Lung ultrasound compared to chest X-ray for the diagnosis of CAP in children.

BACKGROUND: Community-acquired pneumonia (CAP) represents one of the most common infectious diseases among children. Diagnosis of CAP is mainly clinical. Chest X-ray (CXR) remains the gold standard for the diagnosis in severe or controversial conditions. Recently, some authors have focused on the application of ultrasound in lung diseases but the role of lung ultrasound (LUS) in the diagnosis of CAP is still debated. We aimed to study the concordance between LUS and CXR in evaluating specific signs of CAP. As a secondary aim, we sought to determine the sensitivity and specificity of LUS in CAP diagnosis compared with CXR. Finally, we evaluated the role of LUS during the follow up. METHODS: We enrolled 68 children (<16 years old) hospitalized from October 2018 to September 2019 with a clinical and radiological diagnosis of CAP (cases: N = 41), or with no respiratory diseases (controls: N = 27), in whom a CXR was performed for clinical indications. All the children underwent LUS during hospitalization. The average time needed to perform LUS was 5-10 min for each child, and 19/41 cases were re-evaluated by LUS and CXR 30 days after discharge. RESULTS: Lung ultrasound confirmed CAP diagnosis in 40/41 patients. Concordance between the two techniques was K = 0.88 for the right lung and K = 0.70 for the left lung. Lung ultrasound showed a sensitivity of 97% and a specificity of 96% compared with CXR. At the follow up, sensitivity increased to 100% while specificity was 94%. CONCLUSIONS: Our study showed a potential benefit of LUS compared with CXR in the diagnosis and the follow up of CAP.

Lung ultrasound in bronchiolitis.

BACKGROUND: Bronchiolitis is the most common acute viral infection of the lower respiratory tract in infants. Clinical severity is associated with different risk factors; however, no clinical, laboratory, or radiological findings are able to predict the course of the disease in full-term infants. Lung ultrasound (LUS) is a valid technique for the diagnosis and evaluation of pediatric respiratory diseases. AIMS: The aim of our study was to correlate an LUS score with a clinical score, to describe lung ultrasound findings in cases and controls, and to compare LUS findings with chest X-ray (CXR) in infants hospitalized with bronchiolitis. METHODS: We conducted a single-center, longitudinal, prospective study on 92 infants. Sixty-three out of 92 infants were hospitalized for acute bronchiolitis (cases) and twenty-nine out of 92 for diseases not involving the respiratory system (controls). All patients with bronchiolitis underwent a clinical evaluation with the assignment of a clinical severity score and performed lung ultrasound with the assignment of an LUS score. Twenty-three out of 63 infants with bronchiolitis underwent also a CXR for clinical indications. Control infants performed only LUS. RESULTS: In infants with bronchiolitis LUS score showed a positive correlation with the clinical score (r = .62, p < .001) and the length of hospitalization (r = .42; p < .001). The need of oxygen therapy was more frequent in the patients with higher LUS score (p < .001). LUS findings observed in the cases were the presence of B-lines, subpleural consolidations, and abnormalities of the pleural line. No LUS alterations were observed in the controls. In patients who performed LUS and CXR, we found a correlation between the presence of abnormalities of the pleural line with LUS and the presence of air trapping with CXR (r = .55; p = .007).

Evaluation of Allergic Diseases, Symptom Control, and Relation to Infections in a Group of Italian Elite Mountain Bikers.

