Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant. RESULTS: Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001). CONCLUSIONS: Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.

Precordial pain, leukocytosis and bicytopenia in a teenager with systemic juvenile idiopathic arthritis under immunosuppressive therapy / Dor precordial, leucocitose e bicitopenia em adolescente com artrite idiopática juvenil sistêmica em terapia imunossupressora

ABSTRACT Objective: To highlight the importance of the new classification criteria for the macrophage activation syndrome (MAS) in systemic juvenile idiopathic arthritis in order to reduce morbidity and mortality outcome related to this disease. Case description: A 12-year-old female patient with diagnosis of systemic juvenile idiopathic arthritis under immunosuppression therapy for two years developed cough, acute precordial chest pain, tachypnea, tachycardia and hypoxemia for two days. Chest tomography showed bilateral laminar pleural effusion with bibasilar consolidation. The electrocardiogram was consistent with acute pericarditis and the echocardiogram showed no abnormalities. Laboratory exams revealed anemia, leukocytosis and increased erythrocyte sedimentation rate, as well as C-reactive protein rate and serum biomarkers indicative of myocardial injury. Systemic infection and/or active systemic juvenile idiopathic arthritis were considered. She was treated with antibiotics and glucocorticoids. However, 10 days later she developed active systemic disease (fever, evanescent rash and myopericarditis with signs of heart failure) associated with macrophage activation syndrome, according to the 2016 Classification Criteria for Macrophage Activation Syndrome in Systemic Juvenile Idiopathic Arthritis. She was treated for five days with pulse therapy, using glucocorticoids, immunoglobulin and cyclosporine A, with improvement of all clinical signs and laboratory tests. Comments: Myopericarditis with signs of heart failure associated with MAS is a rare clinical presentation of systemic juvenile idiopathic arthritis. Macrophage activation syndrome occurs mainly during periods of active systemic juvenile idiopathic arthritis and may be triggered by infection. Knowledge about this syndrome is crucial to reduce morbidity and mortality.

RESUMO Objetivo: Destacar a importância do conhecimento sobre os novos critérios de classificação para síndrome de ativação macrofágica (SAM) na artrite idiopática juvenil sistêmica para reduzir a morbidade e mortalidade desse desfecho. Descrição do caso: Adolescente do sexo feminino de 12 anos de idade, em terapia imunossupressora por diagnóstico de artrite idiopática juvenil sistêmica há 2 anos, com quadro de tosse, dor precordial aguda, taquipneia, taquicardia e hipoxemia há 2 dias. A tomografia de tórax evidenciou efusão pleural laminar bilateral com consolidação bibasal. O eletrocardiograma foi compatível com pericardite aguda, e o ecocardiograma foi normal. Os exames laboratoriais revelaram anemia, leucocitose e aumento da velocidade de hemossedimentação, proteína C-reativa e marcadores séricos de lesão miocárdica. Infecção sistêmica e/ou doença sistêmica em atividade foram consideradas. A paciente foi tratada com antibióticos e glicocorticoide. Entretanto, dez dias depois, evoluiu com doença sistêmica em atividade (febre, exantema e miopericardite com insuficiência cardíaca) associada à SAM, de acordo com o 2016 Classification Criteria for Macrophage Activation Syndrome in Systemic Juvenile Idiopathic Arthritis, e necessitou de cinco dias de pulsoterapia com glicocorticoide, imunoglobulina e ciclosporina A, com melhora de todos os parâmetros clínicos e laboratoriais. Comentários: A miopericardite com sinais de insuficiência cardíaca associada à SAM é uma apresentação clínica rara da artrite idiopática juvenil sistêmica, que ocorre principalmente em períodos de atividade sistêmica da doença e pode ser deflagrada por infecções. O conhecimento sobre essa síndrome é fundamental para reduzir morbidade e mortalidade desse grave desfecho.

PRECORDIAL PAIN, LEUKOCYTOSIS AND BICYTOPENIA IN A TEENAGER WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS UNDER IMMUNOSUPPRESSIVE THERAPY.

