Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

SNPs, adipokynes and adiposity in children with asthma.

OBJECTIVES: Asthma and obesity are complex disorders influenced by environmental and genetic factors. We performed an integrative review of genetic polymorphisms and adipokines effects in children and adolescents with asthma and obesity. DATA SOURCES: Articles focused on these issues were collected from SciELO, PubMed, LILACS, Embase and ScienceDirect electronic databases, in 2009-2020 period. STUDY SELECTIONS: 22 articles were selected, including clinical trials, analyses approaches, case-control studies, meta-analysis and Mendelian randomization studies. RESULTS: Leptin concentrations were higher in obesity and asthma. The high value of BMI and Leptin indicated severe asthma. Adiponectin may be reduced in obese children. The high value of BMI and low level of Adiponectin may indicate severe asthma. Some linkage of PRKCA gene, asthma and BMI was observed. FTO T allele rs62048379 was positively associated with overweight/obesity, related to protein and PUFA:SFA ratio intake and influences the choice of more energy-dense foods. FTO rs9939609 effects are more pronounced among children with insufficient vitamin D levels. CONCLUSION: Leptin may be a potential predictor for asthma control in children. BMI and Adiponectin could have certain predictive value for asthma. FTO gene was related to a higher mean BMI Z-score and accelerated developmental age per allele. Strong genetic heterogeneity influencing on asthma and obesity susceptibilities is evident and related to distinct genetic features. GWAS with childhood obesity in asthma contributed to greater insights, mainly on later childhood. Standardized definitions for asthma and overweight/obesity in studies approaching adipokines and SNPs would provide stronger evidence in deciding the best management.

Contribution of Xpert MTB/RIF to clinical diagnosis in adolescents with tuberculosis in Rio de Janeiro, Brazil.

SETTING: Rio de Janeiro, RJ, Brazil, a high tuberculosis (TB) burden city.OBJECTIVE: To compare the sociodemographics, clinical characteristics, care process indicators (CPIs) and treatment outcomes among adolescents with pulmonary TB (PTB) and those with PTB + extrapulmonary TB (EPTB), who underwent testing with Xpert® and sputum culture.DESIGN: This was a retrospective study of data from three national databases from 2014 to 2016 of adolescents (aged 10-18 years) residing and notified in Rio de Janeiro City. Three groups were identified according to their Xpert and culture results: Group 1, Xpert- and culture-positive; Group 2, Xpert-positive and culture-negative; and Group 3, Xpert- and culture-negative. Study CPIs were as follows: the time between 'sample collection and Xpert result release', 'sample collection and treatment initiation' and 'notification and treatment outcome'.RESULTS: Of 258 adolescents included in the study, 223 (86.4%) were in Group 1, 20 (7.8%) in Group 2 and 15 (5.8%) in Group 3. Groups 1 and 2 had a similar profile. Compared to Group 1, Group 3 had a higher proportion of HIV-positive cases (21.4% vs. 3.0%, P = 0.016), adolescents with a hospital diagnosis (53.3% vs. 7.6%, P < 0.001), and PTB + EPTB cases (20% vs. 0.4%; P < 0.001). There were no statistically significant differences in CPIs or treatment outcomes.CONCLUSION: The clinical diagnosis was decisive in more critical or complex patients, despite Xpert-negative results.

Childhood tuberculosis and human immunodeficiency virus status in Brazil: a hierarchical analysis.

SETTING: Human immunodeficiency virus (HIV) infection may impact tuberculosis (TB) diagnosis, clinical presentation and treatment outcomes in children as the signs and symptoms of both diseases overlap. OBJECTIVE: To compare the sociodemographic and clinical profiles of childhood TB according to HIV status in Brazil. METHODS: This was a cross-sectional study of data on subjects aged <15 years retrieved from the Brazilian National Electronic Disease Registry (Sistema de Informação de Agravos de Notificação) database on TB to compare TB-HIV coinfected patients and patients with TB only registered between 2007 and 2011. A hierarchical logistic regression model was applied. RESULTS: Of 6091 cases analysed, 780 (12%) were TB-HIV patients, while 5311 (87%) presented with TB only. TB-HIV patients were more likely to be institutionalised (OR 2.22, 95%CI 1.43-3.46), to present with relapsed TB (OR 5.03, 95%CI 2.02-12.5) and be readmitted after treatment default (OR 16.7, 95%CI 4.34-64.46). They were also more likely to have unfavourable outcomes, including default (OR 2.85, 95%CI 1.81-4.49), death due to TB (OR 2.76, 95%CI 1.27-6.03) and death from other causes (OR 5.59, 95%CI 2.63-11.8). CONCLUSION: Our study highlights the challenges of using national registers for research into childhood TB.

