[Post-COVID syndrome: A reflection and opinion paper]. / Síndrome post-COVID: Un documento de reflexión y opinión.

A high proportion of people who have suffered from COVID-19 report, after recovery from the acute phase of the disease, clinical manifestations, both subjective and objective, that continue beyond 3 weeks or even 3 months after the original clinical disease. There is still no agreed nomenclature to refer to this condition, but perhaps the most commonly used is post-COVID syndrome. The Scientific Committee on COVID of the Madrid College of Physicians (ICOMEM) has discussed this problem with a multidisciplinary approach in which internists, infectious disease specialists, psychiatrists, pneumologists, surgeons, geriatricians, pediatricians, microbiologists, family physicians and other specialists have participated, trying to gather the existing information and discussing it in the group. The clinical manifestations are very variable and range from simple fatigue to persistent fibrosing lung lesions with objective alterations of pulmonary function. Post-COVID syndrome seems to be particularly frequent and severe in adults who have required admission to Intensive Care Units and has a peculiar behavior in a very small group of children. The post-COVID syndrome, which undoubtedly exists, is at first sight not clearly distinguishable from clinical manifestations that which occur after other acute viral diseases and after prolonged stays in ICUs due to other diseases. Therefore, it offers excellent research opportunities to clarify its pathogenesis and possibly that of other related entities. It is possible that progressively there will be an increased demand for care among the millions of people who have suffered and overcome acute COVID for which the health authorities should design mechanisms for the agile management of care that will possibly require well-coordinated multidisciplinary groups. This paper, structured in questions on different aspects of the post-COVID syndrome, attempts to stage the current state of this problem.

[Emergence of invasive pneumococcal disease caused by non-vaccine serotypes in the era of the 7-valent conjugate vaccine]. / Serotipos no vacunales emergentes causantes de enfermedad neumocócica invasora en la era de la vacuna 7-valente.

INTRODUCTION: There has been an increased incidence in invasive pneumococcal disease (IPD) produced by non-vaccine serotype (NVS) of Streptococcus pneumoniae after the introduction of PCV7. Our objective was to describe the epidemiological, clinical and microbiological characteristics of IPD caused by NVS in a tertiary hospital in Madrid. PATIENTS AND METHODS: Retrospective (1998-2004) and prospective (2005-2009) study evaluating IPD caused by NVS in children. The study was divided into three periods: P1 (1998-2001) when PCV7 was not commercialized; P2 (2002-2005) with 40% vaccine coverage among children; and P3 (2006-2009) when the vaccine was added to the Childhood Immunization Schedule in Madrid. RESULTS: We analyzed 155 cases of IPD. One hundred and fifty of these isolates were serotyped (100 were NVS). There was an increase in the prevalence of IPD from P1 (31%) to P2 (54%) and P3 (91%). The most relevant emerging serotypes were 19A, 7F, 1, 5, 3 and 15C. The most significant clinical syndromes produced by some specific serotypes were as follows: lower respiratory tract infection (LRTI) by serotypes 1, 3, 5 and 15C; LRTI, primary bacteremia and meningitis by serotype 19A; and primary bacteremia by serotype 7F (66%). The large majority (83.8%) of NVS were sensitive to penicillin. CONCLUSIONS: There has been an increased prevalence of IPD caused by NVS since the introduction of PCV7. These changes should prompt the introduction of new pneumococcal vaccines, which include most of the NVS, in the childhood immunization calendar to prevent IPD in children.

[Increase in the incidence of invasive pneumococcal disease caused by serotype 19A prior to the implementation of the expanded pneumococcal vaccines]. / Aumento de la incidencia de enfermedad neumocócica invasora producida por el serotipo 19A previo a la introducción de las vacunas neumocócicas ampliadas.

OBJECTIVE: To describe the epidemiology, clinical syndromes and microbiological characteristics of serotype 19A as the main cause of invasive pneumococcal disease (IPD) in children admitted to a tertiary hospital in Spain. METHODS: A retrospective (1998-2004) and prospective (2005-2009) study was conducted on children with IPD produced by serotype 19A. The study was divided into three periods (P): P1 (1998-2001) when PCV7 had not been commercialized; P2 (2002-2005) with 40% vaccine coverage among children; and P3 (2006-2009) when the vaccine was added to the Childhood Immunization Schedule in Madrid. RESULTS: A total of 155 isolates of Streptococcus pneumoniae (SP) producing IPD were analysed, with 21 of them being serotype 19A (14%). An increased prevalence of serotype 19A was found: 2/45 cases (4.4%) in P1, 3/41 cases (7.3%) in P2 and 16/69 cases (23.2%) in P3. It occurred mostly in children younger than 2 years (16/21; 76%). This serotype was the main cause of meningitis (5/20; 25%), pleural empyema (3/22; 14%) and bacteraemic mastoiditis (2/4; 50%). Thirteen isolates (61.5%) had an MIC ≥ 0.12µ/ml for penicillin in extra-meningeal infections, and 3 of the 5 isolates causing meningitis (60%) had an MIC ≥ 1µ/ml for cefotaxime. CONCLUSIONS: Serotype 19A was the main causal agent of IPD in the PCV7 era (P3), with high antibiotic resistance rates. This serotype was responsible for all types of IPD, being the main cause of meningitis.

