[Spondylodiscitis in children: a review. A propos of two cases]. / La spondylodiscite chez l'enfant: a propos de deux observations.

Spondylodiscitis is defined as an infection of the intervertebral disc and the adjacent vertebral bodies. It represents, at the most, 2-4% of osteoarticular infections in children and its clinical presentation is often insidious. The specific condition of the young child (isolated discitis) is explained by some anatomical peculiarities. We report two cases of spondylodiscitis in children of different ages and review the pediatric characteristics, the role of imaging, the bacteriological diagnosis and the management of this disease.

Chronic respiratory failure due to toxic epidermal necrosis in a 10 year old girl.

Toxic epidermal necrosis is a severe mucocutaneous disease with a high mortality rate. A third of the patients surviving the acute phase will develop pulmonary complications. The most frequent complication is bronchiolitis obliterans. Despite well-conducted treatment, in most cases, lung injury often leads to chronic respiratory failure. We describe here the case of a young patient that presented a toxic epidermal necrosis at the age of 3 years. Poor therapeutic compliance result in chronic respiratory failure and after 7 years of follow-up, pulmonary transplant remains the only long-term alternative. Close monitoring of respiratory symptoms in the course of toxic epidermal necrosis, intense treatment as soon as they appear and a long-term follow-up are essential to postpone chronic respiratory failure.

[Clinical case of the month. Left recurrent neck abscess revealing a fourth branchial cleft fistula]. / Le cas clinique du mois. Abcès cervical gauche récidivant révélateur d'une fistule de la quatrième fente branchiale.

The fourth branchial cleft fistula, which can be the origin of a recurrent left neck abscess, is a rare congenital malformation. Its diagnosis can be difficult. A ten-year-old girl presented with a left painful swelling of the neck. At ultrasonography and tomodensitometry, the diagnosis of thyroglossal cyst was suspected. Antibiotics were prescribed before surgical resection. The intervention was successful and the peroperative macroscopic aspect of the lesion suggested a dermoid cyst. Four months later, the same symptoms reappeared with fever. An intravenous antibiotic therapy was started while a magnetic resonance imaging demonstrated a possible aero-digestive tract fistula. Two days later, the patient developed an aero-cutaneous fistula. Oral antibiotics were started. Five months later, the girl came back for a second recurrence. A few days after her admission, she developed again an aero-cutaneous fistula. The diagnosis of surinfected fourth cleft fistula was made. An antibiotic therapy was started until the second intervention. After discussion about embryology, we describe the physiopathology, the differential diagnosis and the management of a fourth branchial cleft fistula causing recurrent left neck abscess.

External validation of the bacterial meningitis score in children hospitalized with meningitis.

UNLABELLED: The Bacterial Meningitis Score (BMS) is considered as the rule with the highest sensitivity to safely distinguish between aseptic and bacterial meningitis (BM). OBJECTIVE: The objective of our study was to evaluate the performance of the score and its usefulness for the clinician. METHOD: Retrospective analysis of two Belgian academic hospitals-based cohort studies. All consecutive children aged 29 days to 18 years admitted for acute meningitis between January 1996 and December 2008 was eligible. The BMS (risk of bacterial meningitis if seizure, positive cerebrospinal fluid (CSF) Gram staining, CSF protein level (3) 80 mg/dl, CSF neutrophil count 1,000/ mm3 or blood neutrophil count > or = 10,000/mm3) was applied to all patients with meningitis defined by CSF pleocytosis > 8 WBC/mm3. RESULTS: 174 patients were included in the final analysis of whom 26 (15%) had BM. Of the 93 patients categorized as having with no risk for BM (BMS score = 0), 2 patients had BM, one of which had petechial rash (negative predictive value 97.8%). BMS had a sensitivity of 92.3%. Risk of BM was significantly related to the BMS score: 6/147 (4%) patients with BMS < or = 1 had BM compared to 20/27 (74%) patients with BMS > 1. CONCLUSIONS: Our study reports a lower sensitivity of the BMS than observed in previous validation studies. We suggest to include the BMS in a decision tree aiming to optimize the ordering of laboratory investigations including viral and bacterial PCR testing in any child with CSF pleocytosis.