OBJECTIVE: To highlight the importance of the new classification criteria for the macrophage activation syndrome (MAS) in systemic juvenile idiopathic arthritis in order to reduce morbidity and mortality outcome related to this disease. CASE DESCRIPTION: A 12-year-old female patient with diagnosis of systemic juvenile idiopathic arthritis under immunosuppression therapy for two years developed cough, acute precordial chest pain, tachypnea, tachycardia and hypoxemia for two days. Chest tomography showed bilateral laminar pleural effusion with bibasilar consolidation. The electrocardiogram was consistent with acute pericarditis and the echocardiogram showed no abnormalities. Laboratory exams revealed anemia, leukocytosis and increased erythrocyte sedimentation rate, as well as C-reactive protein rate and serum biomarkers indicative of myocardial injury. Systemic infection and/or active systemic juvenile idiopathic arthritis were considered. She was treated with antibiotics and glucocorticoids. However, 10 days later she developed active systemic disease (fever, evanescent rash and myopericarditis with signs of heart failure) associated with macrophage activation syndrome, according to the 2016 Classification Criteria for Macrophage Activation Syndrome in Systemic Juvenile Idiopathic Arthritis. She was treated for five days with pulse therapy, using glucocorticoids, immunoglobulin and cyclosporine A, with improvement of all clinical signs and laboratory tests. COMMENTS: Myopericarditis with signs of heart failure associated with MAS is a rare clinical presentation of systemic juvenile idiopathic arthritis. Macrophage activation syndrome occurs mainly during periods of active systemic juvenile idiopathic arthritis and may be triggered by infection. Knowledge about this syndrome is crucial to reduce morbidity and mortality.

Mean platelet volume, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in determining the diagnosis or outcome in children with snakebite. / Volumen plaquetario medio, índice de neutrófilos/linfocitos e índice de trombocitos/linfocitos para determinar el diagnóstico y/o pronóstico en niños con mordedura de serpiente.

BACKGROND: The objective of this study is to evaluate the relationships between the mean platelet volume (MPV), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) variables and diagnosis or prediction of outcome in children with snakebite envenomation. METHODS: Children diagnosed with snakebite envenomation and a control group of healthy subjects were retrospectively evaluated. Patients were classified into three groups as mild, moderate and severe. RESULTS: 142 children were enrolled in the study. Leukocytosis (p= 0.003), neutrophilia (p= 0.026) and thrombocytopenia (p= 0.034) were significantly more common in severe snakebite envenomation, although no statistical significant were found in association with MPV, NLR and PLR between snakebite envenomation groups. The mean MPV, NLR and PLR were found to be significantly higher in children with snakebite compared to than among healthy controls. CONCLUSIONS: Our results suggested that MPV, NLR and PLR may be useful for the diagnosis as inflammatory markers in snakebite envenomation.

OBJETIVO: Evaluar la relación entre las variables de volumen plaquetario medio (VPM), índice de neutrófilos/linfocitos (INL) e índice de trombocitos/linfocitos (ITL) y el diagnóstico o la predicción del desenlace en los niños con intoxicación por mordedura de serpiente. MÉTODOS: Se realizó una evaluación retrospectiva de niños con diagnóstico de intoxicación por mordedura de serpiente y un grupo de referencia de sujetos sanos. Se clasificó a los pacientes en tres grupos de intoxicación: leve, moderada y grave. CONCLUSIONS: Según nuestros resultados, el uso del VPM, el INL y el ITL podría servir para el diagnóstico como marcadores inflamatorios en los casos de intoxicación por mordedura de serpiente.

[Treatment conditioning variables in elderly patients with acute myeloid leukemia. An institutional experience]. / Variables condicionantes del tratamiento en pacientes añosos con leucemia mieloide aguda. Experiencia institucional.

Patients over 60 years old with acute myeloid leukemia (AML) have a worse prognosis due to several factors that determine the therapeutic outcome. The main predictors of mortality in patients with AML reported in the literature were analyzed in our population. The primary objective was to analyze overall survival. The secondary objective was to determine treatment-related mortality, defined as death within eight weeks of starting treatment. It was designed as a retrospective study. A total of 133 treatment naive patients were included, from January 1991 to August 2014. The adjusted analysis showed that the most important variables to determine overall survival were the WBC count = 30 000 at diagnosis [adjusted HR 2.19 (1.06-4.53), p = 0.03)] and the Performance Status (ECOG) 3 or 4 [aHR 4.63 (1.69-12.68), p < 0.001)]. Performance Status 3-4 was the only variable that conditioned treatment related mortality, showing in the univariate analysis an OR 5.44 (CI 1.93-15.28, p < 0.001). It was also the only variable that kept its statistical power in the multivariate analysis adjusted OR (aOR) 12.40 (IC 1.12-137.17, p = 0.04). The inherent poor outcome in elderly patients diagnosed with AML is not fully understood. The best way of assessing these elderly patients should probably include not only age but the best way of assessing these elderly patients should probably include not only age but laboratory, genetic and molecular studies. Especially designed comorbidity and fragility indices should be included, along with functional status. Leukocytosis and poor quality of life were identified as the most powerfull factors for predicting mortality in our study.