Hemoptisis leve en un niño inmigrante. Puesta al día diagnóstica / Mild emoptysis immigrant child: Diagnostic up-date

Presentamos el caso de un varón de 9 años de edad, de origen peruano, con antecedentes de tos crónica y expectoración hemoptoica discontinua de tres meses de evolución en el que se detecta un infiltrado pulmonar persistente en la radiografía de tórax. Describimos la norma de actuación con este tipo de pacientes así como la problemática creada en la detección de la causa subyacente del sangrado. La hemoptisis es un signo infrecuente en la práctica pediátrica pero muy angustiante para el paciente y su familia, así como para el médico, para quién supone un reto diagnóstico-terapéutico. Su baja incidencia e n el niño puede llevar a retrasos iniciales en su diagnóstico e incluso a que este signo pase inadvertido. El espectro de entidades patológicas que pueden causarla es muy amplio y habitualmente las más frecuentes son las causas infecciosas, aunque también pueden subyacer otras enfermedades potencialmente graves. Por ello es prioritario conocer su etiología exacta y decidir la consiguiente actitud terapéutica (AU)

We present the case of a 9 year-old child form Peru with a background of chronic cough and discontinuous hemotoxic expectoration of 3 months evolution in which persistent pulmonary infiltrate was detected don the chest x-ray. We describe the action guidelines with this type of patients as well as the problems created in the detection of the underlying cause of bleeding. Hemoptysis is an uncommon sign in the pediatric practice, however it produces much anxiety for the patient and their family, as well as for the physician, for whom it supposes a diagnostic-therapeutic challenge. Its low incidence in the child may lead to initial delays in its diagnosis and this sign may even go unnoticed. The spectrum of pathological conditions that may cause it is very wide and usually the most frequent ones are infectious causes, although there may be other underlying potentially severe diseases. Therefore, it is of priority to know the exact etiology and t decide the consequent therapeutic attitude (AU)

Efectividad de racecadotrilo en el tratamiento de la gastroenteritis aguda / Effectiveness of racecadotril in the treatment of acute gastroenteritis

Objetivos: Evaluar la efectividad del tratamiento combinado de rehidratación oral y racecadotrilo frente a rehidratación oral en niños con gastroenteritis aguda. Pacientes: Niños entre 3 y 36 meses de edad que acuden al servicio de urgencias con un cuadro de más de 3 deposiciones diarreicas en las 12 horas previas, de menos de 7 días de evolución, sin tratamiento antidiarreico o antibiótico previo, cuyos progenitores firmen un consentimiento informado. Se reclutaron un total de 148 pacientes (70 en el grupo rehidratación oral+ racecadotrilo y 78 en el grupo de rehidratación oral). Resultados: Los pacientes en tratamiento con racecadotrilo mostraron un mayor y más rápido descenso del número de deposiciones en las primeras 48 horas tras el seguimiento (p <0,0001). Tanto la duración del cuadro diarreico como del tratamiento fue menor en este grupo (p <0,005; p <0,0001), y presentaron una mayor consistencia de las deposiciones. Finalmente, se ha observado un número menor de nuevas visitas a urgencias (p <0,0001) e ingresos hospitalarios a las 24 y 48 horas (p <0,005; p <0,0001) entre los pacientes tratados con racecadotrilo. Conclusiones: Racecadotrilo disminuye el número de deposiciones en las primeras 48 horas en los niños con gastroenteritis aguda, acortando la duración de la enfermedad, y éstos precisan menos visitas a urgencias e ingresos hospitalarios (AU)

