The spread of drug-resistant tuberculosis in children: an Italian case series.

Drug-resistant paediatric tuberculosis (TB) is an overlooked global problem. In Italy, the epidemiology of TB has recently changed and data regarding drug-resistant forms in the paediatric setting is scanty. The aim of this case series was to report the cases of drug-resistant TB, diagnosed between June 2006 and July 2010 in four Italian tertiary centres for paediatric infectious diseases, in children and adolescents living in Italy. Twenty-two children were enrolled, of these 17 were resistant to one or more drugs and five had multidrug-resistant TB. All but one child were either foreign born or had at least one foreign parent. Twenty-one patients completed their treatment without clinical or radiological signs of activity at the end of treatment, and one patient was lost to follow up. The outcomes were good, with few adverse effects using second-line anti-TB drugs. Although this series is limited, it might already reflect the worrisome increase of drug-resistant TB, even in childhood.

A case of acute disseminated encephalomyelitis following influenza virus A-H1N1 infection.

We describe a case of acute disseminated encephalomyelitis (ADEM) occurring in a three-year old girl with influenza A (H1N1)v infection and manifesting with seizures and ataxia. The brain MRI revealed bilateral hyperintense signal changes in basal ganglia and brain stem. The patient was treated with intravenous methylprednisolone bolus followed by tapering steroids and progressively recovered without neurologic sequelae at the latest follow-up. ADEM may represent a rare postinfectious complication following novel pandemic influenza A H1N1v which should be taken into account in the differential diagnosis of associated neurologic manifestations for the specific therapeutic approach and adequate follow-up.

An adolescent with persistent cervical lymphadenopathy and retropharyngeal abscess: case report.

Tuberculosis keeps on representing a serious threat worldwide and one of the major challenge of our century. Different strategies have been developed in order to eradicate the disease, and particular attention is paid to children, who are at great risk for developing severe manifestations and poor outcome. Age at exposure, nutritional conditions and immune status can lead to great variability of disease expressions, with subsequent difficulties in making an appropriate and rapid diagnosis. Moreover, children coming from tuberculosis-endemic areas should be carefully evaluated for M. tuberculosis infection. Here we present a infrequent manifestation of extrapulmonary tuberculosis in a 13-years-old girl coming from Latin America: a superficial persistent cervical lymphadenopathy was associated with a totally asymptomatic retropharyngeal abscess. Diagnostic approach was discussed. Treatment consisted with a combination of surgical drainage of the abscess and a prolonged combined 6-month chemotherapy. The cervical lymphadenopathy disappeared and no relapses were found during the subsequent follow up.

Prospective incidence study of bloodstream infection in infants and children with central venous catheters after cardiac surgery in Italy.

This prospective observational study was designed to assess the incidence of, risk factors for, and outcome of catheter-related bloodstream infection in children undergoing cardiac surgery. A staff specifically trained to handle the central venous catheters with proper aseptic techniques and an appropriate patient to medical staff ratio remain the most effective measures to prevent this infection.

Possible donor-recipient bartonellosis transmission in a pediatric liver transplant.

Bartonella henselae is the causative agent of cat-scratch disease and other disorders, including hepatosplenic granulomatosis. This infection has only rarely been reported after solid organ transplantation, where it can mimic the more common post-transplant lymphoproliferative disease. Here we present a case of asymptomatic B. henselae hepatic and lymph nodal granulomatosis in a pediatric patient who had received orthotopic liver transplant 2 months before; we hypothesize that the causative agent was transmitted from the donor. This infection developed early in the post-transplant period; the disease involved only the graft liver and the regional lymph nodes, and the patient did not have a cat or any history of contact, scratches, or bites by a cat. In our patient this infection resolved successfully with a combination of 2 associated antibiotics and reduction of immunosuppressive therapy.

Prolonged follow up of seven patients affected by hepatosplenic granulomata due to cat-scratch disease.

This study is a retrospective analysis of seven patients with hypoechogenic lesions in the liver and/or spleen due to Bartonella henselae, who were followed from 1998 through to 2005 by the Department of Pediatrics, Turin University. In addition to showing constitutional symptoms, four children had skin lesions suggestive of injuries inflicted by cats, and one child had a history of exposure to cats. The origin of the infection remained undefined in the other two patients. Humoral tests enabled a precise diagnosis in all children. Treatment with macrolides or combinations of two active antibiotics for at least 2-3 weeks led to the definitive clearance of infection, although residual intraparenchymal lesions persisted in five patients for several months or years. Conclusion B. henselae serology allows an easy diagnosis of multiple hepatosplenic granulomata, a clinical picture that appears to be under-recognized. Macrolides or a combination of two active antibiotics for 2-3 weeks leads to a rapid clinical response and a definitive clearance of infection.