Variables condicionantes del tratamiento en pacientes añosos con leucemia mieloide aguda: Experiencia institucional / Treatment conditioning variables in elderly patients with acute myeloid leukemia. An institutional experience

Los mayores de 60 años con leucemia mieloide aguda (LMA) tienen peor pronóstico que el resto de los pacientes. En la literatura se expresan diferentes factores que podrían condicionar su supervivencia. Se propuso determinar cuáles fueron los principales determinantes de supervivencia global en nuestra población; y como objetivo secundario cuáles estaban vinculados con mortalidad temprana, entendida la misma como muerte dentro de las ocho semanas de iniciado el tratamiento. Para ello se diseñó un estudio de cohorte retrospectivo que incluyó 133 pacientes no tratados previamente. El análisis ajustado a covariables demostró que las variables de mayor peso para determinar supervivencia global fueron el recuento leucocitario ≥ 30 000 al diagnóstico [HR ajustado 2.19 (1.06-4.53), p = 0.03)] y el estado general (ECOG) 3 o 4 [HRa 4.63 (1.69-12.68), p < 0.001)]. En cuanto a mortalidad relacionada al tratamiento, el estado general (ECOG) 3-4 mostró ser la única variable que mantuvo su poder estadístico en el análisis multivariado con OR ajustado (ORa) 12.40 (IC 1.12-137.17, p = 0.04). El mal resultado inherente a los pacientes añosos con diagnóstico de LMA no se entiende por completo aún. Probablemente la mejor forma de evaluarlos debería tener en cuenta no solo la edad, sino también resultados de laboratorio, de estudios genéticos y moleculares, utilizando índices específicos de comorbilidad, estado general y alguna evaluación geriátrica de fragilidad. Este estudio identificó que la leucocitosis y el mal estado general fueron los factores que mostraron un mayor poder en la predicción de la mortalidad.

Patients over 60 years old with acute myeloid leukemia (AML) have a worse prognosis due to several factors that determine the therapeutic outcome. The main predictors of mortality in patients with AML reported in the literature were analyzed in our population. The primary objective was to analyze overall survival. The secondary objective was to determine treatment-related mortality, defined as death within eight weeks of starting treatment. It was designed as a retrospective study. A total of 133 treatment naive patients were included, from January 1991 to August 2014. The adjusted analysis showed that the most important variables to determine overall survival were the WBC count ≥ 30 000 at diagnosis [adjusted HR 2.19 (1.06-4.53), p = 0.03)] and the Performance Status (ECOG) 3 or 4 [aHR 4.63 (1.69-12.68), p < 0.001)]. Performance Status 3-4 was the only variable that conditioned treatment related mortality, showing in the univariate analysis an OR 5.44 (CI 1.93-15.28, p < 0.001). It was also the only variable that kept its statistical power in the multivariate analysis adjusted OR (aOR) 12.40 (IC 1.12-137.17, p = 0.04). The inherent poor outcome in elderly patients diagnosed with AML is not fully understood. The best way of assessing these elderly patients should probably include not only age but the best way of assessing these elderly patients should probably include not only age but laboratory, genetic and molecular studies. Especially designed comorbidity and fragility indices should be included, along with functional status. Leukocytosis and poor quality of life were identified as the most powerfull factors for predicting mortality in our study.

