[Pediatric brucellosis : A case report and literature review]. / Brucellose : revue de la littérature à propos d'un cas pédiatrique.

Brucellosis is an overlooked infection of widespread geographic distribution. This disease is rarely evoked when assessing unexplained pediatric fever, and only 20-30 cases (children and adults) are confirmed per year. Risk factors for contracting brucellosis are exposure to bodily fluids and consumption of unpasteurized dairy products from infected animals. Most cases of brucellosis are associated with traveling to or importing contaminated goods from endemic areas. Here, we report a case of brucellosis in a 16-month-old patient hospitalized for an acute febrile illness in a French general pediatric ward. An antibiotic regimen of rifampicin and co-trimoxazole given over 6 weeks led to successful cure without relapse. The child had eaten a cake made from unpasteurized goat's milk and imported from Oran, a region in Algeria. His mother had consumed the same cake and was hospitalized for brucellosis 15 days later. Clinicians should suspect brucellosis when encountering febrile patients who have traveled to endemic areas, been exposed to body fluids or products of abortion of farm animals, or consumed unpasteurized products.

[Pediatric exposures to laundry pods or capsules: more toxic than traditional laundry products?]. / Expositions des enfants aux lessives capsules, écodoses ou pods : plus toxiques que les lessives traditionnelles ?

UNLABELLED: New concentrated laundry pods, available on the European market for approximately 10 years, are associated with more severe intoxications compared to classic laundry detergents. AIM: To compare symptoms and severity after exposure to classic laundry detergents and new laundry pods in a pediatric population. MATERIAL AND METHODS: Retrospective study conducted between 1st January 2002 and 30th June 2013 including all laundry detergent exposure patients admitted to our tertiary level pediatric emergency unit. Collected data were age, sex, date, time and location of exposure, type of product (powder, liquid, tablets, pods), estimated ingested quantity, time of admission, clinical symptoms, severity, complications, and progression. RESULTS: Descriptive analysis: eighty-nine children were included. The mean age was 2.1 ± 1.5 years (range, 36 days to 10 years), 65% of patients were aged less than 2 years. The male:female ratio was 1.5 (males, 60%). After exposure, 57% of children were symptomatic and most frequently developed digestive symptoms (75%). Comparative analysis: compared to classic laundry detergent, children exposed to laundry pods were more symptomatic (96% versus 51%, P<0.0001), had more digestive signs (P=0.003), more frequently had bronchospasm (P=0.02), had a higher risk of ocular lesions (P=0.04), and exposure was more severe (poisoning severity score grade 2, 92% versus 59%, P<0.0001). COMMENTS: Laundry pod toxicity is more severe. The chemical composition of laundry pods has a higher concentration of surfactants and ethoxylated alcohols; they have a higher viscosity and hydrotropic power. The addition of water seems to modify the alkalinity, which explains the severity of ENT, gastric, and corneal lesions. CONCLUSION: The declaration to national poison centers of these intoxications should be pursued by emergency pediatricians, physicians, and pediatric intensivists. Family physicians can encourage parents to declare adverse effects to the National Consumer Product Safety Commission. Parents need to be better informed of the risk of laundry pods and strictly keep this type of product out of the reach of children. Given that it took 7 years after the first warning by the French poison centers to obtain safety recommendations for manufacturers, it is important to maintain pressure on companies to obtain the necessary modification of the physicochemical properties and child-resistant packaging.

[Home falls in infants before walking acquisition]. / Accidents domestiques par chute avant l'âge de la marche.