Brazilian paediatricians' awareness of national guidelines for community-acquired pneumonia.

BACKGROUND: The Integrated Management of Childhood Illness (IMCI) strategy uses simple clinical signs for the diagnosis and severity evaluation of community-acquired pneumonia (CAP). OBJECTIVE: To describe paediatrician awareness of the IMCI strategy for CAP. DESIGN: A cross-sectional study analysing a descriptive case of severe CAP, presented as part of the Brazilian Board of Paediatrician Evaluation (BBPE) tests. RESULTS: Eighty-six (774/898) per cent of paediatricians followed the IMCI protocol to treat CAP. Although hospitalisation was considered in 90% of the answers, only 35% based this decision on lower chest indrawing. CONCLUSION: The BBPE showed that most physicians are aware of the IMCI recommendations.

Evaluation of a proposed diagnostic scoring system for pulmonary tuberculosis in Brazilian children.

In a case-control study to evaluate a systematic scoring system for diagnosing pulmonary tuberculosis (PTB) in children, cases had gastric lavage cultures positive for Mycobacterium tuberculosis and recovered after anti-tuberculosis treatment, while controls had negative cultures and recovered with non-anti-tuberculosis treatment. Radiological aspect (OR = 25.39), contact with a tuberculous adult (OR = 10.67) and tuberculin skin test > or = 10 mm (OR = 8.23) were associated with PTB diagnosis. The sensitivity of the score ranged from 58% to 89% and the specificity from 98% to 86%, with cut-offs of respectively > or = 40 or > or = 30. The scoring system may be a useful diagnostic method in areas with a high prevalence of TB.

Adverse effects of BCG revaccination: a report on 13 cases from Rio de Janeiro, Brazil.

SETTING: BCG revaccination is not used worldwide. In Brazil, it has been recommended since 1994 in children aged 6 to 14 years. Reports in the medical literature of adverse reactions due to revaccination are rare. BCG revaccination remains officially recommended by the Brazilian health authorities, based on the current epidemiological tuberculosis situation in the country. OBJECTIVE: We report 13 cases of children and adolescents with complications due to BCG revaccination. DESIGN: Case reports of patients followed up in a pneumology unit of a university pediatric hospital from May 1996 to December 2000. RESULTS: There were seven males and six females, whose ages ranged from 7-12 years. Adverse reactions occurred between 21 days and 9 months after BCG revaccination. All 13 cases had a scar from prior BCG vaccination. All cases treated received isoniazid, 10 mg/kg/day, in the morning until the end of cure. The duration of treatment varied, but all cases were successfully cured. CONCLUSION: Although adverse reactions are rare, it is important to continue monitoring them in order to learn more about them and to be able to orient health professionals to perform appropriate assessment and timely treatment when they occur.

[Pulmonary involvement in children with AIDS: clinical study and necropsy of 14 cases]. / Acometimento pulmonar em crianças com a síndrome da imunodeficiência humana (AIDS): estudo clínico e de necrópsia de 14 casos.

BACKGROUND: To describe clinical, laboratorial, radiological, and histopathological lung findings from necroscopy of aidetic children with pulmonary disease. MATERIAL AND METHODS: Fourteen children admitted at the Hospital Universitário Antônio Pedro - Universidade Federal Fluminense, Niterói, RJ, and Instituto de Puericultura e Pediatria Martagão Gesteira - Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, between 1989 and 1996, were revised in a retrospective survey. RESULTS: Eight were males (57%). The median age was 1.2 years old (from three months to nine years). Nine children (64.4%) were younger than 24 months old. The HIV transmission was vertical in 10 (71%) children. In these cases, five mothers were contaminated from heterosexual relations. Pneumonia (n=8), oral candidiasis (n=8), and diarrhea (n=5) were the most common previous conditions. The most frequent signs and symptoms on admission were fever (n=12), respiratory distress (n=10), cough (n=10), peripheral lymphadenopathy (n=11), hepatomegaly and/or splenomegaly (n=10), and malnutrition (n=9). The chest x-rays findings were condensation (n=5) and diffuse infiltrates (n=6) patterns. The microscopic lung characteristics were compatibles with pneumonia by cytomegalovirus (CMV) (n=9), bacteria (n=8), Pneumocystis carinii (n=3), Toxoplasma gondii (n=1), Hystoplasma capsulatum (n=1) and Lymphocytic interstitial pneumonia (n=1). The association between CMV and bacteria was observed in six cases. CONCLUSIONS: Age less than two years old, vertical transmission, inespecific clinical presentation of pneumonia, and infiltrates and condensation patterns at the x-rays were the predominant characteristics. Cytomegalovirus and bacteria were the most common etiologic agents, being their association frequent. Lymphocytic interstitial pneumonia and pneumonia by P. carinii were not common causes of pulmonary disease.