OBJECTIVES: This study estimates the prevalence of allergic diseases in a group of Italian elite mountain bikers, compares the prevalence of infectious episodes between allergic and nonallergic athletes, and evaluates asthma and rhinitis symptom control in allergic athletes. DESIGN: Two hundred twenty-six Italian nonsmoking mountain bikers received by mail the Allergy Questionnaire for Athletes (AQUA) and completed it. The RhinAsthma Patient Perspective (RAPP) questionnaire was sent to the 108 participants with a positive AQUA score and 104 returned the questionnaire. METHODS: Athletes with an AQUA score ≥5 or <5 were defined AQUA+ (allergic) or AQUA- (nonallergic), respectively. RhinAsthma Patient Perspective questionnaire total score ≥15 was indicative of a poor control of symptoms. RESULTS: Of the 226 athletes, 47.8% were AQUA+, whereas 52.2% were AQUA-. A higher number of AQUA+ athletes reported frequent upper respiratory tract infections (URTIs) and herpes labialis than AQUA- athletes (P < 0.001), and the prevalence of URTI was greater in the subgroup of AQUA+ athletes who trained ≥3 hours per session. According to RAPP questionnaire score, 21.1% of AQUA+ mountain bikers had a poor control of asthma and rhinitis symptoms. CONCLUSIONS: Our study shows a high prevalence of allergy among Italian elite mountain bikers whose asthma and rhinitis symptoms are poorly controlled in about a fifth of the sample. Allergic athletes, mainly those training more than 3 hours per session, are at higher risk of URTI and herpes labialis. Screening programs to detect allergic diseases and to evaluate symptom control in athletes should be strongly encouraged.

Staphylococcus Aureus in chronic airway diseases: An overview.

This review investigates about the role of Staphylococcus Aureus (S. aureus) and S. aureus enterotoxins (SEs) in the pathogenesis of several chronic airway diseases. S. aureus is part of normal human flora and may colonize the skin and the upper airways. SEs acting as superantigens can induce an intense T cell activation and through the release of interleukin (IL) - 4, 5, and 13, can promote a polyclonal IgE response and eosinophilic inflammation. S. aureus can damage epithelial cells inducing the release of the so-called "alarmins" responsible of the activation of Type 2 innate lymphoid cells (ILC-2) linked to an IL-5 mediated airway eosinophilic inflammation. SEs sensitization has been recently associated with the eosinophilic endotypes of both nasal polyps and late onset severe asthma. Studies investigating the effect of biological therapies in SEs sensitized patients should be performed in order to better define the role played by S. aureus in the different endotypes of severe asthma and/or chronic rhinosinusitis.

Pertussis: New preventive strategies for an old disease.

In the last twenty years, despite high vaccination coverage, epidemics of pertussis are occurring in both developing and developed countries. Many reasons could explain the pertussis resurgence: the increasing awareness of the disease, the availability of new diagnostic tests with higher sensitivity, the emergence of new Bordetella pertussis (B. pertussis) strains different from those contained in the current vaccines, the asymptomatic transmission of B. pertussis in adolescents and adults and the shorter duration of protection given by the acellular pertussis (aP) vaccine. New preventive strategies have already been implemented, such as booster doses of aP vaccine in adolescents and adults, maternal immunisation during pregnancy and the "cocooning" strategy, but more are still needed. Knowing what is new about this old disease is necessary to reduce its incidence and to protect infants too young to be vaccinated, which have the highest risk of complications and death.

Modifiable risk factors associated with bronchiolitis.