UNLABELLED: Minor head trauma is frequent among infants and leads to numerous visits to emergency departments for neurological assessment to evaluate the value of cerebral CT scan with the risk for traumatic brain injuries (TBI). OBJECTIVES: To analyze the epidemiological characteristics of nonwalking infants admitted after falling at home and to analyze associated factors for skull fractures and TBI. PATIENTS AND METHODS: Between January 2007 and December 2011, all children aged 9 months or younger and admitted after a home fall to the pediatric emergency unit of a tertiary children's hospital were included. The data collected were age, sex, weight and height, body mass index; geographic origin, referral or direct admission, mode of transportation; month, day and time of admission; causes of the fall, alleged fall height, presence of an eyewitness, type of landing surface; Glasgow Coma Scale (GCS) score, application of the head trauma protocol, location and type of injuries, cerebral CT scan results, length of hospital stay, progression, and neglect or abuse situations. RESULTS: DESCRIPTIVE ANALYSIS: within the study period, 1910 infants were included. Fifty-four percent of children were aged less than 6 months with a slight male prevalence (52%). Falls from parental bed and infant carriers accounted for the most frequent fall circumstances. GCS score on admission was equal to 14 or 15 in 99% of cases. A cerebral CT scan was performed in 34% of children and detected 104 skull fractures and 55 TBI. Infants aged less than 1 month had the highest rate of TBI (8.5%). Eleven percent of patients were hospitalized. A situation of abuse was identified in 51 infants (3%). UNIVARIATE ANALYSIS: Male children and infants aged less than 3 months had a higher risk of skull fractures (P = 0.03 and P = 0.0003, respectively). In the TBI group, children were younger (3.8 ± 2.6 months versus 5.4 ± 2.5 months, P < 0.0001), fell from a higher height (90.2 ± 29.5 cm versus 70.9 ± 28.7 cm, P < 0.0001), were more often admitted on a weekend or day off, and had more skull fractures (54% versus 6%, P < 0.001). MULTIVARIATE ANALYSIS: all variables showing P < 0.2 in the univariate analysis were entered into the model. In the final model, three variables continued to be associated with a risk of TBI: being referred by a physician (OR 4.6 [2.2-9.6], P < 0.0001), being younger than 3 months old (OR 3.1 [1.7-5.7], P = 0.0002), falling from a height greater than 90 cm (OR 3.1 [1.7-5.6], P = 0.0002). COMMENTS: Before walking acquisition, children are particularly vulnerable and have the highest rate of TBI after a vertical fall. In this age group, the rate of abuse is also higher. Given this double risk, numerous cerebral CT scans are performed (35-40% of the target population). This protocol, however, leads to a low proportion of detected TBI (<10%) compared to the high number of CT scans and an additional risk of irradiation. CONCLUSION: As no validated predictive score exists and pending the contribution of the S-100B protein assay, the identification of infants at high risk for TBI and justifying neuroimaging is based on the search for predisposing factors and circumstances.

[Analysis of neonate admissions to the pediatric emergency department]. / Fréquentation des urgences pédiatriques par les nouveau-nés.

UNLABELLED: Neonate admissions follow the general growing concern of emergency department use. OBJECTIVE: To analyze the epidemiological characteristics of a cohort of neonates admitted to a tertiary-level pediatric emergency department. MATERIAL AND METHODS: Prospective study conducted between August 2008 and April 2009 including all neonates aged 28 days or less admitted to the pediatric emergency department. The data collected for neonates were age, sex, premature or term birth, feeding mode, mode and reason of admission, time of admission, neonatal history, length of stay, and progression. For children admitted between August and October, any later consultations were analyzed during the following 6 months. The data collected for mothers were age, number of live births, living conditions, delivery mode, length of stay in the maternity ward, and occupation. RESULTS: Descriptive analysis: 538 neonates were included, the mean age was 17 days, the male:female ratio was 1.13. Twenty-nine children were premature (5.4%), 13% had previous conditions (jaundice, maternofetal infection, gastroesophageal reflux). Half the babies were formula-fed. Medical reasons were the most frequent (90%); 8% of children were admitted after a trauma. Almost ½ the neonates were hospitalized (47%). In the group of children followed for possible later consultations, 59 children were readmitted, totalling 103 consultations mainly for the same medical reason. The mothers' average age was 30 years, 53% were primiparae, and the mean length of stay in the maternity ward was 5 days. Comparative analysis: the neonate sex-ratio and prematurity rate were similar to those of the regional area. They differed from other admissions in their higher rate of nighttime consultations (18% versus 8%, P<0.001), physician referrals (23% versus 17%, P<0.001), and a higher rate of hospitalization (relative risk [RR] equal to 3.27 [3.01-3.54], P<0.001). The medical severity responded to the all or nothing principle: they were more often admitted for simple consultation (RR=1.31 [1.19-1.45], P<0.001), and for unstable conditions (RR=2.70 [2.36-3.07], P<0.001). A higher risk of emergency department use was noted if the mother was a first-time mother, young, living alone, and in a neighborhood near a hospital, with no occupation and the neonate aged less than 15 days. CONCLUSION: Initially associated with the reduction in the length of stay in the maternity ward, the increase of neonates' admissions to the pediatric emergency department is known to have several origins and is related to neonates' vulnerability or previous medical conditions, their familial environment, and sociological factors.

[Severe hydrogen sulfide intoxication: a pediatric case of survival]. / Intoxication accidentelle grave à l'hydrogène sulfuré: un cas pédiatrique de survie.

We report a paediatric case of survival following severe hydrogen sulfide (H2S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H2S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H2S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.

[Treatment and prognosis of idiopathic intracranial hypertension in children. Retrospective study (1995-2009) and literature review]. / Traitement et pronostic de l'hypertension intracrânienne idiopathique de l'enfant. Étude rétrospective (1995-2009) et revue de la littérature.