Spontaneous occurrence of malignant lymphoma in sheep: case report / Ocorrência espontânea de linfoma maligno em ovelha: relato de caso

There are very few reports of lymphoma in sheep in the literature. Therefore, the aim of the present study was to report the prevalence of this disease among sheep cared for in the Clinic of Cattle in the Campus Garanhuns of the Federal Rural University of Pernambuco (UFRPE). The results were obtained from a four year old sheep (weight 40 kg) that had been reared in a semi-intensive system. The owner reported that he had acquired this animal three months earlier from another herd and that, one month later; he had noticed that the animal was apathetic, no appetite and distanced itself from the herd. The animal was treated unsuccessfully on the farm. The animal exhibited clinical signs of apathy, tachycardia, cachexia and anorexia, as well as ruminal and intestinal hypomotility. The hemogram showed evidence of leukocytosis by neutrophilia, with the presence of deteriorated leukocytes in the blood smear. The serology (IDGA) for the enzootic bovine leukosis virus was negative. The ultrasound confirmed severe lung disease. The animal died after seven days. In the necropsy there was a mass in the subcutaneous tissue adhered to chest sternal there was a notable increase in the volume adhered in the external caudal subcutaneous region, with nodular characteristics and a whitish coloration. Identical, although smaller, nodulations were visualized in the serous membrane of the reticulum and the abomasum, with metastases in the kidneys, omentum, mesenteric lymph nodes, diaphragm, heart and lungs. The histopathology revealed atypical mantle structures,with multiple vacuoles and interspersed fibrous stroma. The tumoral cells were small, round, basophilic, with scarce cytoplasm and a large, round nucleus, with hyperchromatic qualities, dense chromatin and rare mitosis. The results of the present study confirm that this was a case of atypical lymphosarcoma in the sheep in question.(AU)

Os relatos na literatura de linfoma em ovinos são escassos, logo o objetivo deste trabalho é relatar a ocorrência dessa doença em uma ovelha atendida na Clínica de Bovinos, Campus-Garanhuns/ UFRPE. Os achados foram obtidos de uma ovelha mestiça de quatro anos, pesando 40 kg, criada em sistema semi-intensivo. O proprietário relatou que adquiriu esse animal há três meses de outro rebanho e que há dois observou que o animal ficou apático, com perda do apetite e separado do rebanho, foi medicado na propriedade sem sucesso. Clinicamente apresentou um quadro de apatia, taquicardia, caquexia, anorexia, bem como hipomotilidade ruminal e intestinal. No hemograma evidenciou-se leucocitose por neutrofilia, com presença de leucócitos degenerados no esfregaço sanguíneo. A sorologia (IDGA) para vírus da Leucose Enzoótica Bovina foi negativa. Além desses achados, a ultrassonografia revelou um comprometimento pulmonar grave. O animal veio a óbito após sete dias. Na necropsia observou-se uma massa no tecido subcutâneo, aderida à região torácica caudal esternal, firme com características nodular e de coloração esbranquiçada. Nodulações idênticas e de tamanhos menores foram visualizadas na serosa do retículo e abomaso, com metástases nos rins, omento, linfonodos mesentéricos, diafragma, coração e pulmão. A histopatologia revelou estruturas atípicas disposta na forma de manto, com múltiplos vacúolos, com estroma fibroso entremeado. As células tumorais caracterizam-se por serem pequenas e arredondadas, basofílicas, com citoplasma escasso, núcleo grande e redondo, hipercromático, com cromatina densa e com raras mitoses. Estes achados indicam uma forma de linfoma espontâneo em ovelha.(AU)

Spontaneous occurrence of malignant lymphoma in sheep: case report / Ocorrência espontânea de linfoma maligno em ovelha: relato de caso