Aim: To assess the effectiveness of combination therapy with oral rehydration solution and racecadotril versus oral rehydration solution as monotherapy in children with acute gastroenteritis. Patients: Patients aged 3 to 36 months attended to in the emergency department with diarrhea (three or more watery stools over the previous 12 hours) of less than 7 days’ duration were included if the parents signed a written informed consent form. Patients previously treated with antidiarrheal or antibiotic agents were not enrolled. One hundred forty-eight patients were included (70 in the racecadotril group and 78 in the monotherapy group). Results: Patients treated with combined oral rehydration solution and racecadotril passed a lower number of stools during the first 48 hours of follow-up (p <0.0001). The duration of their diarrhea and treatment period was also shorter (p <0.005;p <0.0001) and the consistency of the stools was better. There were fewer visits to emergency services (p <0.0001) and hospital admissions within 24 and 48 hours (p <0.005; p <0.0001) in patients treated with racecadotril. Conclusions: In children with acute gastroenteritis, racecadotril has been shown to be effective in terms of reducing the number of stools within the first 48 hours and is associated with a shorter disease course and fewer visits to emergency services, as well as hospital admissions (AU)

Vacunación en niños inmigrantes / Vaccination in immigrant children

Immigration and international adoptions in Spain have increased over recent years. In general, the children come from developing countries with low vaccination coverage. An assessment of the vaccination status of every immigrant child or adopted child should be carried out as soon as possible. Depending on the results of the assessment the necessary vaccines should be given, until the child is up to date with the calendar of each of the Autonomous Communities (ideally the calendar recommended by the AEP, the Spanish Association of Paediatrics).Only those vaccines for which reliable, written information is available should be taken into consideration (taking into account the number of doses, the interval and the age at which they were given) and an «administered vaccine» should be considered to be a «valid vaccine». In general, when in doubt, it is preferable to revaccinate; alternatively, certain serologic tests can be carried out (diphtheria, tetanus, poliovirus 1-2 and 3,measles, rubella and parotitis). Quick vaccination schedules should be chosen, injecting the highest possible number of doses at once and taking advantage of any visit for its administration. In developing countries the following vaccines are not systematically administered: the heptavalent vaccine against pneumococcal disease, the Hib conjugate vaccine, the vaccine against meningococcal C disease and against chicken pox(AU)

En los últimos años se ha producido en España un aumento dela inmigración y de la adopción internacional. Los niños provienen generalmente de países en vías de desarrollo con coberturas vacunales bajas. En todo niño inmigrante o adoptado se debe realizar lo antes posible una evaluación de su estado vacunal y, en función de éste, completar las inmunizaciones, hasta adaptarlo al calendario de cada una de las comunidades autónomas (idealmente el recomendado por la Asociación Española de Pediatría). Sólo hay que tener en cuenta las vacunas de las que se disponga de información fiable por escrito (teniendo en cuenta el número de dosis, el intervalo y la edad a la que se administraron),y considerar que toda «vacuna administrada es vacuna válida». En general, ante la duda, es preferible revacunar; alternativamente se pueden realizar determinaciones serológicas (difteria, tétanos, poliovirus 1-2 y 3, sarampión, rubéola y parotiditis). Se debe optar por pautas de vacunación rápida, inyectando el mayor número de dosis posibles a la vez y aprovechando cualquier visita para su administración. No se administran de modo sistemático en países en vías de desarrollo la vacuna heptavalente frente al neumococo, la vacuna Hib-conjugada ni la vacuna frente al meningococo C y frente a la varicela(AU)

Hepatitis virales / Viral hepatitides

En conjunto, las hepatitis virales suponen un importante problema mundial, con unas elevadas tasas de incidencia y prevalencia, que varían ampliamente según las distintas regiones. Hasta ahora se han caracterizado cinco tipos distintos de virus causantes de hepatitis, con unas características clínicas y epidemiológicas diferentes. El A y el E se transmiten por vía fecal-oral y no producen enfermedad crónica. Por otro lado, el B, el D y el C se transmiten por vía parenteral y sexual principalmente, y pueden ocasionar, sobre todo en población pediátrica, una afectación crónica. En el estudio inicial del niño inmigrante se debe incluir el cribado serológico de la infección por el virus de la hepatitis B. Aunque la vacunación frente a este virus es universal, no se suele realizar de modo adecuado la inmunoprofilaxis en el recién nacido. La hepatitis A es endémica en países en vías de desarrollo. Suele afectar a niños que regresan a su país para visitar a amigos y familiares, por lo que es especialmente importante indicar la vacunación o la administración de gammaglobulina hiperinmune, según el caso, antes del viaje. La incidencia de hepatitis C en general es baja en la infancia (<0,2%); sólo se debe realizar un cribado serológico en niños inmigrantes con factores de riesgo (antecedente de transfusión, hijos de madre con virus de la hepatitis C positivo, etc.)(AU)