Microbiological investigations on a nosocomial case of Legionella pneumophila pneumonia associated with water birth and review of neonatal cases.

A case of Legionella pneumophila 1 pneumonia, confirmed by positive serology and urinary antigen, occurred in a 7-day old neonate after water birth in hospital. As respiratory samples were not available for culture, further microbiological investigations were performed in neonate and environment, in order to recognize the source of infection. The hospital water supply was contaminated by L. pneumophila 1 strains (300-2000 cfu/L) of two monoclonal subtypes of Pontiac subgroup. L. spiritensis (10-225 cfu/L) was isolated from cold tap water of the patient's home. PCR from tap and humidifiers water of the patient's home was positive for Legionella spp, but not for L. pneumophila. Because L. pneumophila 1, responsible of child infection, was only isolated from the hospital pool water for waterbirthing, we conclude that the infant acquired the nosocomial legionellosis by prolonged delivery in contaminated water, perhaps by aspiration. Infection control measures for waterbirthing are highly recommended. A review of neonatal case of legionellosis is also presented. As this rare infection may have a high fatality rate if unrecognized, pediatricians should be aware of the possibility of the legionellosis in newborns.

Legionella pneumophila pneumonia in a newborn after water birth: a new mode of transmission.

We report a case of Legionella pneumophila pneumonia in a 7-day old neonate. Because the hospital water, and particularly the pool water for water birthing, was contaminated by L. pneumophila serogroup 1, the newborn was infected following prolonged delivery in contaminated water, perhaps by aspiration. This is the first case of nosocomial Legionella pneumonia in neonate after water birth.

Nosocomial infections in pediatric cardiac surgery, Italy.

OBJECTIVE: To evaluate the incidence of nosocomial infection (NI) in pediatric patients who received cardiothoracic surgery and to identify possible associated risk factors. DESIGN: Prospective observational study. SETTING: The cardiac surgery and cardiac intensive care units at the Regina Margherita Children's Hospital, Turin, Italy. PATIENTS: All patients who underwent surgery from July 20, 1998, to July 19, 1999, were enrolled, except patients with operative catheterization only. METHODS: Clinical data were collected daily from July 20, 1998, to July 19, 1999. NIs were diagnosed according to US Centers for Disease Control and Prevention criteria. RESULTS: 104 patients were included in the present study, 80 (76.9%) of whom underwent extracorporeal circulation. The NI ratio was 48.1% (50/104); the percentage of patients with NI was 30.8% (32/104): 23.1% developed one infection, 7.7% two or more. The rate of NI was 2.17 per 100 days of hospitalization (50/2,304). The most common pathogen was Pseudomonas aeruginosa. Important risk factors were length of preoperative admission >5 days, total length of admission >10 days, open chest during postoperative phase, and cyanotic heart disease. There was a significant association between sepsis and central venous catheterization for 3 days or more. Rate of sepsis was 19 per 1,000 catheter days (16/852). CONCLUSION: NIs represent a frequent complication for children who undergo heart surgery. Based on our data, we suggest decreasing the preoperative stay as much as possible. The higher NI incidence in patients with an open chest postoperatively suggests that an alternative antibiotic strategy should be considered for these patients.

Human immunodeficiency virus infection as risk factor for mother-to-child hepatitis C virus transmission; persistence of anti-hepatitis C virus in children is associated with the mother's anti-hepatitis C virus immunoblotting pattern.

To determine the rate of vertical transmission of hepatitis C virus (HCV), we prospectively studied 45 babies born to anti-HCV-positive women with or without concomitant infection with the human immunodeficiency virus (HIV). We performed a second-generation recombinant immunoblotting assay, alanine transaminase (ALT) evaluation, and HCV-RNA testing on sera from 27 infants of HCV+, HIV- mothers and 18 babies of HCV+, HIV+ women, at birth and thereafter. After birth, HCV antibodies progressively disappeared within 12 months in all children but one, whose mother was HCV+, HIV+; this child was the only one who showed detectable levels of HCV-RNA and abnormal ALT values throughout the follow-up (range, 12 to 27 months). Viremia was persistently negative, and ALT levels were continuously normal in the remaining infants, showing that "seronegative" infection with HCV was absent in both groups. Clearance of passively acquired anti-HCV antibodies was found to be slower among babies born to HIV+ mothers (22.3% vs. 3.8% at 12 months, P = .03) and children whose mothers showed three or four anti-HCV reactivities by immunoblotting maintained anti-HCV for longer periods compared with babies born to mothers with one or two anti-HCV reactivities (P = .0001). Seventeen of 27 babies born to HCV+, HIV- mothers were breast-fed, and none of them was infected, confirming the apparent safety for HCV of breast milk. In summary, according to our study, vertical transmission of HCV is an infrequent event, and the presence of HIV in the mother is not an important co-factor for transmission of HCV infection.