BACKGROUND: We sought to clarify possibly modifiable risk factors related to pollution responsible for acute bronchiolitis in hospitalized infants. METHODS: For this observational study, we recruited 213 consecutive infants with bronchiolitis (cases: median age: 2 months; age range: 0.5-12 months; boys: 55.4%) and 213 children aged <3 years (controls: median age: 12 months; age range: 0.5-36 months; boys: 54.5%) with a negative medical history for lower respiratory tract diseases hospitalized at 'Sapienza' University Rome and IRCCS Bambino Gesù Hospital. Infants' parents completed a standardized 53-item questionnaire seeking information on social-demographic and clinical characteristics, indoor pollution, eating habits and outdoor air pollution. Multivariate logistic regression analyses were run to assess the independent effect of risk factors, accounting for confounders and effect modifiers. RESULTS: In the 213 hospitalized infants the questionnaire identified the following risk factors for acute bronchiolitis: breastfeeding ⩾3 months (OR: 2.1, 95% confidence interval [CI]: 1.2-3.6), presence of older siblings (OR: 2.8, 95% CI: 1.7-4.7), ⩾4 cohabitants (OR: 1.5, 95% CI: 1.1-2.1), and using seed oil for cooking (OR: 1.7, 95% CI: 1.2-2.6). Having renovated their home in the past 12 months and concurrently being exposed daily to smoking, involving more than 11 cigarettes and two or more smoking cohabitants, were more frequent factors in cases than in controls ( p = 0.021 and 0.05), whereas self-estimated proximity to road and traffic was similar in the two groups. CONCLUSIONS: We identified several risk factors for acute bronchiolitis related to indoor and outdoor pollution, including inhaling cooking oil fumes. Having this information would help public health authorities draw up effective preventive measures - for example, teach mothers to avoid handling their child when they have a cold and eliminate exposure to second-hand tobacco smoke.

Respiratory syncytial virus bronchiolitis, weather conditions and air pollution in an Italian urban area: An observational study.

BACKGROUND: In this study we sought to evaluate the association between viral bronchiolitis, weather conditions, and air pollution in an urban area in Italy. METHODS: We included infants hospitalized for acute bronchiolitis from 2004 to 2014. All infants underwent a nasal washing for virus detection. A regional agency network collected meteorological data (mean temperature, relative humidity and wind velocity) and the following air pollutants: sulfur dioxide, nitrogen oxide, carbon monoxide, ozone, benzene and suspended particulate matter measuring less than 10µm (PM10) and less than 2.5µm (PM2.5) in aerodynamic diameter. We obtained mean weekly concentration data for the day of admission, from the urban background monitoring sites nearest to each child's home address. Overdispersed Poisson regression model was fitted and adjusted for seasonality of the respiratory syncytial virus (RSV) infection, to evaluate the impact of individual characteristics and environmental factors on the probability of a being positive RSV. RESULTS: Of the 723 nasal washings from the infants enrolled, 266 (68%) contained RSV, 63 (16.1%) rhinovirus, 26 (6.6%) human bocavirus, 20 (5.1%) human metapneumovirus, and 16 (2.2%) other viruses. The number of RSV-positive infants correlated negatively with temperature (p < 0.001), and positively with relative humidity (p < 0.001). Air pollutant concentrations differed significantly during the peak RSV months and the other months. Benzene concentration was independently associated with RSV incidence (p = 0.0124). CONCLUSIONS: Seasonal weather conditions and concentration of air pollutants seem to influence RSV-related bronchiolitis epidemics in an Italian urban area.

Intratracheal Thyroid: A Different Approach.

During embryonic development, the abnormal migration of thyroid tissue may cause ectopic localization of the gland in the intralaryngotracheal space. This case report describes the management of a young patient with a recent diagnosis of asthma. During bronchoscopy, a large mass occupying the tracheal lumen was discovered. After tracheotomy to protect the airway, an incisional biopsy was performed and revealed an intratracheal ectopic thyroid. The deep incisions through the tracheotomy to the base of the lesion allowed colloidal content to leak out of the mass until complete resolution of airway obstruction. Fifteen days later the patient was released totally rehabilitated.

Parents as source of pertussis transmission in hospitalized young infants.

