A 20-year retrospective study of osteoarticular tuberculosis in a pediatric third level referral center.

PURPOSE: The objective of the present study is to describe the clinical, diagnostic, radiological and therapeutic aspects of osteoarticular tuberculosis (OATB) in patients in a tertiary pediatric hospital, to know if the diagnosis of OATB in pediatrics is a challenge due to its insidious clinical presentation. METHODS: A retrospective, descriptive study of the cases of Tuberculosis (TB) in children was carried out. A total of 159 cases met the condition for the analysis. RESULTS: The most frequent TB modality was extrapulmonary in 85%. Out of this, only 29% was OATB. The mean age was 4.9 years (range 8 months-16 years). Eighty-six per cent of cases received Bacille Calmette-Guérin (BCG) vaccination at birth. Median time of symptoms prior to diagnosis was 8 months. Microbiological confirmation was achieved only in five cases, with a high sensitivity to the antimicrobial treatment. Mycobacterium bovis BCG strain Tokio 172 was confirmed in three cases. Mortality rate was 0% during the time of study CONCLUSION: Our study describes the epidemiological characteristics of OATB cases in Mexican children. This data revealed a high prevalence of bone and joint TB infection. Pediatric OATB should be considered in cases with lytic bone lesions, fever and local pain. In countries with BCG immunization program, M. bovis should not be forgotten as an etiological agent. The low detection rate with one technique approach highlights the urgent need for more sensitive test to diagnose OATB in children.

Pulmonary tuberculous: Symptoms, diagnosis and treatment. 19-year experience in a third level pediatric hospital.

BACKGROUND: Pulmonary tuberculosis (PTB) is an infectious disease that involves the lungs and can be lethal in many cases. Tuberculosis (TB) in children represents 5 to 20% of the total TB cases. However, there are few updated information on pediatric TB, reason why the objective of the present study is to know the real situation of PTB in the population of children in terms of its diagnosis and treatment in a third level pediatric hospital. METHODS: A retrospective study based on a revision of clinical files of patients less than 18 years old diagnosed with PTB from January 1994 to January 2013 at Instituto Nacional de Pediatria, Mexico City was carried out. A probable diagnosis was based on 3 or more of the following: two or more weeks of cough, fever, tuberculin purified protein derivative (PPD) +, previous TB exposure, suggestive chest X-ray, and favorable response to treatment. Definitive diagnosis was based on positive acid-fast bacilli (AFB) or culture. RESULTS: In the 19-year period of revision, 87 children were diagnosed with PTB; 57 (65.5%) had bacteriologic confirmation with ZN staining or culture positive (in fact, 22 were ZN and culture positive), and 30 (34.5%) had a probable diagnosis; 14(16.1%) were diagnosed with concomitant disease, while 69/81 were immunized. Median evolution time was 21 days (5-150). Fever was found in 94.3%, cough in 77%, and weight loss in 55.2%. History of contact with TB was established in 41.9%. Chest X-ray showed consolidation in 48.3% and mediastinal lymph node in 47.1%. PPD was positive in 59.2%, while positive AFB was found in 51.7% cases. Culture was positive in 24/79 patients (30.4%), PCR in 20/27 (74.1%). 39 (44.8%) patients were treated with rifampin, isoniazid, and pyrazinamide while 6 (6.9%) received the former drugs plus streptomycin and 42 (48.3%) the former plus ethambutol. There were three deaths. CONCLUSIONS: PTB in pediatric population represents a diagnostic challenge for the fact that clinical manifestations are unspecific and the diagnosis is not confirmed in all cases; that is why clinical suspicion, X-ray findings and PPD are indispensable for opportune start of treatment.

Tuberculosis of the ribcage by dissemination of Koch bacilli.

