SARS-CoV2 coronavirus: so far polite with children. Debatable immunological and non-immunological evidence

The reasons for the relative resistance of children to certain infections such as that caused by coronavirus SARS-CoV2 are not yet fully clear. Deciphering these differences can provide important information about the pathogenesis of the disease. Regarding the SARS-CoV2 virus, children are at the same risk of infection as the general population of all ages, with the most serious cases being found in infants. However, it has been reported that the disease is much less frequent than in adults and that most cases are benign or moderate (even with high viral loads), provided there are no other risk factors or underlying diseases. It is not clear why they have lower morbidity and virtually no mortality. A series of findings, relationships and behavioral patterns between the infectious agent and the child host may account for the lower incidence and a greatly attenuated clinical presentation of the disease in children

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SARS-CoV2 coronavirus: so far polite with children. Debatable immunological and non-immunological evidence.

The reasons for the relative resistance of children to certain infections such as that caused by coronavirus SARS-CoV2 are not yet fully clear. Deciphering these differences can provide important information about the pathogenesis of the disease. Regarding the SARS-CoV2 virus, children are at the same risk of infection as the general population of all ages, with the most serious cases being found in infants. However, it has been reported that the disease is much less frequent than in adults and that most cases are benign or moderate (even with high viral loads), provided there are no other risk factors or underlying diseases. It is not clear why they have lower morbidity and virtually no mortality. A series of findings, relationships and behavioral patterns between the infectious agent and the child host may account for the lower incidence and a greatly attenuated clinical presentation of the disease in children.

Routine infant vaccination of pneumococcal conjugate vaccines has decreased pneumonia across all age groups in Northern Spain.

Since the early 2000s, pneumococcal conjugate vaccines (PCVs) have been shown to be effective in the prevention of pneumonia and invasive pneumococcal diseases. In 2011, the Galician region incorporated PCV in the routine infant immunization, the very first stable program in Spain. We aim to assess direct and indirect benefits of PCV vaccination on all-cause pneumonia in the region across different age groups using an ecological study design. For this, we calculated the annual hospitalization rates using a hospital-based disease registry. We identified all-cause pneumonia, pneumococcal pneumonia and pneumococcal invasive diseases within the registry. Hospitalization rates were computed and compared across three study periods: pre-vaccination (1998-2003), early-vaccination (2005-2009) and routine-vaccination (2011-2015). Across Northern Spain, we identified 114,873 all-cause pneumonia hospitalizations, of which 24,808 were further diagnosed with pneumococcal pneumonia. The majority were elderly > 64 years (67.3%). Hospitalizations from all-cause pneumonia had a net increase from 20.6 (pre-PCV) and 21.4/10,000 (early) to 28.4/10,000 (routine) (+32.7%, p < .0001), this is attributed to the huge number of cases in the elderly age group. In contrast, a net reduction of incidence of hospitalized pneumococcal pneumonia was observed from 6.3/10,000 (pre-PCV) and 5.7/10,000 (early) to 2.4/10,000 (routine) cases (-57.9%, p < .0001). Thus, routine infant vaccination may have resulted to an overall decline of pneumococcal pneumonia in infants, as well as in elderly age groups. However, a paradoxical increase on all-cause pneumonia was observed in Galicia, mostly attributed to the growing number of cases in the elderly population.

Effects of leaf extracts of Protium spruceanum against adult and larval Rhipicephalus microplus.

Rhipicephalus microplus is the ectoparasite responsible for large economic losses in cattle herds. The aim of this study was to investigate the in vitro action of leaf extracts of Protium spruceanum on resistant strains of this tick. Ethanolic extracts (EE) and ethyl acetate extracts (EAE) of P. spruceanum leaves were used against engorged females and larvae by biocarrapaticidogram and larval package (TPL) tests. Chromatographic analyses were performed using a gas chromatograph and showed the presence of the flavonoid catechin in both extracts and the terpenoid ß-amirine only in EAE. EE and EAE were not effective in altering the mortality of engorged females; however, 92% of females treated with the extracts reduced the postures and > 90% of larval hatching was inhibited at 100 mg/ml of extracts. Acaricidal efficacies were > 80% for 100 mg/ml EE and > 90% for EAE at 50 mg/ml. In TPL tests, EE and EAE promoted larval mortality > 88% at 100 mg/ml. In this study, EAE was more effective against adult females and larvae than EE, representing an alternative agent for the integrated control of R. microplus.

Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio / SEIP-AEPAP-SEPEAP consensus document on the aetiology, diagnosis and treatment of bacterial skin infections in out-patients

Las infecciones cutáneas constituyen un motivo de consulta frecuente en dermatología pediátrica. Se revisan las manifestaciones clínicas, el diagnóstico y el tratamiento de los principales cuadros infecciosos bacterianos de la piel, así como de la sobreinfección de las heridas punzantes y por mordedura. Las bacterias más prevalentes en las infecciones cutáneas son Staphylococcus aureus (S. aureus) y Streptococcus pyogenes. El tratamiento es generalmente empírico y solo ante determinadas circunstancias o mala evolución clínica se recomienda el estudio microbiológico. Las infecciones cutáneas superficiales pueden tratarse con antisépticos y antibióticos tópicos (mupirocina o ácido fusídico). El tratamiento sistémico se reserva para formas extensas, graves o con otros factores de riesgo del huésped. En estos casos, el antibiótico de elección dependerá, entre otros factores, de los patógenos sospechados; los más utilizados son penicilina, amoxicilina, amoxicilina-ácido clavulánico y cefalosporinas de primera o segunda generación. Considerando la baja incidencia de S. aureus resistente a la meticilina de adquisición comunitaria en nuestro país, no se recomienda modificar el tratamiento empírico salvo en circunstancias de especial gravedad, recurrencia o antecedente epidemiológico, en cuyo caso el tratamiento recomendado es clindamicina o trimetoprima-sulfametoxazol

Skin infections are a common cause for dermatological consultations in the paediatric setting. A review is presented of the clinical manifestations, diagnosis and treatment of the main bacterial skin infections, as well as the diagnosis and treatment of super-infected puncture and bite wounds. The most prevalent bacteria in skin infections are Staphylococcus aureusand Streptococcus pyogenes. Treatment is usually empirical, since microbiological studies are only recommended under certain circumstances or lack of improvement with common therapies. Superficial skin infections can be treated with local antiseptics or antibiotics (mupirocin or fusidic acid). Systemic treatment is usually reserved for patients with extensive or severe disease or with other risk factors. Systemic treatment depends on the suspected infecting bacteria, with penicillin, amoxicillin, amoxicillin-clavulanic acid and first or second generation cephalosporin being the most frequently used drugs. Due to the low incidence of community-acquired methicillin-resistant infection by S. aureus in Spain, the use of clindamycin or co-trimoxazole is only recommended after severe disease, relapses or a clear epidemiological background

[SEIP-AEPAP-SEPEAP consensus document on the aetiology, diagnosis and treatment of bacterial skin infections in out-patients]. / Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio.

Skin infections are a common cause for dermatological consultations in the paediatric setting. A review is presented of the clinical manifestations, diagnosis and treatment of the main bacterial skin infections, as well as the diagnosis and treatment of super-infected puncture and bite wounds. The most prevalent bacteria in skin infections are Staphylococcus aureus and Streptococcus pyogenes. Treatment is usually empirical, since microbiological studies are only recommended under certain circumstances or lack of improvement with common therapies. Superficial skin infections can be treated with local antiseptics or antibiotics (mupirocin or fusidic acid). Systemic treatment is usually reserved for patients with extensive or severe disease or with other risk factors. Systemic treatment depends on the suspected infecting bacteria, with penicillin, amoxicillin, amoxicillin-clavulanic acid and first or second generation cephalosporin being the most frequently used drugs. Due to the low incidence of community-acquired methicillin-resistant infection by S. aureus in Spain, the use of clindamycin or co-trimoxazole is only recommended after severe disease, relapses or a clear epidemiological background.

Síndrome PFAPA: de la sospecha al diagnóstico / PFAPA syndrome: from suspicion to diagnosis

La fiebre es uno de los principales motivos de consulta en la infancia. Generalmente, se asocia a procesos infecciosos banales, pero cuando se prolonga en el tiempo o los episodios recurren, es necesario hacer el diagnóstico diferencial con infecciones poco habituales, enfermedades autoinmunes, inmunodeficiencias primarias y neoplasias. El síndrome PFAPA (fiebre periódica, faringitis, estomatitis aftosa y adenitis) pertenece al grupo de síndromes de fiebre periódica, y se caracteriza por episodios febriles que aparecen regularmente durante meses alternándose con intervalos asintomáticos. Es la causa más frecuente de fiebre periódica en la infancia, y actualmente es una entidad clínica bien definida. Los corticoides son el pilar fundamental del tratamiento; resuelven el episodio de manera llamativa, hecho que constituye un criterio diagnóstico. El diagnóstico precoz y el tratamiento adecuado permiten mejorar la calidad de vida del paciente y su entorno, evitando la toxicidad farmacológica. Presentamos los casos de 2 niñas en edad preescolar con síndrome PFAPA (AU)

