥6 months of age were initially diagnosed with KD, as compared to only 38.2% of infants <6 months. Clinical features of KD were more commonly observed in the older cohort: oral changes (92 vs. 75%, P = 0.0023), extremity changes (74.6 vs. 57.1%, P = 0.029), and cervical lymphadenopathy (67.6 vs. 37.1%, P = 0.0004). Whether treated in the first 10 days of illness or after the 10th day, infants <6 months were at greater risk of developing a coronary artery aneurysm compared to KD patients ≥6 months treated at the same point in the course of illness [ ≤ 10 days (53.8 vs. 9.4%, P = 0.00012); >10 days (50 vs. 7.4%, P = 0.043)]. Conclusion: Our data show that despite treatment in the first 10 days of illness, infants <6 months of age in Latin America have a higher risk of developing a coronary artery aneurysm. Delay in the diagnosis leads to larger coronary artery aneurysms disproportionately in these infants. Thus, suspicion for KD should be high in this vulnerable population.

Use of Adjunctive Therapy in Acute Kawasaki Disease in Latin America.

Objective: To characterize the use of adjunctive therapy in Kawasaki disease (KD) in Latin America. Methods: The study included 1,418 patients from the Latin American KD Network (REKAMLATINA) treated for KD between January 1, 2009, and May 31, 2017. Results: Of these patients, 1,152 received only a single dose of IVIG, and 266 received additional treatment. Age at onset was similar in both groups (median 2 vs. 2.2 years, respectively). The majority of patients were male (58 vs. 63.9%) and were hospitalized with the first 10 days of fever (85.1 vs. 84.2%). The most common adjunctive therapy administered was steroids for IVIG-resistance, followed by additional doses of IVIG. The use of biologics such as infliximab was limited. KD patients who received adjunctive therapy were more likely to have a lower platelet count and albumin level as well as a higher Z score of the coronary arteries. Conclusion: This is the first report of adjunctive therapies for KD across Latin America. IVIG continues to be the initial and resistance treatment, however, steroids are also used and to a lesser extent, biological therapy such as infliximab. Future studies should address the barriers to therapy in children with acute KD throughout Latin America.

[Blood cultures in newborns: optimizing sample collection and performance]. / Hemocultivos en recién nacidos: optimizando la toma de muestra y su rendimiento.

The request of blood cultures in medical care is frequent, especially in Neonatal Units, where it is performed routinely in case of suspected early or late sepsis. The purpose of this document is to standardize the sampling technique in order to increase its performance and establish criteria to interpret a positive blood culture.

[Immigration and impact on infectious diseases of the newborn]. / Inmigración e impacto en la infectología de recién nacidos.

Over the past few years immigration has become an important issue in Chile. Particular attention should be paid in foreign pregnant mothers. Infectious diseases screening in this group greatly reduce the risk of transmission to the fetus with appropriate therapy.

[Aspergillus fumigatus mediastinitis in an immunocompetent pediatric patient after heart surgery]. / Mediastinitis por Aspergillus fumigatus en un paciente pediátrico inmunocompetente posterior a una cardiocirugía.

Postsurgical aspergillosis occurs primarily in immunocompetent patients whose main predisposing factor is the loss of skin and mucosal integrity during surgery. Local infection tends to be destructive and refractory to treatment and relapses are common. It is important to consider aspergillosis in the differential diagnosis of slowly progressive and destructive surgical site infections with negative bacterial cultures. We present the case of a child who developed Aspergillus fumigatus mediastinitis months after heart surgery.

[TORCH syndrome: Rational approach of pre and post natal diagnosis and treatment. Recommendations of the Advisory Committee on Neonatal Infections Sociedad Chilena de Infectología, 2016]. / Síndrome de TORCH: enfoque racional del diagnóstico y tratamiento pre y post natal. Recomendaciones del Comité Consultivo de Infecciones Neonatales Sociedad Chilena de Infectología, 2016.

There is a lot of bacterial, viral or parasite infections who are able to be transmitted vertically from the mother to the fetus or newborn which implicates an enormous risk for it. The TORCH acronym is used universally to refer to a fetus or newborn which presents clinical features compatible with a vertically acquired infection and allows a rational diagnostic and therapeutic approach. The traditional "TORCH test" is nowadays considered not appropriate and it has been replaced for specific test for specific pathogens under well defined circumstances. The present document reviews the general characteristics, epidemiology, pathogenesis, diagnostic and therapeutic options for the most frequently involved pathogens in the fetus or newborn with TORCH suspicion.

Gravedad de infecciones respiratorias agudas bajas por adenovirus en los años 2015 y 2016 en el hospital de niños Roberto del Rio / Severity of acute lower respiratory infections due to adenovirus in the years 2015 and 2016 at the Roberto del Rio children's hospital

OBJETIVO. Comparar la gravedad de las infecciones respiratorias agudas bajas (IRAb) producidas por Adenovirus (ADV) entre los años 2015 y 2016, en el Hospital de Niños Roberto del Río. MÉTODOS. Se identificó a pacientes hospitalizados por IRAb por ADV, y se registró edad, sexo, días de hospitalización, ingreso a unidad de paciente crítico (UPC), necesidad de ventilación mecánica (VM), entre otros. Se comparó la evolución de los pacientes, y se analizó la relación entre gravedad y presencia de infecciones asociadas a atención de salud (IAAS). RESULTADOS. Se identificó 158 pacientes hospitalizados por IRAb por ADV. La relación hombre: mujer fue 6:4, con una edad promedio de 17.4 meses. La media de días de hospitalización fue de 9.88 el 2015 y 16.06 el 2016 (p=0.01). El promedio de días de oxigenoterapia fue de 5.86 el 2015 y 8.76 el 2016. Un 22.8% (n:36) de los pacientes ingresó a UPC, y el 20.25% (n:32) requirió VM. Un 41.8% de los casos (n:66) correspondió a IAAS. 3 pacientes fallecieron. CONCLUSIONES. Durante el 2016 hubo hospitalizaciones más prolongadas en comparación al 2015, sin diferencias estadísticamente significativas en relación a requerimientos de oxigenoterapia, VM y fallecimiento. La prolongación de la hospitalización se podría asociar a mayor presencia de IAAS.

OBJETIVE. To compare the severity of lower respiratory infections produced by Adenovirus between 2015 and 2016 at the Hospital de Niños Roberto del Río. METHODS. We identified patients hospitalized for lower respiratory tract infection for ADV and we recorded age, sex, days of hospitalization, admission to Intensive Care Unit (ICU), need for mechanical ventilation (MV), among others. The evolution of the patients between the two years were compared. The relationship between severity and the presence of nosocomial infections was also analyzed. RESULTS. We identified 158 hospitalized patients for ADV. The male:female ratio was 6:4, with an average age of 17.4 months. The mean of hospitalization days was 9.88 days in 2015 and 16.06 days in 2016 (p = 0.01). The average number of oxygen therapy days was 5.86 in 2015 and 8.76 in 2016. The 22.8% (n: 36) of cases required admission in the ICU, and 20.25% (n: 32) required MV. The 41.8% (n: 66) of cases corresponded to nosocomial infections. 3 patients died. CONCLUSIONS. During 2016, there were longer hospitalizations for adenovirus infections compared to 2015, without significant differences in relation to oxygen therapy, MV requirements and death. The prolongation of the hospitalization could be associated by the greater presence of nosocomial infections.