Acometimento pulmonar em crianças com a síndrome da imunodeficiência humana (AIDS): estudo clínico e de necrópsia de 14 casos / Necroscopic study of 14 children with AIDS and pneumonia

OBJETIVOS: Descrever os aspectos clínicos, laboratoriais, radiológicos e anatomopatológicos encontrados em tecidos pulmonares de necrópsias de crianças com Aids e acometimento pulmonar. MÉTODOS: Foram revisados, retrospectivamente, prontuários, radiografias simples de tórax e laudos de necrópsias de 14 crianças com Aids e acometimento pulmonar. RESULTADOS: Oito casos eram do sexo masculino e seis do feminino. As idades variaram de três meses a nove anos, mediana de 1,2, sendo nove deles menores de dois anos. A transmissäo foi vertical em 10 pacientes, dos quais cinco mäes tinham história de contaminaçäo por relaçäo heterossexual; três, por hemotransfusäo e em duas, ignorada. Pneumonia (n=8), candidíase oral (n=8) e diarréia (n=5) foram as doenças prévias mais referidas. Os sinais e sintomas observados à internaçäo foram febre (n=12), dispnéia (n=10), tosse (n=11), linfoadenomegalia (n=11), hepato e/ou esplenomegalia (n=10), desnutriçäo (n=9), palidez (n=8), cianose (n=5) e baqueteamento digital (n=2). Os achados radiológicos mais comuns foram infiltrados difusos (n=6) e condensaçöes (n=5). As alteraçöes histológicas pulmonares foram compatíveis com pneumonia pelo citomegalovírus (n=9), por bactérias (n=8), por Pneumocystis carinii (n=3), por Hystoplasma capsulatum (n=1), por Toxoplasma gondii (n=1) e pneumonia intersticial linfocítica (n=1). A associaçäo CMV e bactéria foi observada em seis casos. CONCLUSÖES: Houve predomínio de menores de dois anos, de transmissäo vertical, de quadro clínico inespecífico de doença pulmonar e de infiltrados e condensaçöes à radiografia. Citomegalovírus e bactérias foram os agentes mais comuns, sendo freqüente a sua associaçäo. Pneumonia Intersticial Linfocítica e Pneumonia pelo P. carinii näo foram causas freqüentes de doenças pulmonares

[Relationship between serological diagnosis (ELISA) and severity of pulmonary tuberculosis in children]. / Relação entre o diagnóstico sorológico (ELISA) e a gravidade da tuberculose pulmonar na infância.

Forty eight children from 0 to 13 years old were submitted to the enzyme-linked immunosorbent assay (ELISA) serological test with a view to detect anti PPD IgG antibodies, for diagnosis of pulmonary tuberculosis and to establish the relationship between immune response and radiological gravity of pulmonary tuberculosis (mild, moderate and severe). There were 29 children with pulmonary tuberculosis and 19 children without tuberculosis. The median ELISA optical density were: 0.098 in children with primary complex (mild); 0.092 in children with pneumonic pattern (moderate) and 0.134 in children with miliary tuberculosis (severe). These data show higher positive serological test results in severe forms of pulmonary tuberculosis (p = 0.0007).

[Epidemiology of childhood tuberculosis in the city of Rio de Janeiro, Brazil]. / Epidemiologia da tuberculose infantil na cidade do Rio de Janeiro, RJ.

Data was drawn from a study on the epidemiological trends of tuberculosis among children of Rio de Janeiro county, Brazil. There was an increased incidence of tuberculosis among children and epidemiological health indicators were above the national average.

[Childhood tuberculosis] / Tuberculose na criança.