Fever is one of the most frequent reasons for medical consultation during childhood. Usually is related to minor viral infections, but when lasts over time or episodes recur, it is necessary to make differential diagnosis of unusual infections, autoimmune diseases, immunodeficiencies and neoplasms. The PFAPA syndrome (periodic fever, pharyngitis, aphthous stomatitis and adenitis) belongs to the group of periodic fever syndromes characterised by episodes of fever that recur regularly for several months, alternating with healthy periods. It is the most common recurrent periodic fever disorder described in childhood and the clinical manifestations of PFAPA syndrome episodes are well known. Corticoids are the treatment of choice and resolve the febrile episode, and this spectacular outcome is used as diagnostic criterion. Early diagnosis and appropriate treatment can significantly improve the quality of life of both patients and families, and prevent drug toxicity. We present two preschool girls with PFAPA syndrome (AU)

Reacción paradójica al tratamiento antituberculoso en un caso de tuberculosis pulmonar / Paradoxical reaction to the treatment of a patient with pulmonary tuberculosis

Los pacientes con tuberculosis pueden presentar un empeoramiento transitorio de la enfermedad después de iniciar un tratamiento antituberculoso adecuado. Es lo que se denomina «reacción paradójica al tratamiento antituberculoso». Es más frecuente en pacientes infectados por el virus de la inmunodeficiencia humana, pero también ocurre en los no infectados. Son pacientes que, tras una mejoría inicial, presentan nuevas lesiones o las ya existentes empeoran. Se ha sugerido que estas reacciones se deben a la recuperación del sistema inmunitario que ocurre en el curso de un tratamiento. El diagnóstico sólo es posible después de un estudio exhaustivo que descarte otras causas de empeoramiento de la enfermedad, especialmente el fracaso o el incumplimiento terapéutico. El tratamiento es sintomático en las reacciones leves, y no es preciso modificar el régimen inicial de fármacos. En las formas más graves los expertos aconsejan el uso de corticoides, tema que aún es motivo de discusión. El conocimiento de estas reacciones permite informar adecuadamente a los pacientes y sus familias, y evitar procedimientos invasivos y modificaciones innecesarias en el tratamiento. Presentamos el caso de una niña de 2 años de edad con tuberculosis pulmonar y adenitis cervical tuberculosa, que presentó una reacción paradójica un mes y medio después de iniciado el tratamiento antituberculoso. Se revisa la bibliografía relacionada (AU)

Patients with tuberculosis (TB) may show a transitional worsening of their disease after starting an adequate tuberculosis drugs therapy. That is a so-called paradoxical reaction. It is more frequent in patients infected by the human immunodeficiency virus (HIV), but it can also take place in non-infected ones. These are patients who, after an initial improvement, develop new lesions or suffer worsening of pre-existing ones. It has been suggested that these reactions are caused by a recovery of the altered immune response as a result of appropriate treatment. The diagnosis is only possible after an exhaustive study that excludes other potential causes of worsening, especially treatment failure or non-adherence to the treatment. The treatment is merely symptomatic in case of mild reactions and it is not necessary to modify the therapeutic plan. In the most severe reactions, experts suggest the use of corticosteroids, although the latter is still subject of discussion. The knowledge of these reactions allows providing accurate information to the patients and their families, therefore avoiding invasive procedures and unnecessary modifications of the treatment. We report the case of a two-year-old girl with pulmonary tuberculosis and tuberculous cervical adenitis presenting paradoxical reaction one month and a half after initiating the treatment for tuberculosis. The related literature is reviewed (AU)

Documento de consenso de la Sociedad de Infectología Pediátrica sobre el tratamiento de la infección fúngica basado en la respuesta inmunológica / Spanish Paediatric Infectious Diseases Society Consensus Document on the Treatment of Fungal Infections Based on the Immune Response

