Invasive aspergillosis and allogeneic hematopoietic stem cell transplantation in children: a 15-year experience.

Despite progress in diagnosis and treatment, invasive aspergillosis (IA) remains a principal cause of mortality due to infection after allogeneic hematopoietic stem cell transplantation (AHSCT). In order to clarify the course of IA among children receiving an AHSCT before the advent of new drugs such as voriconazole or caspofungin, we retrospectively reviewed the medical records of all proven and probable IA between January 1986 and December 2000. 1) Ten children developed IA after AHSCT, mostly long after transplantation. Overall incidence was 2.7%. Seven of those children experienced 1 or more complications after AHSCT and before IA. Mortality was 90% with a median survival of 23 days (2-90). 2) Five children underwent AHSCT after a previous episode of IA. All patients were treated with systemic antifungal therapy combined with surgery. Median time between IA and AHSCT was 110 days (73-370). Two children were diagnosed with IA relapse after transplantation. One child was cured while the other died of IA and AHSCT complications. AHSCT could be considered even in the setting of previous IA, but established strategies implementing newer less toxic antifungal agents as treatment or prophylaxis in high-risk patients are needed.

Rat bite fever caused by Streptobacillus moniliformis in a child: human infection and rat carriage diagnosed by PCR.

A child owning pet rats developed an eruptive fever with blisters, polyarthritis, and spectacular desquamation of the hands. Streptobacillus moniliformis was identified after culture of the child's blister fluid and was detected in rat samples by molecular methods. Such detection in the pet of a human victim of rat bite fever has not been reported previously.

Antileukemic and long-term effects of two regimens with or without TBI in allogeneic bone marrow transplantation for childhood acute lymphoblastic leukemia.

Between September 1986 and June 1997, 24 children with high-risk ALL in CR1 were allografted after TAM (fractionated TBI, high-dose Ara-C, and melphalan; n = 10) or BAM protocol (busulfan, high-dose Ara-C, and melphalan; n = 14). The EFS for transplants from sibling donors was 33% with TAM and 62% with BAM (P = 0.148). The probability of acute GvHD was 70% with TAM and 15% with BAM (P = 0.003). Four of 17 evaluable patients relapsed: one after TAM and three after BAM. In all, 46 other children transplanted in CR beyond CR1 were studied for sequelae. Long-term side effects were more frequent in TAM vs BAM. In children with ALL, busulfan may be a good alternative to TBI to improve the quality of life.

Assessment of acyclovir intraindividual pharmacokinetic variability during continuous hemofiltration, continuous hemodiafiltration, and continuous hemodialysis.

The use of intravenous acyclovir can be particularly complicated in pediatric patients with evolving renal impairment, because of intraindividual pharmacokinetic variability linked to the patient's clinical condition. The objective of this study was to use therapeutic drug monitoring data to assess acyclovir intraindividual pharmacokinetic variability during several types of renal replacement therapy. Bayesian adaptive control of acyclovir dosage regimen was performed in a pediatric patient with bone marrow transplant who developed severe renal impairment. Acyclovir pharmacokinetic parameter values corresponding to the different techniques and periods of renal replacement therapy were estimated using USCPACK PC Clinical Programs and therapeutic drug monitoring data. Results showed a wide intraindividual pharmacokinetic variability during CAVH, CAVHDF, and CVVHD, reflecting not only the performance of each dialysis technique but also the difficulty in making use of each one. The acyclovir elimination rate constant was higher during CVVHD compared to CAVH or CAVHDF. Bayesian method appears to be valuable in assessing intraindividual pharmacokinetic variability, as it allows the clinician to deal with sparse routine patient data.

[Tetraparesis in an infant after prolonged administration of pancuronium]. / Tétraparésie chez un nourrisson après administration prolongée de pancuronium.