OBJECTIVE: This review paper on tuberculosis in children aims at describing the classical pathogenic findings and to discuss practical features for diagnosis, treatment and prevention, based on Brazilian official rules. METHODS: The author reviews the last 5 years literature on the subject using as sources Medline, Ministry of Health official publications and Brazilian medical publication not included in the Index Medicus, as well. RESULTS: A fluxogram is described for the diagnosis of tuberculosis in children and presented as a proposal for implantation in low complexity health services. Figures displaying tuberculosis treatment models proposed by the Ministry of Health are also showed. New prevention concepts introduced in the last 5 years are presented. CONCLUSIONS: Tuberculosis in children remains a diagnostic challenge. Treatment rules have been well defined. Prevention measures should be reinforced.

[Asphyxiating thoracic dystrophy: a report of 3 cases] / Distrofia torácica asfixiante de Jeune: relato de 3 casos.

OBJECTIVE: To drive pediatrician's attention to a syndrome wwich has as its typical clinical presentation a thoracic cage abnormality which evolves to respiratory distress and death during the first two years of life.METHODS: We describe three cases of patients with clinical and radiographic findings characteristic of asphyxiating thoracic dystrophy (Jeune's Syndrome): short and narrow thoracic cage and abnormal development of the ribs. A brief review of the literature on the subject is also included.RESULTS: The three patients are older then two years of age. They did not present life threatening pulmonary complication nor respiratory distress, in contrast to most of the cases reported in the literature.CONCLUSIONS: Even though the number of occurrences of this syndrome is quite low, it must be consider when conducting a differential diagnostic related to thoracic cage abnormalities. It is important to emphasize the degree of variability of the pulmonary lesions and the progress of the disease. However, most articles on the subject point to a grim outcome.

BCG vaccination in low birth weight newborns: analysis of lymphocyte proliferation, IL-2 generation and intradermal reaction to PPD.

OBJECTIVE: To study vaccinal scar formation and post-vaccinal immune response in newborns with birth weight ranging from 2000 to 2499 g vaccinated in the first week of life with intradermal bacille Calmette-Guérin (BCG) (Moreau-Rio de Janeiro strain). METHOD: Specific immune response to PPD was assessed in 30 low birth weight newborns (mean birth weight = 2311.7 +/- 122.1 g; mean gestational age = 38.1 +/- 1.8 weeks) in comparison to 56 control infants (mean birth weight = 3198.9 +/- 267.2 g; mean gestational age = 38.5 +/- 1.2 weeks. RESULTS: Low birth weight infants have an efficient immune response to vaccinal stimulus when compared to control infants as judged by specific in vitro lymphocyte proliferation (mean SI = 9.7 +/- 12.9 vs SI = 8.8 +/- 10.0, P = 0.72) and IL-2 production (mean SI = 3.1 +/- 3.4 vs SI = 2.6 +/- 2.0, P = 0.38). Intradermal reaction to PPD was also comparable in both groups (mean induration diameter = 9.5 +/- 5.1 mm vs 9.6 +/- 5.0 mm, P = 0.94). CONCLUSION: These data suggest that low birth weight newborns show a good immune response to BCG, thus reinforcing the inclusion of such infants in regular vaccination programs with intradermal BCG.

Carcinoide bronquico - relato de dois casos em criancas. / Bronchial carcinoid - report of 2 cases in children

Os autores descrevem dois casos de adenoma bronquico carcinoide em menores de 16 anos: o primeiro paciente era do sexo feminino, de 11 anos, teve diagnostico clinico-radiologico de tuberculose, e o segundo do sexo masculino, de 15 anos, cursou com pneumonia de repeticao e igualmente chegou a receber tratamento especifico.Em ambos os doentes o exame endoscopico evidenciou tumor endobronquico. Os pacientes foram submetidos a cirurgia, visando a diagnostico e terapeutica. A evolucao foi favoravel nos dois casos

Intradermal BCG vaccination complications--analysis of 51 cases.

The authors describe 51 cases of local complications due to intradermal BCG vaccination which occurred among 117 533 children between 1974 and 1979, in the city of Niteroi (Rio de Janeiro State). The ages ranged from 0 to 16 years and the lesions observed were abscesses, enlargement of regional lymph nodes, chronic ulceration, and ulceration associated with enlarged lymph nodes. The patients were treated with isoniazid, except 2 who required surgical drainage, with favourable results in all cases.