INTRODUCTION: Tuberculosis (TB) is an infectious, transmissible and immune disease caused by the Mycobacterium tuberculosis-complex (MTBC). Although osteoarticular tuberculosis (OATB) has been widely described, the ribcage variety remains a rare form. CASE REPORT: A thirteen-month-old male and a twenty-month-old female, both with pain and increased volume of anterolateral left rib cage were described. Physical examination revealed the presence of a soft consistent mass at the level of the 9th and 5th costal arches in the male and female patients respectively. Upon clinical evaluation, tuberculosis was suspected, which was confirmed by X-ray and histopathological studies. After confirmation, the management, based on anti-tuberculosis therapy was started as follows: nine months of anti-tuberculosis therapy for the male patient and fourteen months for the female. The outcomes were favorable for both patients. However, further interventions, consisting of abscess drainage in the male patient and excisional biopsy in the female patient were necessary. With these therapeutic interventions, to date, the patients are without any evidence of active TB.

BCG: a vaccine with multiple faces.

BCG has been recommended because of its efficacy against disseminated and meningeal tuberculosis. The BCG vaccine has other mechanisms of action besides tuberculosis protection, with immunomodulatory properties that are now being discovered. Reports have shown a significant protective effect against leprosy. Randomized controlled trials suggest that BCG vaccine has beneficial heterologous (nonspecific) effects on mortality in some developing countries. BCG immunotherapy is considered the gold standard adjuvant treatment for non-muscle-invasive bladder cancer. BCG vaccine has also been tested as treatment for diabetes and multiple sclerosis. Erythema of the BCG site is recognized as a clinical clue in Kawasaki disease. BCG administration in the immunodeficient patient is associated with local BCG disease (BCGitis) or disseminated BCG disease (BCGosis) with fatal consequences. BCG administration has been associated with the development of autoimmunity. We present a brief review of the diverse facets of the vaccine, with the discovery of its new modes of action providing new perspectives on this old, multifaceted and controversial vaccine.

Case Report: Chest Wall Tuberculosis without Pulmonary Involvement in Three Pediatric Immunocompetent Patients.

Primary rib cage tuberculosis (TB) is an infrequent form of presentation and represents 1% of all cases of osteoarticular TB. We report three cases of children who were previously healthy and who began with swelling of the anterior surface of the rib as initial manifestation of TB. The most important clinical presentations in this series were swelling and pain, with lytic lesions and a soft tissue mass in image studies simulating oncologic pathologies. Because none of the cases had positive epidemiological contact, TB was initially not considered, so the delay in diagnosis from the onset of symptoms was 4, 1, and 2 months, respectively. The diagnosis was made through histomorphological analyses. Treatment was administered during 12, 10, and 9 months. Posttreatment studies did not show any evidence of extrapulmonary TB and until date, the patients remained without relapse or active disease. The findings in our cases illustrate that the diagnosis of chest wall TB should be suspected in all patients from endemic areas who present rib injury.

Linezolid-associated optic neuropathy in a pediatric patient with Mycobacterium nonchromogenicum: A case report.

BACKGROUND: Toxic optic neuropathies are alterations of the optic nerve and can be caused by environmental, pharmacological, or nutritional agents. CASE: It is about a 7-year-old male patient, a native of the State of Mexico, Mexico who was diagnosed with cervical mycobacterial lymphadenitis that required management with linezolid. OBSERVATIONS: After 7 months of treatment, visual acuity of the left eye decreased and was accompanied by headache. Neuroinfection and other central nervous system affections were discarded. An adverse effect related to treatment with linezolid was suspected, and linezolid was suspended. The symptoms subsided after discontinuation; however, the patient continued to show decreased visual acuity of the left eye, assessed by his ability to count 2 fingers. The right eye remained unaffected. CONCLUSIONS: Neurotoxicity can be decreased by reducing the total dose of linezolid or by administrating it in an intermittent form. To avoid progression and loss of vision, we suggest frequent periodic ophthalmological evaluation in patients treated with linezolid.

Clinical and laboratory characteristics of infectious mononucleosis by Epstein-Barr virus in Mexican children.

