[3 pediatric cases of leptospirosis]. / Trois observations pédiatriques de leptospirose.

Three children presented with an association of pains, infectious syndrome, acute renal failure, hepatitis and meningitis, that lead to the diagnosis of leptospirosis. The clinical spectrum of this rare disease are recalled.

[Reye's syndrome]. / Le syndrome de Reye.

Reye's syndrome is an acute disease of childhood characterized by non-inflammatory cerebral pathology associated with hepatic pathology (steatosis). When untreated, its course is very severe, with a 30 p. 100 mortality rate. The diagnosis rests on the occurrence of a suggestive clinical sequence (influenza-like syndrome followed by a latent period, then vomiting and disturbances of consciousness) and on particular laboratory findings: high serum ammonia and transaminase levels, hypoprothrombinaemia and frequent hypoglycaemia in neonates. As soon as the condition is diagnosed, massive intravenous carbohydrate therapy must be initiated. Several factors intervene in the pathogenesis of Reye's syndrome; the responsibility of treatment with salicylates and of hereditary enzymopathies is discussed.

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.

[Reye's syndrome. A current entity which remains enigmatic]. / Le syndrome de Reye. Une actualité qui reste énigmatique.

Reye's syndrome (RS) has been defined by the CDC as an acute non-inflammatory encephalopathy and hepatopathy, with no reasonable explanation for the cerebral and hepatic abnormalities. The diagnosis of RS is made by a constellation of clinical and laboratory features, none of which are pathognomonic. The demonstration of a fatty infiltration on liver biopsy is not really specific. On the other hand, the mitochondrial ultrastructural abnormalities appear to be characteristic of RS. Cerebral edema with intracranial hypertension represents the most immediate threat to life, the cause of the encephalopathy being unknown. The treatment of RS consists in perfusion of hypertonic glucose solution and management of intracranial hypertension. Grade I RS should be recognized early and treated with intravenous glucose. A number of metabolic disorders may yield a clinical picture resembling RS. These include disturbances of organic acid metabolism, urea cycle defects, and disorders of carbohydrate metabolism. The pathogenesis of RS is a mitochondrial insult induced by different viruses, drugs, exogenous toxins, and genetic factors. In the USA, pilot studies showed that a majority of RS cases may be attributable to salicylate use. In France, RS remains unfrequent although no precise epidemiological data are available. An epidemiological study appears therefore necessary for a better understanding of this mysterious syndrome. There is a need for a biological marker of the mitochondrial injury.

[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.

[Myocardial incompetence in meningococcal purpura in children. Early hemodynamic study]. / L'incompétence myocardique dans le purpura méningococcique de l'enfant. Etude hémodynamique précoce.

In order to investigate the haemodynamic changes involved at the very beginning of meningococcal purpura fulminans, a prospective study was conducted in 10 children in whom a Swan-Ganz catheter was introduced on admission into the pulmonary artery. The first measurements performed 6 to 14 hours (mean: 10.2h) after the first signs of purpura were detected showed in every case a state of shock with fall in tissue oxygen consumption values and reduction of ventricular performance, although the systemic blood pressure was preserved and the central venous pressure was normal. In patients admitted at an early stage, 4 to 6 hours after the onset and directly from home, hypovolaemia predominated and masked the myocardial insufficiency. Patients referred by another hospital and whose hypovolaemia had already been corrected (i.e. 9 to 12 h after the onset) had full myocardial incompetence with fall in cardiac index, rise in capillary pressure and lowering of the ventricular function curve. Under beta-adrenergic stimulants combined with re-expansion of blood volume according to haemodynamic variations, the state of shock was reversed within 48 to 72 hours, and all patients in this series survived. These findings confirm that myocardial incompetence is constant and occurs at an early stage of purpura fulminans.

[Value of plasma fibronectin in pediatric intensive care]. / Valeur de la fibronectine plasmatique en réanimation pédiatrique.

This work was undertaken to demonstrate the pathophysiologic and prognostic value of plasma fibronectin measurement in critically ill children. Fibronectin was measured by laser-nephelometry in 25 children (group 1) whose ages ranged from 1 month to 12 years (mean: 13.8 months). All presented with severe infections. The control group consisted of 16 children with various benign disorders, whose ages ranged from 3 months to 13 years (mean: 3.6 years). Fibronectin plasma levels in group 1 (mean: 0.16 g/l +/- 0.08) and in the control group (mean: 0.28 +/- 0.10) were significantly different (alpha less than 0.001). The initial concentration and the kinetics of this protein during evolution seem to have a good diagnostic and prognostic value in severe infections in children.

[Massive hemoperitoneum caused by rupture of the spleen, a complication of congenital afibrinogenemia. Conservative treatment]. / Hémopéritoine massif par rupture de la rate, complication d'une afibrinogénémie congénitale. Traitement conservateur.

An hemorrhagic shock caused by spontaneous spleen rupture in a 14 year old child with a congenital afibrinogenemia is reported. A conservative treatment was carried out with perfusions of whole blood and fibrinogen and with regular echographic examinations and a splenectomy was avoided.