As a whole, viral hepatitides are an important problem on a world level, with high rates of incidence and prevalence, which vary greatly according to the different regions. Until now five different hepatitis-causing viruses have been characterised, with certain different clinical and epidemiological characteristics. Hepatitides A and E are faecal-orally transmitted and do not produce chronic diseases. Hepatitides B, D and C, on the other hand, are mainly transmitted parenterally and sexually, and can cause chronic diseases, especially among the paediatric population. The initial study of the immigrant child should include the serologic tests for the HBV infection. Although the vaccination against that virus is universal, the immunoprophylaxis does not tend to be carried out properly in new borns. Hepatitis A is endemic to developing countries. It tends to affect children who return to their countries to visit family members and friends, which is why it is especially important that the hyperimmune gamma-globulin vaccination/administration is given, as the case may be, before the trip. In general, the incidence of hepatitis C is low in infancy (<0.2%), and serologic tests should only be carried out in immigrant children with risk factors (with a history of transfusions, children of HCV positive mothers, etc.)(AU)

Lesión foruncular producida por Cordylobia anthropophaga / Furuncular lesions produced by Cordylobia anthropophaga

El aumento reciente de la inmigración, así como los viajes hacia países subsaharianos e iberoamericanos, ha producido un incremento de ciertas infestaciones, como son las miasis. Es importante conocer el ciclo biológico del artrópodo, así como las características clínicas de su infestación para incluirlo dentro del diagnóstico diferencial de un forúnculo de mala evolución. Las sencillas medidas de prevención y de tratamiento eficaz nos obligan a realizar recomendaciones básicas ante un viaje a zonas endémicas(AU)

The recent increase in immigration, as well as in travel to sub-Saharan and Latin American countries, has resulted in an increase in certain infestations such as myiasis. It is important to know the life cycle of arthropods, as well as the clinical characteristics of their infestation, so they can be included in the differential diagnosis of a furuncle with a complicated course. We provide recommendations concerning simple preventive measures for those who plan to travel to endemic zones and an effective treatment(AU)

Neurocisticercosis / Neurocysticercosis

El término neurocisticercosis hace referencia a la invasión del neuroeje por la forma larvaria de la Taenia solium. Constituye la parasitosis más frecuente del sistema nervioso central. Actualmente se presenta como una enfermedad emergente en nuestro medio, en relación con el aumento de la inmigración procedente de áreas endémicas, por lo que debería considerarse dentro del diagnóstico diferencial ante un paciente con clínica y antecedentes epidemiológicos compatibles. A pesar de tratarse de una enfermedad de elevada prevalencia mundial, no existe consenso sobre su manejo terapéutico. Se presenta el caso de un varón de 13 años, procedente de Ecuador, que acude a nuestro centro tras presentar un episodio de crisis convulsiva generalizada(AU)

The term neurocysticercosis refers to the invasion of the neuroaxis by the larval form of Taenia solium. It is the most common parasitic disease of the central nervous system. It is currently an emerging disease in our general population as a result of the increased immigration from endemic areas. Thus, it should be considered in the differential diagnosis in patients with compatible clinical and epidemiological histories. Despite the fact that this disease is highly prevalent worldwide, there is no consensus concerning its therapeutic management. We present the case of a 13-year-old boy from Ecuador who was brought to our hospital after a generalized seizure(AU)

Trombosis de la vena subclavia en una adolescente sin factores de riesgo / Thrombosis of the subclavian vein in an adolescent with no risk factors

La trombosis venosa profunda es una entidad poco frecuente en pediatría. En los últimos años se ha observado un aumento de su incidencia, relacionado con una mayor utilización de catéteres centrales. Exponemos el caso de una niña previamente sana, sin factores de riesgo cardiovascular, que acude al servicio de urgencias por presentar enrojecimiento, edema, aumento de la trama vascular y sensación de opresión en el brazo derecho de 3 semanas de evolución. Se realizaron hemograma, bioquímica sanguínea y coagulación básica, con resultados normales. La eco-Doppler puso de manifiesto una trombosis de la vena subclavia derecha. Se indicó tratamiento ambulatorio, inicialmente con heparina de bajo peso molecular, y se mantuvo una pauta de anticoagulantes orales durante 6 meses. Una vez suspendido el tratamiento, se realizó un estudio de trombofilia, con resultados normales. Un año después, la niña se encuentra asintomática y sin tratamiento. El manejo de este grupo de pacientes se realiza según lo indicado en estudios sobre series de adultos, ya que los trabajos pediátricos publicado sal respecto son escasos(AU)