PURPOSE: This study was planned to collect evidences of familial pertussis transmission to infants younger than 6 months of age. Understanding the dynamics of transmission of pertussis in families is essential to plan effective prevention strategies that could be integrated in pertussis control. METHODS: The seroprevalence of IgG antibodies to pertussis toxin (PT-IgG) and prolonged cough symptoms were evaluated in parents of 55 infants aged <6 months hospitalized for confirmed pertussis. Parents of 33 infants with lower respiratory tract infection (LRTI) and parents of 57 healthy infants admitted as outpatients for hip ultrasound examination (HE) were enrolled as controls. RESULTS: Parents of pertussis cases had PT-IgG levels significantly higher as compared to LRTI and HE parents. More than 40 % were compatible as transmitters of pertussis to their babies, since they had a level of PT-IgG ≥ 100 IU/ml, which is considered diagnostic for a recent pertussis episode. Based on serology, the percentage of pertussis cases that had at least one parent as source of infection was 49.1 %. When cough symptoms were taken into account, the percentage of parents putative transmitters of the infection to their infants increased to 56.4 %. CONCLUSIONS: Parents are scarcely aware of the household transmission of pertussis to their newborns. Our study highlights the need to advise parents about the likelihood of transmission to the newborn and to be particularly aware of coughing symptoms in the household. Since infection can be asymptomatic, a serological survey of family members should also be considered.

Risk Factors for Virus-induced Acute Respiratory Tract Infections in Children Younger Than 3 Years and Recurrent Wheezing at 36 Months Follow-Up After Discharge.

BACKGROUND: We sought to know more about how 14 common respiratory viruses manifest clinically, and to identify risk factors for specific virus-induced acute respiratory tract infections (ARTIs) in children younger than 3 years old and for wheezing at 36-month follow-up. METHODS: We retrospectively studied the clinical records for 273 full-term children (median age, 2.9 months; range, 0.26-39; boys, 61.2%) hospitalized for ARTIs, whose nasopharyngeal specimen tested positive for a respiratory virus and 101 children with no history of respiratory diseases (median age, 8 months; range, 0.5-36.5; boys, 58.4%). At 12, 24 and 36 months after children's discharge, all parents were interviewed by telephone with a structured questionnaire on wheezing episodes. RESULTS: The most frequently detected viruses were respiratory syncytial virus in bronchiolitis, human rhinovirus in pneumonia and human bocavirus in wheezing. Multivariate analysis identified, as risk factors for virus-induced ARTIs, the presence of siblings [odds ratio (OR): 3.0 (95% confidence interval [CI]: 1.8-5.2)], smoking cohabitants (OR: 2.3 (95% CI: 2-4.2)] and breastfeeding lasting less than 3 months [OR: 0.5 (95% CI: 0.3-0.9)]. The major risk factor for respiratory syncytial virus-induced ARTIs was exposure to tobacco smoke [OR: 1.8 (95% CI: 1.1-3.2)]. Risk factors for human rhinovirus-induced ARTIs were attending day-care [OR: 5.0 (95% CI: 2.3-10.6)] and high eosinophil blood counts [OR: 2.6 (95% CI: 1.2-5.7)]. The leading risk factor for recurrent wheezing was exposure to tobacco smoke [OR: 2.5 (95% CI: 1.1-15.6)]. CONCLUSIONS: Each respiratory virus leads to a specific clinical manifestation. Avoiding exposing children to tobacco smoke might restrict viral spread from sick parents and siblings to younger children, prevent severe respiratory diseases, and possibly limit sequelae.

Bronchiolitis: Analysis of 10 consecutive epidemic seasons.

Bronchiolitis is the leading cause of hospitalization in infants under 12 months. Our aims were to analyze epidemiological characteristics of infants with bronchiolitis over 10 consecutive seasons and to evaluate whether there are any clinical differences between infants hospitalized for bronchiolitis during epidemic peak months and infants in non-peak months. We enrolled consecutive enrolled 723 previously healthy term infants hospitalized at the Paediatric Emergency Department, "Sapienza" University of Rome over the period 2004-2014. Fourteen respiratory viruses were detected from nasopharyngeal aspirates by molecular methods. Clinical and demographic data were extracted from clinical charts. Viruses were detected in 351 infants (48.5%): RSV in 234 (32.4%), RV in 44 (6.1%), hBoV in 11 (1.5%), hMPV in 12 (1.6%), co-infections in 39 (5.4%), and other viruses in 11 (1.5%). Analyzing the 10 epidemic seasons, we found higher incidence for bronchiolitis every 4 years with a peak during the months December-January. Infants hospitalized during peak months had lower family history for asthma (P = 0.003), more smoking mothers during pregnancy (P = 0.036), were slightly higher breastfed (0.056), had lower number of blood eosinophils (P = 0.015) and had a higher clinical severity score (P = 0.017). RSV was detected mostly during peak months, while RV was equally distributed during the seasons. We found some variations in bronchiolitis incidence during epidemics, and discriminative characteristics in infants hospitalized for bronchiolitis during peak months and in non-peak months, that might reflect two different populations of children. Pediatr Pulmonol. 2016;51:1330-1335. © 2016 Wiley Periodicals, Inc.