There are very few reports of lymphoma in sheep in the literature. Therefore, the aim of the present study was to report the prevalence of this disease among sheep cared for in the Clinic of Cattle in the Campus Garanhuns of the Federal Rural University of Pernambuco (UFRPE). The results were obtained from a four year old sheep (weight 40 kg) that had been reared in a semi-intensive system. The owner reported that he had acquired this animal three months earlier from another herd and that, one month later; he had noticed that the animal was apathetic, no appetite and distanced itself from the herd. The animal was treated unsuccessfully on the farm. The animal exhibited clinical signs of apathy, tachycardia, cachexia and anorexia, as well as ruminal and intestinal hypomotility. The hemogram showed evidence of leukocytosis by neutrophilia, with the presence of deteriorated leukocytes in the blood smear. The serology (IDGA) for the enzootic bovine leukosis virus was negative. The ultrasound confirmed severe lung disease. The animal died after seven days. In the necropsy there was a mass in the subcutaneous tissue adhered to chest sternal there was a notable increase in the volume adhered in the external caudal subcutaneous region, with nodular characteristics and a whitish coloration. Identical, although smaller, nodulations were visualized in the serous membrane of the reticulum and the abomasum, with metastases in the kidneys, omentum, mesenteric lymph nodes, diaphragm, heart and lungs. The histopathology revealed atypical mantle structures,with multiple vacuoles and interspersed fibrous stroma. The tumoral cells were small, round, basophilic, with scarce cytoplasm and a large, round nucleus, with hyperchromatic qualities, dense chromatin and rare mitosis. The results of the present study confirm that this was a case of atypical lymphosarcoma in the sheep in question.

Os relatos na literatura de linfoma em ovinos são escassos, logo o objetivo deste trabalho é relatar a ocorrência dessa doença em uma ovelha atendida na Clínica de Bovinos, Campus-Garanhuns/ UFRPE. Os achados foram obtidos de uma ovelha mestiça de quatro anos, pesando 40 kg, criada em sistema semi-intensivo. O proprietário relatou que adquiriu esse animal há três meses de outro rebanho e que há dois observou que o animal ficou apático, com perda do apetite e separado do rebanho, foi medicado na propriedade sem sucesso. Clinicamente apresentou um quadro de apatia, taquicardia, caquexia, anorexia, bem como hipomotilidade ruminal e intestinal. No hemograma evidenciou-se leucocitose por neutrofilia, com presença de leucócitos degenerados no esfregaço sanguíneo. A sorologia (IDGA) para vírus da Leucose Enzoótica Bovina foi negativa. Além desses achados, a ultrassonografia revelou um comprometimento pulmonar grave. O animal veio a óbito após sete dias. Na necropsia observou-se uma massa no tecido subcutâneo, aderida à região torácica caudal esternal, firme com características nodular e de coloração esbranquiçada. Nodulações idênticas e de tamanhos menores foram visualizadas na serosa do retículo e abomaso, com metástases nos rins, omento, linfonodos mesentéricos, diafragma, coração e pulmão. A histopatologia revelou estruturas atípicas disposta na forma de manto, com múltiplos vacúolos, com estroma fibroso entremeado. As células tumorais caracterizam-se por serem pequenas e arredondadas, basofílicas, com citoplasma escasso, núcleo grande e redondo, hipercromático, com cromatina densa e com raras mitoses. Estes achados indicam uma forma de linfoma espontâneo em ovelha.

Prediction of bacterial meningitis based on cerebrospinal fluid pleocytosis in children

Children with cerebrospinal fluid pleocytosis are frequently treated with parenteral antibiotics, but only a few have bacterial meningitis. Although some clinical prediction rules, such as bacterial meningitis score, are of well-known value, the cerebrospinal fluid white blood cells count can be the initial available information. Our aim was to establish a cutoff point of cerebrospinal fluid white blood cell count that could distinguish bacterial from viral and aseptic meningitis. A retrospective study of children aged 29 days to 17 years who were admitted between January 1st and December 31th, 2009, with cerebrospinal fluid pleocytosis (white blood cell > 7 µL-1) was conducted. The cases of traumatic lumbar puncture and of antibiotic treatment before lumbar puncture were excluded. There were 295 patients with cerebrospinal fluid pleocytosis, 60.3% females, medium age 5.0 ± 4.3 years distributed as: 12.2% 1-3 months; 10.5% 3-12 months; 29.8% 12 months to 5 years; 47.5% >5 years. Thirty one children (10.5%) were diagnosed with bacterial meningitis, 156 (52.9%) viral meningitis and 108 (36.6%) aseptic meningitis. Bacterial meningitis was caused by Neisseria meningi tidis (48.4%), Streptococcus pneumoniae (32.3%), other Streptococcus species (9.7%), and other agents (9.7%). cerebrospinal fluid white blood cell count was significantly higher in patients with bacterial meningitis (mean, 4839 cells/µL) compared to patients with aseptic meningitis (mean, 159 cells/µL, p < 0.001), with those with aseptic meningitis (mean, 577 cells/µL, p < 0.001) and with all non-bacterial meningitis cases together (p < 0.001). A cutoff value of 321 white blood cell/µL showed the best combination of sensitivity (80.6%) and specificity (81.4%) for the diagnosis of bacterial meningitis (area under receiver operating characteristic curve 0.837). Therefore, the value of cerebrospinal fluid white blood cell count was found to be a useful and rapid diagnostic test to distinguish between bacterial and nonbacterial meningitis in children.