Deep venous thrombosis is rarely seen in paediatrics. In recent years an increase has been noted in its incidence, linked to the greater use of central catheters. We report on the case of a previously healthy girl, free of cardiovascular risk factors, who came to the emergency services with reddening, o edema, increased vascular markings and a feeling of tightness in her right arm of 3 weeks of evolution. A haemogram, blood biochemistry analysis and basic coagulation tests were performed, with normal results. The echo-Doppler revealed a thrombosis of the right subclavian vein. An out-patient treatment was prescribed, initially with low-molecular-weight heparin, and a course of oral anticoagulants was maintained for 6 months. Once the treatment was stopped, a thrombophilia study was performed, with normal results. One year later, the girl is asymptomatic and without treatment. This group of patients is treated according to the findings of the studies on series of adults, since very few paediatric studies have been published on the subject(AU)

Hidatidosis hepática / Hepatic hydatidosis

La hidatidosis sigue causando una importante morbimortalidad en diversas partes del mundo. El diagnóstico definitivo de la afectación hepática depende de la combinación de técnicas de imagen y estudios serológicos. El tratamiento de elección continúa siendo la cirugía, especialmente en quistes de gran tamaño o complicados. Presentamos el caso clínico de un paciente de 5 años, a quien se detecta en una exploración rutinaria una masa abdominal localizada en el hipocondrio derecho. Había estado en contacto con un perro que estaba correctamente desparasitado. Mediante ecografía y resonancia magnética nuclear abdominales se diagnostica un quiste hepático de 11 cm de diámetro. La serología confirma la etiología, ya que presenta título de anticuerpos frente a Echinococcus de 1/128. Dado el tamaño del quiste, se opta por un tratamiento quirúrgico mediante quistectomía. Tanto el estudio del líquido quístico (se observan Echinococcus granulosus) como la histología de la pieza quirúrgica son diagnósticas de quiste hidatídico. La evolución clínica de la paciente fue satisfactoria, negativizándose los anticuerpos frente a Echinococcus al año de seguimiento(AU)

Hydatidosis continues to be an important cause of morbimortality in several parts of the world. The definitive diagnosis of the hepatic disease depends on the combination of imaging techniques and serological studies. Surgery continues to be the preferred treatment, especially in the case of large or complicated cysts. We present the clinical case of a 5-year-old patient in whom, during a routine examination, an abdominal mass located in the right hypochondrium was found. The patient had been in contact with a dog that was properly de wormed. Through an ultrasound scan and abdominal NMR imaging a hepatic cyst measuring 11 cm in diameter was diagnosed. The serology confirms the etiology since it shows a titre of antibodies against Echinococcus of 1/128. In view of the size of the cyst the chosen treatment was surgery consisting of a cystectomy. Both the study of the cystic fluid (Echinococcus granulosus are seen) as well as the histology of the surgical specimen are diagnostic of a hydatid cyst. The patient’s clinical evolution was satisfactory, with the antibodies against Echinococcus becoming negative after the patient had been followed up for a year(AU)

Imagen torácica con 'efecto masa' en el mediastino posterior / Chest image showing a 'mass efect' inposterior mediastinum

Presentamos un caso de tuberculosis pulmonary en un lactante de mes y medio de edad que ingresa por presentar un cuadro clínico respiratorio progresivo, fiebre y rechazo al alimento. La radiografía de tórax pone de manifiesto un aumento de densidad en la región posterior de hemitórax izquierda, que ejerce un 'efecto masa' en el mediastino posterior. Se muestran las características de esa imagen; se establece el diagnóstico diferencial de las masas localizadas en el mediastino posterior; se destaca la radiografía de tórax como una prueba muy sensible para el diagnóstico de la tuberculosis pulmonar; por último, se señala la pauta de actuación ante una imagen de estas características, así como la importancia en pediatría de ciertas técnicas consideradas agresivas, como la fibrobroncoscopia, pero que en realidad son pruebas sencillas y con una gran productividad diagnóstica y terapéutica

We present a case of pulmonary tuberculosis in a month-and-a-half-old infant who was admitted to the hospital with progressive respiratory problems, fever and food refusal. Chest radiography revealed evidence of increased density in the posterior region of left hemithorax, causing a 'mass effect' in posterior mediastinum. The features of this image are shown, and the authors discuss the differential diagnosis of masses localized inposterior mediastinum, stressing the fact ches radiography is a highly sensitive technique for the diagnosis of pulmonary tuberculosis. Finally, the y point out the approach that should be adopted in the case of images with these features, as well as the importance in pediatrics of certain techniques, such as fiberoptic bronchoscopy, that are considered to be aggressive but, in reality, are simple tests with a high diagnostic and therapeutic yield

Mastoiditis por Fusobacterium necrophorum / Mastoiditis due to Fusobacterium necrophorum

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