Clinical, virological and epidemiological assessment of 2009 influenza A (H1N1) pandemic in a Belgian university hospital.

BACKGROUND: Recommendations were applied before and during the Belgian pandemic (2009) H1N1 influenza wave at a university hospital (420 beds), for optimizing isolation processes and therapeutic management of possible and confirmed infected cases. METHODS: All patients presenting to the Emergency Department (ED) between August 1st and December 31st 2009 were screened for ILI symptoms, and were isolated for clinical assessment in case of positive screening. Patients categorized as possible influenza cases and who required hospitalization were isolated in dedicated wards. Specific diagnostic algorithms were implemented. Medical charts were retrospectively reviewed and matched with results of the microbiology laboratory. Patient's characteristics were analyzed, the contribution of laboratory diagnosis on therapy and lengh of stay (LOS) in isolation was also assessed. RESULTS: 310 patients out of 6068 had a positive screening for ILI, of these, 265 were retained as possible influenza cases and 139 required hospitalization. Twenty-eight children (8 requiring hospitalization) and 20 hospitalized adult patients had confirmed influenza infection. Five adult patients were admitted to the intensive care unit (ICU), 3 requiring extracorporeal membrane oxygenation (ECMO). There was no death related to the new influenza strain. The majority of confirmed patients were diagnosed during the Belgian epidemic wave, with a sensitivity of antigen detection of 50% in children and 35% in adults comparatively to real-time PCR (RT-PCR). CONCLUSIONS: The impact of (2009) H1N1 pandemic influenza remained limited, except for ICU patients requiring ECMO. Implementation of screening, isolation, and virological diagnosis processes led to significant improvement of patient management.

[Nontuberculous mycobacterial epitrochlear adenitis]. / Adénite épitrochléenne à mycobactérie non tuberculeuse.

We report the case of a 2-year-old girl referred for unilateral epitrochlear lymphadenitis caused by Mycobacterium avium. Adenitis is the most frequent presentation of non tuberculous mycobacteria in children. Typical locations are the cervical, submandibular, axillar, inguinal, mediastinal, and parotid regions. To our knowledge, this is the first observation of an epitrochlear location. The diagnosis was made by evidencing the causal bacterium but also by the exclusion of other causes such as Bartonella henselae and Mycobacterium tuberculosis infections. Treatment is based on surgical excision, which provides a cure rate of 90%. Macrolides are reserved for extended lesions and/or relapsing lesions despite surgical management.

[A clinical case of spontaneous involution of systemic cat scratch disease]. / Involution spontanée d'une forme systémique de maladie par griffade de chat: à propos d'un cas.

Typical Cat-scratch disease (CSD) manifests as regional lymphadenopathy following cat scratch and sometimes associated with mild fever. There is a lot of atypical manifestations and some of those have systemic involvement. Hepatosplenic CSD is a systemic presentation associating fever of unknown origin with nodules in the liver and/or the spleen. Ultrasound abdominal examination shows nodules (3-30 mm) in the spleen and/or in the liver. Diagnostic is based on serology for B henselae (always IgG + and sometimes IgM +), or polymerase chain reaction (PCR) on the liver to test for the presence of B henselae. Hepatosplenic CSD is rare and therefore underdiagnosed. There is no consensus about the treatment but most of the authors suggest to treat with rifampicine. We report a case of a 4-years-old girl presenting with fever of unknown origin (FUO), high inflammatory markers with normal leukocytosis and hepatosplenic nodules. The diagnosis of CSD was made retrospectively. Evolution was favourable even though no specific antibiotic treatment for Bartonella henselae was administrated.

[Dengue shock syndrome]. / Le cas clinique du mois. A propos d' une fièvre "importée.

Célia, 21 month-old child, presented to our pediatric clinic a few months ago with a fever of unknown origin after a stay in St-Domingue with her parents. Complementary investigations led to a diagnosis of Dengue Fever. The condition, not very frequent and thus not well known in our countries, represents a major world health problem especially because of the global failure of prophylactic measures. If the disease is self-limited in most cases, severe form can occur, with significant mortality and morbidity. Delay in diagnosis and treatment of these severe cases is often fatal.