Prediction of bacterial meningitis based on cerebrospinal fluid pleocytosis in children.

Children with cerebrospinal fluid pleocytosis are frequently treated with parenteral antibiotics, but only a few have bacterial meningitis. Although some clinical prediction rules, such as bacterial meningitis score, are of well-known value, the cerebrospinal fluid white blood cells count can be the initial available information. Our aim was to establish a cutoff point of cerebrospinal fluid white blood cell count that could distinguish bacterial from viral and aseptic meningitis. A retrospective study of children aged 29 days to 17 years who were admitted between January 1st and December 31th, 2009, with cerebrospinal fluid pleocytosis (white blood cell≥7µL(-1)) was conducted. The cases of traumatic lumbar puncture and of antibiotic treatment before lumbar puncture were excluded. There were 295 patients with cerebrospinal fluid pleocytosis, 60.3% females, medium age 5.0±4.3 years distributed as: 12.2% 1-3 months; 10.5% 3-12 months; 29.8% 12 months to 5 years; 47.5% >5 years. Thirty one children (10.5%) were diagnosed with bacterial meningitis, 156 (52.9%) viral meningitis and 108 (36.6%) aseptic meningitis. Bacterial meningitis was caused by Neisseria meningitidis (48.4%), Streptococcus pneumoniae (32.3%), other Streptococcus species (9.7%), and other agents (9.7%). cerebrospinal fluid white blood cell count was significantly higher in patients with bacterial meningitis (mean, 4839cells/µL) compared to patients with aseptic meningitis (mean, 159cells/µL, p<0.001), with those with aseptic meningitis (mean, 577cells/µL, p<0.001) and with all non-bacterial meningitis cases together (p<0.001). A cutoff value of 321white blood cell/µL showed the best combination of sensitivity (80.6%) and specificity (81.4%) for the diagnosis of bacterial meningitis (area under receiver operating characteristic curve 0.837). Therefore, the value of cerebrospinal fluid white blood cell count was found to be a useful and rapid diagnostic test to distinguish between bacterial and nonbacterial meningitis in children.

A 95-year-old woman with leucocytosis and eosinophilia: anaplastic carcinoma in an ectopic thyroid.

A 95-year-old woman had been treated over the past 8 years for progressive dysphagia. When her condition worsened, blood tests revealed the presence of leucocytosis and eosinophilia in the absence of anaemia or thrombocytopenia. Within 11 days of diagnosis, the patient died of respiratory failure. Necropsy showed normal thyroid tissue and an absence of infectious disease. However, an upper mediastinal tumour was found and was histopathologically diagnosed as a neoplastic transformation of the ectopic thyroid. Only 1% of endothoracic goitres present as ectopic or autonomous goitre with no parenchymal or vascular connection to the thyroid gland. This case represents a very rare situation in which a leukemoid reaction and peripheral hypereosinophilia were observed as a manifestation of an anaplastic thyroid carcinoma in an ectopic mass.

Infección urinaria en pediatría: relación entre clínica, paraclínica y gamagrafía renal / Urinary tract infection in children: relation between symptoms, lab work-up and renal scan