AIM: Idiopathic intracranial hypertension (IIH) may cause severe visual loss due to the optic nerve damage. Routine management involves mainly medical treatment. The aim of this study was to improve diagnosis and management of IIH in children. METHODS: The medical records of all patients with definite IIH seen at the children's hospital of Toulouse between 1995 and 2009 were reviewed. Cases of secondary intracranial hypertension were included because they did not present any cerebral lesions and underwent a similar therapeutic approach. The clinical and ophthalmological data at the beginning and at the end of their treatment was collected. RESULTS: Eighteen children were included in this study. The average age was 10 years and the sex-ratio was equal to 1. There were 3 cases of secondary idiopathic intracranial hypertension in this pediatric group. The main features encountered were headache (15 children) and diplopia (8 children). Abnormal neurological examination was found for 11 patients with abducens nerve paresis in 8 cases, rachialgia in 6 cases, and neurogenic pains (neuralgia, dysesthesia, paresthesia, hyperesthesia) in the other cases. Papilledema was noted in 16 patients. At the initial phase, loss of visual acuity was documented in 6 patients and altered visual field in nine patients. All patients had a medical treatment. When recurrence occurred, each new treatment was documented, for a total of 23 treatments analyzed. Lumbar puncture was the only treatment for 2 patients. In 16 cases, first-line treatment was acetazolamide and it was the second choice in 1 case, with an average dosage of 11.2mg/kg and a mean duration of 2.5 months (15 treatments could be analyzed). This treatment was effective in 11 cases out of 15. Steroids were the initial treatment in 4 cases and second-line treatment in 4 cases (after failed acetazolamide therapy). The dosage was 1.5-2mg/kg for a mean duration of 1.5 months (6 treatments could be analyzed). This treatment was effective in 5 patients out of 6. One patient had dual therapy. No surgical procedure was necessary in this pediatric cohort. Three patients presented relapses of IIH. The outcome was good with no residual visual impairment in the 13 patients analyzed. One patient was still under medication. COMMENTS: Therapeutic management of IIH in a pediatric population is essentially medical, in some cases limited to lumbar puncture. The first-line treatment is acetazolamide, but this study shows that low doses and short duration are usually chosen. Doses must be increased and treatment prolonged to avoid the use of corticosteroids as a second-line treatment and prevent possible relapses that require close monitoring of visual function. CONCLUSION: The visual prognosis is generally better for this age group compared to adults and no risk factors for visual sequelae were identified. A standardized protocol for management of IIH was proposed.

[Pediatric adder bites]. / Morsures de vipères chez l'enfant.

UNLABELLED: Adder bites and their progression to severe envenomations are more frequent in children than in adults. AIM: To describe the clinical, biological, and therapeutic characteristics of children bitten by adders and to identify risk factors associated with severe envenomations corresponding to grades II and III of the Audebert et al. classification (Toxicon 1992). MATERIAL AND METHODS: A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary children's hospital. The data collected were: age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity based on the Audebert et al. classification; presence of fang marks; prehospital care; use of specific immunotherapy (Viperfav(®)), associated treatments; length of stay; orientation, progression, and any complications. RESULTS: Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years (range, 1.8-15 years). Bites occurred more often between 12:00 pm and 6:00 pm (62%), and were most often located in the lower extremities (77%). The classification of envenomation was: 83% low grade (grade 0, absence of envenomation, fang marks present; grade I, minor envenomation) and 17% high grade (grades II and III, moderate and severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav(®) F(ab')(2) fragments against Vipera aspis, Vipera berus, and Vipera ammodytes). The mean time from bite to Viperfav(®) injection was 23 ± 11 h (range, 8-36 h). Being bitten on the upper extremities (p < 0.001), during the afternoon (p = 0.025), feeling an immediate violent pain (p = 0.037), and high initial glycemia (p = 0.016) were associated with a significant risk of progressing to high-grade envenomation. There was no significant correlation between age, gender, and upper extremity bite. In the final model of the multivariate statistical analysis, three factors remained associated with this risk: bite location in the upper extremities (relative risk [RR] = 60.5 [3.5-1040[; p = 0.005), immediate violent pain (RR = 21.5 [1.3-364.5[; p = 0.03), and female gender (RR = 17.5 [0.9-320.3[; p = 0.053). CONCLUSION: A certain number of criteria seem related with a more significant risk of progression to high-grade envenomation following an adder bite. These results need to be studied on a larger cohort of patients. Bites to the upper extremities should be handled with caution because of the association with more severe envenomation.