[Limp with fever in adolescent: about 2 cases of pyomyositis]. / Boiterie fébrile chez l'adolescent: à propos de 2 observations de pyomyosite.

The authors report on 2 cases of limp with fever in adolescents, which developed after vigorous physical activity and were due to pyomyositis. Clinical, biological and radiological findings of the disorder are reviewed. Treatment is discussed. Early diagnosis and treatment are crucial for good prognosis.

Early skin sensitization to aeroallergens.

BACKGROUND: Early detection of aeroallergen sensitization is important as a prognosis factor but may be more difficult in young children. OBJECTIVE: We sought to demonstrate that skin sensitization to aeroallergens was present in a selected group of 0-2-year-old children and that it was associated with environmental exposure and a family history of allergic disease. METHODS: Data on exposure and history were extracted from the files of 824 children seen in the asthma clinic and who were skin tested to a panel of aero- and food allergens. RESULTS: Forty percent of our children demonstrated atopy, 28% were sensitized to aeroallergens, the majority of which to house dust mite. Higher sensitization rates were found in children with large weals to histamine (P<0.001) and in those who slept with soft toys [odds ratio (OR) 1.45, 95% confidence interval (CI) 1.02-2.08]. With a definition of sensitization including the size of the weal to histamine, there was a negative association with a personal history of eczema only (OR 0.66, 95% CI 0.45-0.99). There was no gender-dependent effect and no association with day-care attendance. CONCLUSION: This is one of the largest studies to evaluate skin testing in a selected population of young children. We found a high prevalence of sensitization to aeroallergens, which was associated with exposure to soft toys. Further follow-up of this population will allow assessment of the predictive value of this sensitization.

Optimal assessment of the ability of children with recurrent respiratory tract infections to produce anti-polysaccharide antibodies.

Specific anti-polysaccharide antibody deficiency (SPAD) is an immune disorder. Diagnostic criteria have not yet been defined clearly. One hundred and seventy-six children evaluated for recurrent respiratory tract infections were analysed retrospectively. For each subject, specific anti-pneumococcal antibodies had been measured with two enzyme-linked immunosorbent assays (ELISAs), one overall assay (OA) using the 23-valent pneumococcal polysaccharide vaccine (23-PPSV) as detecting antigen and the other purified pneumococcal polysaccharide serotypes (serotype-specific assay, SSA) (serotypes 14, 19F and 23F). Antibody levels were measured before (n = 176) and after (n = 93) immunization with the 23-PPSV. Before immunization, low titres were found for 138 of 176 patients (78%) with OA, compared to 20 of 176 patients (11%) with the SSA. We found a significant correlation between OA and SSA results. After immunization, 88% (71 of 81) of the patients considered as responders in the OA test were also responders in the SSA; 93% (71 of 76) of the patients classified as responders according to the SSA were also responders in the OA. SPAD was diagnosed in 8% (seven of 93) of patients on the basis of the absence of response in both tests. Thus, we propose to use OA as a screening test for SPAD before 23-PPSV immunization. After immunization, SSA should be used only in case of a low response in OA. Only the absence of or a very low antibody response detected by both tests should be used as a diagnostic criterion for SPAD.

[Necrotizing pneumonia in children: apropos of 4 cases]. / Pneumonie nécrosante de l'enfant: à propos de 4 cas.

OBJECTIVES: To describe the necrotizing pneumonia in children, a severe affection which prevalence seems to increase; to review literature. PATIENTS AND METHODS: We report 4 cases of necrotizing pneumonia: symptoms, agents, diagnostic tools, treatment and long term evolution. RESULTS: In 2 cases, pneumatoceles could be seen at chest X-ray. Two patients presented a deficiency of anti-pneumococcal antibodies. Three needed insertion of a pleural chest tube of whom 1 had a resection of a small piece of necrotic lung. Duration of hospitalisation is longer than in uncomplicated pneumonias. CONCLUSION: Necrotizing pneumonia is a severe affection. Diagnosis has to be made by lung CT. Long term evolution is excellent in pediatric population with serious management at hospital.