Objetivo: describir la relación entre hallazgos clínicos, laboratorio y gamagrafía renal estática (GR-DMSA) en pacientes pediátricos hospitalizados por infección del tracto urinario (ITU) en el Hospital de San José. Materiales y métodos: estudio descriptivo, de corte transversal. Se incluyeron 130 pacientes entre tres meses y 14 años de edad. Se tomó información de las historias clínicas revisando las variables: edad, género, fiebre, estado general, leucocitosis en hemograma, velocidad de sedimentación globular (VSG), proteína C reactiva, hipostenuria, nitritos y estearasas leucocitarias (EL) en uroanálisis, comparando cada una de ellas con el resultado de la GR-DMSA. Resultados: el 76% de los pacientes mostró pielonefritis con GR-DMSA. El 87,7% de éstos eran lactantes y preescolares y el 72% niñas. Se realizaron análisis bivariados utilizando como medida de asociación el riesgo relativo (RR) y como medida de la precisión el intervalo de confianza (IC) del 95%. Se encontró que los pacientes que presentan leucocitosis, aumento de la VSG y EL positivas tienen probabilidad 1,81 veces mayor de presentar pielonefritis. Conclusiones: si un paciente presenta leucocitosis, VSG elevada y EL positiva, no se recomienda realizar GR-DMSA, dado que la probabilidad que curse con pielonefritis es 81%. La sensibilidad de estos laboratorios es del 76% y la especificidad del 58%, comparada con la GR-DMSA.

Objective: to describe the relation between clinical symptoms, lab work-up and static renal scan (DMSA) in pediatric in-patients with urinary tract infection (UTI) at the San José Hospital. Materials and methods: a descriptive, cross-sectional study was undertaken. A total of 130 children aged 0.3 months to 14 years were enrolled in the study. Their clinical histories were reviewed considering the following variables: age, gender, fever, general status, leukocytosis (on CBC), erythrocyte sedimentation rate (ESR), C-reactive protein level, hypostenuria, nitrates and leukocyte stearates (LS) in urinalysis, comparing each of them with the DMSA renal scan results. Results: the DMSA revealed pyelonephritis in 76%. Infants and pre-school children accounted for 87.7% of the latter and 72% were females. A bivariable analysis was performed using relative risk (RR) as the measure of association and a confidence interval (CI) of 95% as the accuracy measure. It was found that patients with leukocytosis, increased ESR and positive LS had 1.81-fold greater odds of pyelonephritis. Conclusions: DMSA is not recommended in patients with leukocytosis, increased ESR and positive LS, for the odds of being associated with pyelonephritis is 81%. The sensitivity of lab work-ups was 76% and specificity was 58%, compared to the DMSA renal scan.

Routine laboratory investigations in infants and children presenting with fever and seizures at the University Hospital of the West Indies / Investigaciones de rutina en el laboratorio en relación con infantes y niños que se presentan con fiebre y convulsiones en el Hospital Universitario de West Indies

A retrospective chart review of the case notes of all children aged 6 months to 8 years presenting with fever and seizures to the University Hospital of the West Indies (UHWI) between January 2000 and December 2004 was conducted. Descriptive analyses were performed. Fifty-nine children (median age 1.58 years, range 0.58 to 6.83 years) were entered into the study. The main laboratory abnormalities were metabolic acidosis (23%), anaemia (10%), leukocytosis (35%) and hypomagnesaemia (3%). These were not significantly associated with meningitis or an underlying bacterial infection. There were no significant episodes of hyponatraemia, hypocalcaemia or hypoglycaemia. Meningitis was uncommon and occurred in only two (3.4%) children both younger than 16 months of age and who had other abnormal clinical signs. This study demonstrated that routine performance of haematological and biochemical investigations in children presenting with seizures and fever were of limited value. Lumbar punctures in children older than age 18 months with no other abnormal clinical signs were also found to be of low yield. Current American Academy of Paediatrics (AAP) recommendations that serum electrolytes, calcium, phosphate, magnesium, complete blood count and blood glucose should not be performed routinely in a child with a first simple febrile seizure can be safely applied to this study population.

Se llevó a cabo un estudio retrospectivo de las historias clínicas en busca de notas sobre los casos de todos los niños de 6 meses a 8 años de edad que se presentaron con fiebre y convulsiones en el Hospital Universitario de West Indies (HUWI) entre enero de 2000 y diciembre de 2004. Se realizaron análisis descriptivos. Cincuenta y nueve niños (edad mediana (1.58 años, rango 0.58 a 6.83 años) formaron parte de este estudio. Las principales anormalidades halladas mediante el laboratorio fueron: acidosis metabólica (23%), anemia (10%), leucocitosis (35%), e hipomagnesemia (3%). Éstas no estuvieron significativamente asociadas con meningitis o alguna infección bacteriana subyacente. No hubo episodios significativos de hiponatremia, hipocalcemia o hipoglicemia. La meningitis fue poco común, ocurriendo sólo en dos niños (3.4%), ambos con menos de 16 meses de edad y con otros signos clínicos anormales. Este estudio demostró que el trabajo de rutina realizado en las investigaciones hematológicas y bioquímicas en los niños que se presentaron con fiebre y convulsiones, tuvo un valor limitado. También se halló que las punciones lumbares realizadas a niños de más de 18 meses sin ningún otro signo clínico anormal, tuvieron poco valor. Las recomendaciones actuales de la Academia Americana de Pediatría (AAP) en cuanto a que las pruebas de electrolitos en suero, las mediciones de calcio, fosfato, magnesio, el conteo sanguíneo completo, y la prueba de glucosa en sangre, no deben ser realizadas rutinariamente en un niño con una primera simple convulsión febril, pueden ser aplicadas con seguridad a esta población bajo estudio.