Long-term administration of pancuronium for ventilatory support of adults with ARDS may result in severe tetraparesis, with areflexia and atrophy of distal muscles. This adverse effect occurs rarely in paediatric intensive care units. We describe a case of tetraparesis after prolonged pancuronium infusion in a 9-month-old girl who experienced a severe bronchopneumonia caused by para-influenza virus, requiring endotracheal intubation and mechanical ventilation. To decrease chest wall rigidity, pancuronium was administered over 11 days, with a total dose of approximately 120 mg of pancuronium bromide. The day after discontinuation of the muscle relaxant she had a severe tetraplegia with areflexia, but normal head movements. Electromyography showed a normal neuromuscular transmission. She recovered from tetraplegia three months later. Other causes of peripheral neuropathy were eliminated. Electroencephalograms and head CT-scans were normal. The recovery pattern observed in our patient corresponded to the process of regeneration seen after axonal degeneration. It is suggested that these neuromuscular complications were caused by prolonged high-dosage pancuronium treatment, associated with corticosteroid and aminoglycoside administration.

[A rare cause of hyponatremia during introductory treatment of acute lymphoblastic leukemia in an infant: inappropriate secretion of atrial natriuretic factor?]. / Une cause rare d'hyponatrémie lors du traitement d'induction d'une leucémie aiguë lymphoblastique chez un nourrisson: la sécrétion inappropriée de facteur atrial natriurétique?

BACKGROUND: --Hyponatremia is frequently seen during the treatment of acute lymphoblastic leukemia: its causes are numerous. This work aims to present a case in whom hyponatremia was possibly due to an increased secretion of atrial natriuretic factor. CASE REPORT: --A 3 week-old baby was admitted because of malignant hemopathy. A diagnosis of acute lymphoblastic leukemia was rapidly made and the patient was firstly given alkaline diuresis, urate-oxidase and corticosteroids. Vincristine and daunorubicin were associated one week later. Insertion of a central intravenous line in the right subclavicular artery failed so that this catheter was finally inserted into the left jugular vein. Natremia was 126 mmol/l at that time and dramatically decreased within 24 hours to 109 mmol/l without net changes in water and electrolytic input. At that time, sodium urinary excretion was 6 mmol/kg/day (diuresis: 420 mlF/day). There was no hemodynamic changes, nor digestive or cardiac manifestations. Ultrasonography showed that the left superior cava vein drained into the right cardiac atrium. The catheter was withdrawn and the patient was given sodium supplementation permitting complete and definitive cure of hyponatremia within 2 days. CONCLUSIONS: --All usual causes of hyponatremia having been ruled out in this patient, we postulate that hyponatremia was due to direct stimulation of atrial natriuretic peptide through an increase in atrial pressure secondary to the catheter insertion near the cardiac atrium.

[Colchicine poisoning apropos of a pediatric case]. / Intoxication à la colchicine à propos d'un cas pédiatrique.

Colchicine has been widely used in the treatment of gout and familial mediterranean fever. Overdose is rare mostly in childhood. Colchicine overdose always causes gastrointestinal side effects, bone marrow depression and sometimes neuropathy. The mechanism of colchicine upon the microtubules, provides a better understanding of the pharmacology and also of the multiorgan involvement. We report the case of a ten year old child who ingested 0.6 mg/kg colchicine with a good outcome.

Otoacoustic emissions and brainstem auditory evoked potentials in children with neurological afflictions.

Findings are reported for evoked otoacoustic emissions (EOAEs) recorded from 22 children with neurological afflictions, whose brainstem auditory evoked potentials (BAEPs) were pathological on at least one side (41 ears explored). Our results confirmed that EOAEs are always present in children and infants having normal BAEPs. Absence of EOAE (n = 22) was almost always related to middle ear or cochlear damage with BAEPs indicating diagnoses, respectively, of transmission damage (n = 7) or endocochlear damage (n = 16). Conversely, for BAEP diagnoses of retrocochlear damage (n = 12), EOAEs were always present. EOAEs associated with BAEPs, therefore, appear to offer a well-adapted technique for precise etiological diagnosis of childhood hearing loss. When no wave is identifiable by BAEP recording, EOAE presence indicates retrocochlear damage.

