Predictive factors of dengue severity in hospitalized children and adolescents in Rio de Janeiro, Brazil.

INTRODUCTION: Dengue is one of the most important mosquito-borne infections. Severe cases are more frequently observed in adults. However, in 2008, the State of Rio de Janeiro, Brazil, experienced a severe dengue epidemic that primarily affected children and caused many cases of dengue hemorrhagic fever (DHF) and death. METHODS: A cross-sectional analytical study was conducted to examine laboratory diagnosis and clinical epidemiologic factors for confirmed dengue cases in patients aged less than 16 years, from January to June 2008, at a municipal hospital in the City of Rio de Janeiro, Brazil. Variables associated with severe outcomes and P values less than .05 were evaluated by means of a logistic regression model. RESULTS: Of the 419 dengue cases studied, 296 were classified as DHF and 123 as classical dengue. Six patients who had DHF died. In multivariate analysis, some laboratory and clinical variables were independently associated with DHF: age 5 years or older (odds ratio [OR], 4.94; 95% confidence interval [CI], 1.30-18.71), abdominal pain (OR, 8.59; 95% CI, 3.17-23.27), hepatomegaly (OR, 15.87; 95% CI, 5.38-46.85), and positive tourniquet test (OR, 10.84; 95% CI, 3.96-29.71). Hypoalbuminemia occurred more frequently than hemoconcentration in DHF cases, and high aminotransferase levels were associated with severity. CONCLUSIONS: Age greater than 5 years, abdominal pain, painful hepatomegaly, and positive tourniquet test were predictors of DHF. The high frequency of hepatic impairment suggests that acetaminophen should be avoided in severe cases of dengue.

Predictive factors of dengue severity in hospitalized children and adolescents in Rio de Janeiro, Brazil

Abstract INTRODUCTION: Dengue is one of the most important mosquito-borne infections. Severe cases are more frequently observed in adults. However, in 2008, the State of Rio de Janeiro, Brazil, experienced a severe dengue epidemic that primarily affected children and caused many cases of dengue hemorrhagic fever (DHF) and death. METHODS: A cross-sectional analytical study was conducted to examine laboratory diagnosis and clinical epidemiologic factors for confirmed dengue cases in patients aged less than 16 years, from January to June 2008, at a municipal hospital in the City of Rio de Janeiro, Brazil. Variables associated with severe outcomes and P values less than .05 were evaluated by means of a logistic regression model. RESULTS: Of the 419 dengue cases studied, 296 were classified as DHF and 123 as classical dengue. Six patients who had DHF died. In multivariate analysis, some laboratory and clinical variables were independently associated with DHF: age 5 years or older (odds ratio [OR], 4.94; 95% confidence interval [CI], 1.30-18.71), abdominal pain (OR, 8.59; 95% CI, 3.17-23.27), hepatomegaly (OR, 15.87; 95% CI, 5.38-46.85), and positive tourniquet test (OR, 10.84; 95% CI, 3.96-29.71). Hypoalbuminemia occurred more frequently than hemoconcentration in DHF cases, and high aminotransferase levels were associated with severity. CONCLUSIONS: Age greater than 5 years, abdominal pain, painful hepatomegaly, and positive tourniquet test were predictors of DHF. The high frequency of hepatic impairment suggests that acetaminophen should be avoided in severe cases of dengue.

Circulating cytokines and chemokines associated with plasma leakage and hepatic dysfunction in Brazilian children with dengue fever.

Dengue fever is usually a benign acute viral infection transmitted by arthropods but may evolve to severe clinical manifestations such as coagulation and/or hemodynamic disorders, caused mainly by an increase of vascular permeability. Deregulated circulating immunological factors have been associated with severity. In Brazil severe cases appeared in children only recently and we evaluated the profile of cytokine/chemokine kinetics in 134 hospitalized young patients during the epidemic in Rio de Janeiro in 2008. Inflammatory cytokines TNF and IFNγ were found elevated during the acute phase in children as well as the anti-inflammatory IL10 and chemokines MIF and CXCL10/IP10, all last three persisting longer during the recovery phase. Severe disease fitting the dengue hemorrhagic fever pattern (WHO, 1997) was associated with higher IL10 and CXCL10/IP10 circulating levels (peak levels at seven days with P<0.01 and P<0.001 respectively as compared to DF). These factors were higher in patients pulmonary effusion or ascites (P<0.05 for IL10 and P<0.01 for CXCL10/IP10). Both factors were also associated with liver changes such as AST increase correlated with CXCL10/IP10 (r=0.4300 with P<0.0001) and patients presenting painful hepatomegaly showed higher circulating levels of IL10 (P<0.01, at 7-9 days) and of CXCL10/IP10 (P<0.05, 4-6 days and P<0.001, 7-9 days) when compared to patients without apparent liver alterations. Most cases presented a history of prior infection (93%). This is the first study demonstrating cytokine and chemokine association with severity during dengue fever in Brazilian children. IL10 and CXCL10/IP10 play a role in the disease severity associated with induction of vascular leakage and a novel association with changes in liver dysfunction.