Routine laboratory investigations in infants and children presenting with fever and seizures at the University Hospital of the West Indies.

A retrospective chart review of the case notes of all children aged 6 months to 8 years presenting with fever and seizures to the University Hospital of the West Indies (UHWI) between January 2000 and December 2004 was conducted. Descriptive analyses were performed. Fifty-nine children (median age 1.58 years, range 0.58 to 6.83 years) were entered into the study. The main laboratory abnormalities were metabolic acidosis (23%), anaemia (10%), leukocytosis (35%) and hypomagnesaemia (3%). These were not significantly associated with meningitis or an underlying bacterial infection. There were no significant episodes of hyponatraemia, hypocalcaemia or hypoglycaemia. Meningitis was uncommon and occurred in only two (3.4%) children both younger than 16 months of age and who had other abnormal clinical signs. This study demonstrated that routine performance of haematological and biochemical investigations in children presenting with seizures and fever were of limited value. Lumbar punctures in children older than age 18 months with no other abnormal clinical signs were also found to be of low yield Current American Academy of Paediatrics (AAP) recommendations that serum electrolytes, calcium, phosphate, magnesium, complete blood count and blood glucose should not be performed routinely in a child with a first simple febrile seizure can be safely applied to this study population.

Prevalence, hematology and serum biochemistry in stray dogs naturally infected by Hepatozoon canis in São Paulo / Prevalência, hematologia e bioquímica sérica em cães de rua naturalmente infectados por Hepatozoon canis, em São Paulo

Cães capturados nas ruas de quatro municípios do estado de São Paulo foram examinados para estudar a prevalência de Hepatozoon canis. Dos 222 animais, 13 (5.9 por cento) encontravam-se infectados. Exames hematológicos realizados em nove animais evidenciaram três com anemia e um com leucocitose. A única alteração encontrada nos exames bioquímicos foi hiperglobulinemia.

Prevalence, hematology and serum biochemistry in stray dogs naturally infected by Hepatozoon canis in São Paulo / Prevalência, hematologia e bioquímica sérica em cães de rua naturalmente infectados por Hepatozoon canis, em São Paulo

Cães capturados nas ruas de quatro municípios do estado de São Paulo foram examinados para estudar a prevalência de Hepatozoon canis. Dos 222 animais, 13 (5.9%) encontravam-se infectados. Exames hematológicos realizados em nove animais evidenciaram três com anemia e um com leucocitose. A única alteração encontrada nos exames bioquímicos foi hiperglobulinemia.(AU)

Urgencias oncológicas / Oncology urgency

Las urgencias oncológicas son un capítulo importante dentro de la oncología pediátrica y de especial interés, tanto para los médicos generales como pediatras, ya que éstas son causa de morbimortalidad en pacientes con cáncer y pueden estar presentes desde el momento del diagnóstico. Aunque existe una gran variedad de ellas, en este capítulo sólo abordaremos las de mayor frecuencia como son la lisis tumoral, muchas veces presente al momento del diagnóstico y que puede conducir a una insuficiencia renal; la hiperleucocitosis, que es capaz de producir enfermedad por lisis tumoral o por un síndrome de hiperviscosidad, que se manifiesta por complicaciones pulmonares y neurológicas, siendo la más grave de ellas la hemorragia intracraneala; finalmente revisaremos la urgencia oncológica más frecuente que es la neutropenia febril que es secundaria a la toxicidad por quimioterapia y que puede causar la muerte en estos pacientes.