[Multiple acyl-CoA dehydrogenase deficiency. Report of 2 siblings]. / Déficit multiple en acyl-CoA déshydrogénase. Deux cas dans une même fratrie.

The authors report on two siblings with a multiple acyl-CoA dehydrogenase deficiency. The first child died from a Reye's syndrome when he was 9 month-old. The diagnosis was made in the neonatal period in his brother. Early treatment with glucose and carnitine should prevent acute attacks.

[Diffuse alveolar pertussis with major hyperleukocytosis with "pseudocentrocytic" contingent]. / Pneumocoqueluche alvéolaire diffuse avec hyperleucocytose majeure à contingent "pseudocentrocytique".

A 21 month-old unvaccinated boy was admitted for an acute respiratory distress episode associated with major leukocytosis (maximum = 146 G/l). Transient heart failure and pneumomediastinum occurred but the outcome was favourable. Coughing attacks then occurred and the diagnosis of pertussis was serologically confirmed. This case report is reminiscent of the possible severity of pertussis pneumoniae, the mechanisms of haematologic abnormalities, and stresses to the benefit of pertussis vaccination.

[Results and complications of induction treatment of acute leukemia in children. A personal series of 79 cases (1988-1989)]. / Résultats et complications des traitements d'induction des leucémies aiguës de l'enfant. Série personnelle de 79 cas (1988-1989).

In 1988 and 1989, 79 children have been treated for induction of acute leukemia. 68 presented an acute lymphoblastic leukemia (ALL) and 11 an acute non-lymphoblastic leukemia (ANLL). The complete remission rate was 92% (96% in ALL, 73% in ANLL). Fever occurred in 50% of the children, with positive blood cultures in 11 of them. One child died from streptococcal sepsis. No metabolic disorder was noted. Four patients were transferred into the intensive care unit. After 8 days, the treatment of ALL was continued in the outpatient clinic in more than 50% of the cases. The treatment of ANLL is frequently complicated by hemorrhages and sepsis and needs adapted supportive care in a specialized unit.

Acute renal failure in a child after chewing of match heads.

A few days after ingestion of 40 match heads, a 3-year-old boy was admitted to hospital with oliguric acute renal failure (ARF) requiring peritoneal dialysis during 9 days. A renal biopsy showed acute tubulointerstitial nephritis; the outcome was rapidly favorable and the child recovered normal GFR. It seems to be the first published case of ARF after match poisoning, probably because of the presence of potassium bichromate.

[Nephrocalcinosis and pancreatic calcification after ablation of adrenal adenoma: the role of hypercortisolism?]. / Néphrocalcinose et calcifications pancréatiques aprés ablation d'un adénome surrénalien: rôle de l'hypercortisolisme?

Renal and pancreatic calcifications were observed in an infant who had been surgically treated for Cushing's syndrome associated with an adrenal adenoma. On examination of the relation between this secondary complication and Cushing's syndrome, was carried out and the possible role of the post-operative substitutive treatment is discussed. Close echographic surveillance is advocated in these cases.

Intracranial pressure in childhood central nervous system infections.

To determinate the importance of intracranial hypertension in central nervous system (CNS) acute infections, we studied intracranial pressure (ICP) in 27 patients, age 45 days to 13 years. Fourteen had meningitis and 13 had encephalitis; all were in deep coma with Glasgow Coma Scale 7 or less. Intracranial hypertension defined by a mean ICP above 15 mmHg, was observed in 12 patients with meningitis (86%) and in 9 with encephalitis (69%). Patients with meningitis exhibited a sudden and severe intracranial hypertension. A striking difference was noted between survivors and non survivors who had a very high maximal ICP with a severe reduction of cerebral perfusion pressure (CPP). Intracranial hypertension occurred in all patients with acute primary encephalitis but in only 3/7 patients with post-infectious encephalitis. ICP monitoring seems to be important in the comatose forms of: (1) bacterial meningitis in the early period (2) herpes encephalitis (3) post-infectious encephalitis with severe status epilepticus.