[Pleural effusion in childhood: management algorithm]. / Epanchement pleural de l'enfant: Proposition d'un algorithme de prise en charge.

Based on an increased prevalence of empyema in children,we reviewed the literature on the diagnosis and management of this affection. A retrospective study of 11 children admitted to our hospital in 2003 shows a prolonged hospitalisation (median 18 days) even with adequate treatment. Based on our experience and data from the literature, we propose a management algorithm to allow treatment of children admitted ith pleural effusion.

Cutaneous lesions of disseminated cryptococcosis as the presenting manifestation of human immunodeficiency virus infection in a twenty-two-month-old child.

We report the case of a 22-month-old African boy with cutaneous lesions as the predominant feature of disseminated cryptococcosis (positive blood and cerebrospinal fluid cultures) and as the presenting manifestation of severe vertically acquired HIV infection (CDC C3 category). To our knowledge these cutaneous lesions have never been reported as the initial manifestation of AIDS in children.

[Lyme disease and facial paralysis in children]. / Maladie de Lyme et paralysie faciale de l'enfant.

Lyme disease is one of the most common cause of acute peripheral facial palsy in children. Overall nervous system involvement is also the predominant manifestation of Lyme disease in children, chiefly as facial palsy and/or aseptic meningitis. The medical records of ten patients with discharge diagnosis of facial palsy associated to borreliosis were retrospectively reviewed. The diagnostic criteria for borreliosis included acute peripheral facial palsy associated with erythema migrans (1/10) and/or positive Lyme serology in serum (10/10) or CSF (6/10). Facial palsy was associated with a high rate (9/10) of occult meningitis. Cerebrospinal fluid findings showed lymphocytic pleocytosis associated to moderate increased protein level. PCR assays displayed a very low sensitivity. All patients with meningitis were treated with intravenous ceftriaxone for 3 weeks and received their treatment as outpatients with an heparinised venous catheter. Our study confirm that borreliosis should be considered in every case of peripheral facial palsy and based on the high rate of occult meningitis, we also advocate to perform a lumbar puncture. Although long term prognosis of facial palsy associated with Lyme disease in children appears excellent, current treatment recommendations advocate prolonged antibiotic therapy.

[Laryngitis revealing bacterial tracheitis in a five-year-old child]. / Laryngite révélatrice d'une trachéite bactérienne chez un enfant âgé de cinq ans.

CASE REPORT: We report the case of a five-year-old boy with clinical features of croup and left lower lobe pneumonia. Response to inhaled adrenaline and dexamethasone was incomplete and he developed respiratory distress. Direct laryngoscopy performed in the operating room showed mild glottic and subglottic inflammation. On bronchoscopy, there was thick pus coming from the left lower lobe. He was intubated for three days and regular toilet brought back thick pus. Tracheal fluid culture grew Haemophilius influenzae. COMMENTS: We suggest that he had bacterial tracheitis but that the tracheal involvement was not prominent at the time of diagnosis. CONCLUSION: Laryngoscopy and bronchoscopy in specialized surroundings should be considered for each child with croup unresponsive to conventional treatment, especially in case of lower respiratory tract involvement.

Long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency and early-onset liver cirrhosis in two siblings.

UNLABELLED: We present the clinical, pathological, biochemical, and molecular results on an infant girl with long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency and data on her deceased elder brother for whom this condition was retrospectively diagnosed. Clinical signs were liver enlargement and elevated liver enzymes, failure to thrive, and neurological disease (coma, seizures) triggered by an infectious stress. In the second child hepatic failure and status epilepticus developed during the onset of a rotavirus gastroenteritis. A barbituric coma was induced, but hypotonia and lack of eye pursuit persisted after suppression of antiepileptic drugs. She ultimately died of heart failure. Unlike previously reported cases, both of these patients had early-onset cirrhosis, and severe neurological disease was observed in the second child. CONCLUSION: Liver cirrhosis and brain damage may be underestimated in cases of long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency and may occur early in life.