Miocardite diftérica: correçäo clínico-patológica de 20 cases / Diphtheric myocarditis: clinico-pathological correlation of 20 cases

Os autores descrevem as alteraçöes clínico-patológicas de 20 casos fatais de miocardite diftérica em crianças. Seis delas haviam recebido vacina anti-diftérica sendo que em 2 o esquema de imunizaçöes foi completo. Os achados clínicos mais encontrados foram abafamento de bulhas; taquicardia ou bradicardia, extra-sistólica, bloqueio de ramo esquerdo, bloqueio de ramo direito. Ocorreu bloqueio atrioventricular total em 6 crianças. A radiografia de tórax evidenciou cardiomegalia em 10 casos. A ecocardiografia mostrou diminuiçäo da fraçäo de ejeçäo em 4 e diminuiçäo da movimentaçäo do septo interventricular em 2 casos. A necrose das fibras miocárdicas ocorreu em 15 casos, sendo que em apenas 7 o eletrocardiograma havia mostrado "áreas inativas". Foi colocado marcapasso de demanda em 4 casos por bloqueio atrioventricular grave e mesmo assim ocorreu o óbito por lesäo miocárdica extensa

Miocardite diftérica: estudo de 48 casos / Diphtheric myocarditis: study of 48 cases

Foram estudados 48 casos de miocardite entre 100 crianças com idades variando de um a 14 anos, internadas no serviço DIP do HUAP, de janeiro de l980 a julho de l985. Foram divididos em três grupos, de acordo com a gravidade: grupo 1, constituído de 17 crianças com miocardite leve e todas evoluíram bem; grupo 2, com 16 pacientes com miocardite grave, mas tiveram alta curados; e grupo 3, formado por 15 pacientes com alteraçöes cardíacas graves que evoluíram para o óbito. Entre os dois grupos de miocardite grave foi realizada a estimulaçäo cardíaca artificial com marcapasso provisório em sete pacientes, sendo que destes, quatro tiveram êxito fatal. Das crianças com miocardite grave quatro tinham recebido três doses de vacinaçäo tríplice e um reforço. Concluiu-se que nesta casuística foi feito o diagnóstico de miocardite em porcentagem muito elevada de casos (48%). A mortalidade foi de 15% entre todos os casos de difteria e de 30% entre todos os de miocardite

Avaliaçäo terapêutica de midecamicina e da miocamicina em infecçöes dermatológicas e das vias respiratórias / Therapeutic evaluation of midecamycin and miocamycin in skin infections and respiratory infections

A midecamicina (MDM) e sua forma acetilada, a diacetilmidecamicina ou miocamicina (MOM), foram utilizadas no tratamento de 32 pacientes com amigdalite purulenta, otite média aguda, sinusite aguda, abscesso amigdaliano, pneumonia lobar, bronquite bacteriana aguda, broncopneumonia, piodermite, erisipela, paroníquia bacteriana, ferida penetrante, celulite crônica e furunculose. A cura clínica foi obtida em 90,6% dos casos, empregando-se na maioria de pacientes adultos um comprimido de 500 mg da midecamicina três vezes ao dia e usando-se a miocamicina em crianças na dose de 30 a 40 mg/kg/dia. A medicaçäo foi administrada em intervalos regulares a cada oito horas. Em 55,2% dos casos a resposta clínica foi observada até o sétimo dia de terapêutica. Somente em 6,9% dos casos foi necessário o uso da medicaçäo por mais de 10 dias. Efeitos colaterais representados por náuseas, vômitos, dor abdominal e diarréia foram referidos por quatro dos 25 doentes aos quais administrou-se a midecamicina; somente em um a droga teve que ser suspensa antes de se obter a cura clínica. Näo houve efeitos adversos nos pacientes que receberam a miocamicina. Näo foram observadas alteraçöes hematológicas ou funcionais hepáticas em decorrência do uso dos medicamentos. Considerando sua eficácia, comodidade posológica e pequena freqüência de efeitos colaterais importantes, a midecamicina e a miocamicina afiguram-se antibióticos de utilidade clínica, constituindo-se em novas opçöes para o tratamento de infecçöes respiratórias e dermatológicas causadas por germes sensíveis a sua açäo