[Resuscitation of children in the brain death state from the view of organ procurement for therapeutic purposes]. / Réanimation des enfants en état de mort cérébrale en vue d'un prélèvement d'organes à but thérapeutique.

Thirty-six brain-dead children were managed to allow organ harvesting, which was possible in 21 (7 multi-organ). Optimal ventilation allowed for normal PaO2 and PaCO2 (mean +/- SEM FiO2 = 0.50 +/- 0.05). The management of hemodynamics was quite difficult and cardiac arrest may be due to patient transport, electrolyte disorders and dehydration. Vascular filling was of main importance and required standard solutes (5 or 2.5% glucose, normal saline, Ringer lactate) at a rate of 3.0 +/- 0.5 ml/kg/h, adapted for electrolytes (mainly KCl); sometimes, other solutes may be used: blood (17 patients), human 20% serum albumin (17 patients), plasma (9 patients). This filling was sufficient for 15 patients; the others required inotropic agents: dopamine (17 +/- 8 micrograms/kg/min), dobutamine (42 +/- 18 micrograms/kg/min). Diuresis was more than 3 ml/kg/h in 38% of the patients and desmopressin was used in 3 cases. Hypothermia (minimum 31.2 degrees) had no major consequence. No infection was found. Quality of management of brain-dead patients is of main importance; the possibility of organ harvesting must be evoked in such situations and is the first step in organ transplantations.

[Invasive technics for hemodynamic monitoring in pediatric resuscitation]. / Techniques invasives de monitoring hémodynamique en réanimation pédiatrique.

Cardiovascular monitoring in pediatrics was previously limited by inappropriate material. Following M.M. Pollack's publication, bedside cardiovascular catheterization in children have been developed and used for the last 8 years. These techniques allow the survey and the treatment of latent or patent hemodynamical disturbances with objective data. We describe these invasive techniques and their indications in pediatric intensive care.

[Intracranial pressure in comatose meningitis and encephalitis in children]. / Pression intracrânienne dans les méningites et encéphalites comateuses de l'enfant.

To determine the importance of intracranial hypertension in central nervous system acute infections, we studied intracranial pressure (ICP) in 27 patients, aged 45 days to 13 years. Fourteen had meningitis and 13 had encephalitis; all were in deep coma with a Glasgow Coma Scale 7 or less. Intracranial hypertension defined by a mean ICP above 15 mm Hg was observed in 12 patients with meningitis (86%) and in 9 with encephalitis (69%). Patients with meningitis exhibited a very early and severe intracranial hypertension. A striking difference is noted between survivors and non-survivors who had a very high maximal ICP with a severe reduction in cerebral perfusion pressure. Intracranial hypertension occurred in all patients with acute primitive encephalitis but only in 3/7 patients with post-infectious encephalitis. ICP monitoring seems to be important in the comatose forms of bacterial meningitis in the early period, herpes encephalitis and postinfectious encephalitis with severe status epilepticus.

[Cardiac arrest in children. Causes and future after cardiopulmonary resuscitation]. / L'arrêt cardiaque chez l'enfant. Causes et devenir après réanimation cardio-pulmonaire.

A 24 months retrospective study was carried out to investigate 133 patients with an unexpected cardiorespiratory arrest (CRA). Cardiopulmonary resuscitation (CPR) was undertaken in all cases. 96 patients suffered CRA outside of hospital, 11 patients in the wards of the hospital, and 26 in the pediatric intensive care unit (PICU). Sixty children (44%) responded to initial resuscitation and 20 patients (15%) survived after discharge, 12 (9%) of them with a good neurologic outcome. The best results were obtained in patients with an CRA in the PICU. The results of this study suggest that survival among resuscitated children is not better than that among adults, but can be improved with early recognition and monitoring of children at risk.