BACKGROUND: Infectious mononucleosis (IM) or Mononucleosis syndrome is caused by an acute infection of Epstein-Barr virus. In Latin American countries, there are little information pertaining to the clinical manifestations and complications of this disease. For this reason, the purpose of this work was to describe the clinical and laboratory characteristics of infection by Epstein-Barr virus in Mexican children with infectious mononucleosis. METHODS: A descriptive study was carried out by reviewing the clinical files of patients less than 18 years old with clinical and serological diagnosis of IM by Epstein-Barr virus from November, 1970 to July, 2011 in a third level pediatric hospital in Mexico City. RESULTS: One hundred and sixty three cases of IM were found. The most frequent clinical signs were lymphadenopathy (89.5%), fever (79.7%), general body pain (69.3%), pharyngitis (55.2%), hepatomegaly (47.2%). The laboratory findings were lymphocytosis (41.7%), atypic lymphocytes (24.5%), and increased transaminases (30.9%), there were no rupture of the spleen and no deaths among the 163 cases. CONCLUSIONS: Our results revealed that IM appeared in earlier ages compared with that reported in industrialized countries, where adolescents are the most affected group. Also, the order and frequency of the clinical manifestations were different in our country than in industrialized ones.

Double blind study of placebo and ribavirin as prophylaxis in cases of contact with varicella in children.

The aim of this study was to determine whether or not ribavirin provides protection against varicella in those who come in contact with the virus. In a double blind placebo study, ribavirin (20 mg/kg/day, p.o.) or placebo was administered to children who had contact with varicella. Treatment was administered to 61 children (Group 1) within the first 3 days of contact, 45 of them were immunocompetent and 16 were immunodepressed. Treatment was given to 54 children on the 7th day after contact (Group 2); 48 of them were immunocompetent and 6 immunodepressed. In group 1, 11 (50%) of the immunocompetent treated with ribavirin developed chicken pox while 11 (50%) were asymptomatic. For seroconversion, there was no significant difference (p=0.586). In group 2, we did not find varicella in immunocompetent patients receiving ribavirin (0/24), for placebo there were 2 (2/24) cases of varicella. Varicella was not observed in immunodepressed patients in Group 2. A difference was not observed with the administration of ribavirin at day 3 or 7 versus placebo to prevent development of varicella. This study may have implications for the public health efforts in the prophylaxis of chicken pox.

Infección de vías urinarias: actualización / Infection of the urinary tract: updating

A pesar de que las infecciones de vías urinarias fueron descritas desde hace 200 años, su definición, patogénesis, evolución y manejo continúan generando gran controversia. Definir conceptos como bacteriuria asintomática contra infección de vías urinarias; el papel que desempeñan el reflujo vesicoureteral, obstrucciones bajas del tracto urinario, cálculos renales, ayudarán al clínico a tener un mejor conocimiento de las infecciones urinarias y contribuirán a un mejor manejo. El presente trabajo es una revisión de la historia natural así como de la patogenia, frecuencia, la clasificación actualizada, diagnóstico y una guía del manejo antimicrobiano

Vulvovaginitis en niñas causada por enterobius vermicularis / Vulvovaginitis in girls caused by enterobius vermicularis

La vulvovaginitis es un padecimiento que representa una preocupación para la paciente, sus familiares y en ocasiones para el propio médico, ya que en algunos casos son resistentes al tratamiento habitual. En una revisión de 6 555 enfermas atendidas en consulta externa del Departamento de Enfermedades Infecciosas y Parasitarias del Instituto Nacional de Pediatría, se encontró que s.3% cursaba con vulvovaginitis y 20% de estas últimas presentaba enterobiasis intestinal simultánea. En otro grupo 297 pacientes con enterobiasis intestinal pura, 10% cursaba con vulvovaginitis. En ningún caso se encontró infección de las vías urinarias secundarias a vulvovaginitis por enterobiasis. El tratamiento con un antiparasitario específico contra Enterobius vermicularis más aseo genital con agua y jabón basta para lograr la curación