Viral Load in Infants Hospitalized for Respiratory Syncytial Virus Bronchiolitis Correlates with Recurrent Wheezing at Thirty-Six-Month Follow-Up.

The relationship between viral infection, host immune response in infants with respiratory syncytial virus (RSV) bronchiolitis and subsequent wheezing is discussed. We measured RSV-RNA load and interferon-λ1-3 expression in the nasopharyngeal washings from 68 infants hospitalized for RSV bronchiolitis, and wheezing was assessed 36 months after the first episode of bronchiolitis. Higher RSV-RNA load and higher interferon-λ2/3 levels were found in children with recurrent wheezing at 36-month follow-up.

Recurrent wheezing 36 months after bronchiolitis is associated with rhinovirus infections and blood eosinophilia.

AIM: Links between respiratory syncytial virus bronchiolitis and asthma are well known, but few studies have dealt with wheezing following bronchiolitis induced by other viruses. We assessed the risk factors for recurrent wheezing in infants hospitalised for acute viral bronchiolitis. METHODS: We followed 313 infants for three years after they were hospitalised for bronchiolitis, caused by 14 different viruses, to identify risk factors for recurrent wheezing. Parents provided feedback on wheezing episodes during telephone interviews 12 (n = 266), 24 (n = 242) and 36 (n = 230) months after hospitalisation. RESULTS: The frequency of wheezing episodes diminished during the follow-up period: 137 children (51.7%) at 12 months, 117 (48.3%) at 24 months and 93 (40.4%) at 36 months. The risk of wheeze after three years was OR = 7.2 (95% CI 3.9-13.3) if they had episodes of wheezing during the first year after bronchiolitis, 16.8 (8.7-32.7) if they had episodes of wheezing during the second year and 55.0 (22.7-133.2) if they wheezed during both years. Blood eosinophils >400 cells/µL (OR 7.7; CI 1.4-41.8) and rhinovirus infections (3.1; 1.0-9.4) were the major risk factors for recurrent wheezing. CONCLUSION: Recurrent wheezing 36 months after infant bronchiolitis was associated with rhinoviruses and blood eosinophilia.

Seven percent hypertonic saline--0.1% hyaluronic acid in infants with mild-to-moderate bronchiolitis.

OBJECTIVES: Our study was aimed to evaluate the efficacy of 7% hypertonic saline and 0.1% hyaluronic acid (7% HS-HA) given by inhalation, in infants hospitalized for mild-to-moderate bronchiolitis. METHODS: In a double-blind controlled study, 39 infants (23 boys) <7 months of age (median age 2 months) were enrolled and randomly assigned to receive either nebulized 7% HS-HA (7%NaCl + 0.1%HA) (n:21) or 0.9 normal saline (NS) (n:18) at a dose of 2.5 ml twice a day for 3 days. All infants were assigned a clinical severity score at admission and four times daily during hospitalization. Main outcome measures were number of days hospitalization, safety and daily reduction in the severity score. RESULTS: No difference was found between the two groups for clinical severity score at admission. One child in the study group and two in the NS group interrupted the study protocol; 19% of infants in the study group and 11% in the NS group had mild cough after the aerosol. The length of stay in the control group and treatment groups were 4.8 ± 1.5 versus 4.1 ± 1.9 days, respectively (P = 0.09). There was a trend for shortening the hospitalization days in the treatment group by 14.6%. The use of NS in the control group was identified as an independent risk factor for length of hospital stay using the multivariate logistic regression model (P = 0.04). No difference was observed between the two groups for the clinical score reduction during the first 3 days hospitalization. CONCLUSIONS: 7% HS-HA is a safe and effective therapy in treating infants hospitalized for mild-to-moderate bronchiolitis.