Frecuencia de infecciones nosocomiales en 1986 en el Instituto Nacional de Pediatría / Incidence of nosocomial infections in 1986 in the National Institute of Pediatrics

Se estudiaron un total de 360 infecciones en relación con 6469 egresos, lo que da una tasa de 5.56 infecciones por 100 egresos. Los meses en que se incrementó la frecuencia de infecciones nosocomiales fueron febrero y abril. El número más alto de casos se observó en los servicios de nutrición, oncología, nefrología, infectología y hematología. Las patologías más frecuentes fueron: bacterianas, urosepsis, herida quirúrgica infectada, flebitis y neumonías. De las bacterianas identificadas se informó como los más frecuentes entre los gram negativos E. coli, K pneumoniae y Pseudomona sp y entre los gram positivos a SF epidermidis. Estos datos permiten conocer la frecuencia de las infecciones nosocomiales en el Instituto Nacional de Pediatría. Será posible por ello planear mejor los programas de prevención de infecciones intrahospitalarias y proponer un mejor control que permita una importante disminución en las tasas

Sífilis congénita / Congenital syphilis

Se revisaron 80 casos de sífilis congénita diagnosticados en el Instituto Nacional de Pediatría durante el periodo 1971-1985; 53 (66%) eran del sexo masculino y 27 (34%) del sexo femenino; 33 casos eran niños pretérmino y 39 de término, desconociéndose edad gestacional en ocho casos. Hubo antecedente epidemiológico positivo en los padres en 50 casos (62%), dudoso en 15 y se desconoce en 15; fueron frecuentes las madres solteras (50%) y el abandono paterno (70%). Las madres con antecedente epidemiológico positivo generalmente presentaban poca sintomatología y el 90% de los padres manifestaciones evidentes de sífilis secundaria. Las manifestaciones clínicas que más orientaron al diagnóstico de sífilis congénita fueron las lesiones mucocutáneas presentes en más del 50% de los casos y hepatoesplenomegalia (48%). Se encontró alteración del líquido cefalorraquídeo en 8/36 casos siguiendo un patrón sugestivo de neuroinfección viral más que bacteriana. Los exámenes de laboratorio y gabinete más útiles fueron radiografías de huesos largos. Hubo alteraciones óseas en el 74% de los casos; predominaron la osteocondritis y periostitis de huesos largos. La biometría hemática no fue orientadora. El examen de laboratorio de mayor utilidad fue la serología seriada en los padres y los pacientes; fue positiva en el 98% de los casos. El tratamiento fue a base de penicilina benzatínica 50,000 U/kg/IM dosis única en los casos con LCR normal y PSC 50,000 U/kg/día por 10 días. La evolución una vez establecido el tratamiento fue satisfactoria. La mortalidad fue del 12% debido a proceso septicémico bacteriano agregado y hubo un caso de perforación de colon con peritonitis y septicemia secundaria

Tétanos: estudios de 25 casos / Tetanus: study of 25 cases

Se estudiaron retrospectivamente 25 casos de tétanos atendidos en el Instituto Nacional de Pediatría (INP) comprendidos de Enero/80 a Enero/85, y se compararon los resultados con los publicados por países latinoamericanos, principalmente con los datos obtenidos en el Hospital de Niños Benjamín Bloom (HNBB) de la República de El Salvador, Centro América. Fue más frecuente el tétanos neonatal en un 60% (15/25) principalmente de los estados de Morelos 9/25 y Guerrero 8/25. Las complicaciones más importantes fueron: Sepsis 8/25 y alteraciones respiratorias 8/25. La mortalidad en el INP fue de 28%. Se revisó la tasa de mortalidad a nivel latinoamericano, osciló desde 0.1 x 100,00 hab. en Cuba, hasta 2.4 x 100,00 hab. en Surinam. El HNBB señala una mortalidad del 7.6% en los tétanos neonatal. El número reducido de casos encontrados, no es representativo de la realidad nacional, y se requiere un estudio que comprenda las áreas geográficas, en donde las características socioeconómicas y culturales de la comunidad, aumentan la tasa de frecuencia de esta enfermedad

Seudopapilomatosis laríngea de origem probablemente tuberculoso en un preescolar / Laryngeal pseudopapilomatosis probably of tuberculosis etiology, in a preschool child

La tuberculosis laríngea fue una enfermedad común en el pasado asociada a la presencia de tuberculosis pulmonar activa. En la actualidad, con el advenimiento de la quimioterapia antituberculosa, su presentación es rara y se observa principalmente en adultos, siendo en la edad pediátrica un diagnóstico difícil de establecer en ausencia de lesión pulmonar radiológica. El síntoma principal es la disfonía de evolución progresiva; la radiografia de tórax muestra en la mayoría de los casos evidencia de tuberculosis pulmonar. El diagnóstico se confirma por laringoscopia, biopsia e identificación del Mycobacterium tuberculosis en el esputo. Se presenta el caso de una paciente que ingresó por disfonía de evolución progresiva; en la laringoscopia se observaron papilomas laríngeos siendo la biopsia compatible con tuberculosis. El estudio de Combe y la radiografia de tórax fueron positivos; el PPD y el cultivo para M. tuberculosis fueron negativos. Se describe el cuadro clínico y radiológico así como los hallazgos patológicos, similares a los descritos en la literatura

Orquiepidimitis en la infancia: reporte de un caso / Orchiepididymitis in infancy: a case report

La tuberculosis genital en la infancia es rara. Se presenta con más frecuencia en la puberdad. Se describe el caso de un paciente masculino de 2 años 7 meses de edad con tuberculosis miliar y tumoración de etiología fímica, comprobada por estudio histopatológico y respuesta al tratamiento antifímico

Mucormicosis rinocerebral en un niño con leucemia. Informe de un caso / Rhynocerebral mucormycosis in a child with leukemia. A case report

La mucormicosis es una infección aguda causada por hongos del orden de los mucorales que colonizan los tractos respiratorio e intestinal de personas sanas y causan enfermedad en personas inmunodeficientes, es más común en aquellos que cursan con diabetes mellitus y con menor frecuencia en personas con leucemia o linfomas. Una de las formas más frecuentes de mucormicosis es la rinocerebral, en la cual los pacientes presentan lesiones que inician a partir de la cavidad oral y avanzan destruyendo el paladar y estructuras faciales, septum nasal, senos y posteriormente el cerebro. El tratamiento consiste en debridación quirúrgica radical y manejo farmacológico con anfotericina B. Se comunica el caso de un niño de ocho años con leucemia mieloblástica variedad L1 que posterior a un ciclo de quimioterapia presenta mucormicosis rinocerebral corroborada por aislamiento del microorganismo (mucor sp.) y es tratada con anfotericina B con buena respuesta al tratamiento; a los cuatro meses presentan recaída por lo que se realiza debridación quirúrgica y se continúa terapia antimicótica, con la que evoluciona adecuadamente

Importancia de la artritis séptica en niños: análisis de cien casos del Instituto Nacional de Pediatría / Importance of the septic arthritis in children: analysis of one hundred cases at the National Institute of Pediatrics

Se revisaron los expedientes clínicos de 100 pacientes hospitalizados en el Instituto Nacional de Pediatría entre enero de 1985 y diciembre de 1987, con el diagnóstico de artritis séptica. El 36% de los casos correspondió a menores de 1 año de edad. Las articulaciones más afectadas fueron la cadera, la rodilla y el hombro. El estafilococo fue el agente causal más frecuente en todas las edades, aunque en recién nacidos los gramnegativos juegan un papel muy importante. Se encontró H. influenzae en el grupo de 4 meses a 5 años. La mortalidad por complicaciones fué del 5%; el 30% de los egresados quedaron con secuelas. Los resultados globales no difieren notablemente de lo revisado en la literatura.