Interferon lambda 1-3 expression in infants hospitalized for RSV or HRV associated bronchiolitis.

OBJECTIVES: The airway expression of type III interferons (IFNs) was evaluated in infants hospitalized for respiratory syncytial virus (RSV) or rhinovirus (HRV) bronchiolitis. As an additional objective we sought to determine whether a different expression of IFN lambda 1-3 was associated with different harboring viruses, the clinical course of bronchiolitis or with the levels of well established IFN stimulated genes (ISGs), such as mixovirus resistance A (MxA) and ISG56. METHODS: The analysis was undertaken in 118 infants with RSV or HRV bronchiolitis. Nasopharyngeal washes were collected for virological studies and molecular analysis of type III IFN responses. RESULTS: RSV elicited higher levels of IFN lambda subtypes when compared with HRV. A similar expression of type III IFN was found in RSVA or RSVB infected infants and in those infected with HRVA or HRVC viruses. Results also indicate that IFN lambda 1 and IFN lambda 2-3 levels were correlated with each other and with MxA and ISG56-mRNAs. In addition, a positive correlation exists between the IFN lambda1 levels and the clinical score index during RSV infection. In particular, higher IFN lambda 1 levels are associated to an increase of respiratory rate. CONCLUSIONS: These findings show that differences in the IFN lambda 1-3 levels in infants with RSV or HRV infections are present and that the expression of IFN lambda 1 correlates with the severity of RSV bronchiolitis.

Bordetella pertussis in infants hospitalized for acute respiratory symptoms remains a concern.

BACKGROUND: Preliminary results suggest that pertussis infection might be considered in infants during a seasonal respiratory syncytial virus (RSV) outbreak. METHODS: In order to analyze clinical features and laboratory findings in infants with pertussis hospitalized for acute respiratory symptoms during a seasonal RSV outbreak, we conducted a retrospective single-center study on 19 infants with pertussis (6 boys; median age 72 days) and 19 matched controls (RSV-bronchiolitis), hospitalized from October 2008 to April 2010. B. pertussis and RSV were detected from nasopharyngeal washes with Real Time-PCR. RESULTS: Infants with pertussis were less often breastfeed than infants with RSV bronchiolitis (63.2% vs 89.5%; p <0.06). Clinically, significantly fewer infants with pertussis than controls had more episodes of whooping cough (63.2% vs 0.0%; p < 0.001) and also less frequently fever at admission (15.8% vs 68.4%; p <0.01), apnea (52.6% vs 10.5%; p <0.006), and cyanosis (52.6% vs 10.5%; p < 0.006). Infants with pertussis had more often no abnormal chest sounds on auscultation than infants with RSV bronchiolitis (0% vs 42,1%; p < 0.005). The absolute blood lymphocyte and eosinophil counts were higher in infants with B. pertussis than in controls with bronchiolitis (23886 ± 16945 vs 10725 ± 4126 cells/mm(3), p < 0.0001 and 13.653 ± 10.430 vs 4.730 ± 2.400 cells/mm(3), p < 0.001). The molecular analysis of 2 B. pertussis isolates for ptxA1, ptxP3, and prn2 genes showed the presence of gene variants. CONCLUSIONS: When infants are hospitalized for acute respiratory symptoms, physicians should suspect a pertussis infection, seek for specific clinical symptoms, investigate lymphocyte and eosinophil counts and thus diagnose infection early enough to allow treatment.