La infección fúngica invasiva es una infección de tipo oportunista que afecta principalmente al paciente inmunodeprimido y crítico y que, a pesar de los avances en el diagnóstico y tratamiento, sigue comportando una elevada morbimortalidad. Esto ha determinado la investigación de tratamientos coadyuvantes a la terapia antifúngica estándar. Entre ellos, destaca el tratamiento basado en la respuesta inmunológica, que comprende el tratamiento inmunomodulador (transfusión de células T y de células dendríticas, factores estimuladores de colonias, interferón gamma, interleucina 12, vacunas antifúngicas, factores de transferencia y ciertos fármacos como la cloroquina) y el tratamiento inmunoterápico que incluye la transfusión de granulocitos, los anticuerpos monoclonales y la inmunoglobulina endovenosa. El presente documento recoge una revisión y actualización de los datos disponibles sobre esta modalidad terapéutica y aporta los conocimientos básicos de la respuesta inmune frente a la infección fúngica para poder comprender mejor el papel de dicha estrategia terapéutica en la respuesta al tratamiento antifúngico convencional, así como sus potenciales indicaciones en el paciente pediátrico. Existen pocos datos sobre evidencia científica y grado de recomendación para su uso (AU)

Despite the emergence of new diagnostic and therapeutic methods, invasive fungal infections are still a major cause of morbidity and mortality in immunocompromised and critical patients. Therefore, adjuvant treatments to the standard antifungal therapy are being investigated, with immunity-based therapy being one of the most important. Both immunomodulatory (dendritic and T cells transfusions, colony stimulating factors, interferón-gamma, interleukin 12, fungal vaccines, transfer factors and certain drugs such as chloroquine) and immunotherapeutic modalities (granulocyte transfusions, monoclonal antibodies and intravenous immunoglobulin) have been described. This document aims to summarise currently available data on immunity-based therapy of fungal infections and to provide basic knowledge on the immune response to fungal infections. This helps to understand how, in selected cases, immunity-based therapy may improve the response to standard antifungal treatment. The potential indications of immunity-based therapy in the paediatric patient are reviewed, although there is still a lack of scientific evidence for its use in children (AU)

[Spanish Paediatric Infectious Diseases Society consensus document on the treatment of fungal infections based on the immune response]. / Documento de consenso de la Sociedad de Infectología Pediátrica sobre el tratamiento de la infección fúngica basado en la respuesta inmunológica.

Despite the emergence of new diagnostic and therapeutic methods, invasive fungal infections are still a major cause of morbidity and mortality in immunocompromised and critical patients. Therefore, adjuvant treatments to the standard antifungal therapy are being investigated, with immunity-based therapy being one of the most important. Both immunomodulatory (dendritic and T cells transfusions, colony stimulating factors, interferón-gamma, interleukin 12, fungal vaccines, transfer factors and certain drugs such as chloroquine) and immunotherapeutic modalities (granulocyte transfusions, monoclonal antibodies and intravenous immunoglobulin) have been described. This document aims to summarise currently available data on immunity-based therapy of fungal infections and to provide basic knowledge on the immune response to fungal infections. This helps to understand how, in selected cases, immunity-based therapy may improve the response to standard antifungal treatment. The potential indications of immunity-based therapy in the paediatric patient are reviewed, although there is still a lack of scientific evidence for its use in children.

[Emerging invasive fungal infections]. / Infecciones fúngicas invasivas emergentes.

The frequency and diversity of invasive fungal infections has changed over the last 25 years. The emergence of less common, but medically important fungi has increased, and the children at risk has expanded, with the inclusion of medical conditions such as cancer, mainly haematological malignancy or stem cell transplant, immunosuppressive therapy, prolonged neutropenia, and T-cell immunodeficiency. Among mould infections, fusariosis and phaeohyphomycosis (Dematiaceous fungi) have been increasingly reported in this group of patients. To successfully manage these challenging infections, it is imperative that paediatricians and sub-specialists remain aware of the optimal and timely diagnosis and therapeutic options. Unlike other common mycoses that cause human disease, there no simple antigen or serological tests available to detect these pathogens in tissue or blood. The outcome for these disseminate, and often refractory fungal infections in neutropenic patients and transplant recipients remains extremely poor, requiring early and aggressive therapy. Unfortunately there are no guidelines outlining the choices for optimal therapy in the treatment of paediatric invasive fungal infections do not exist, and on the other hand are limited paediatric data available comparing antifungal agents in children with proven, probable or suspected invasive fungal infection. The options for treatment rest mainly on some adult guidelines that comment on the treatment of these emerging and uncommon important fungi in children. Despite the sparse clinical trials available on treatment and its poor outcome, options for treatment of invasive fungal infections have increased with the advance of new antifungal agents, with improved tolerability and increased range of activity. The epidemiology, clinical manifestations, diagnosis and treatment of fusariosis and phaeohyphomycosis are discussed in this article.

Infecciones fúngicas invasivas emergentes / Emerging invasive fungal infections

La frecuencia y diversidad de las infecciones fúngicas ha cambiado en los últimos 25 años. La aparición de hongos menos frecuentes pero con importancia médica está aumentando y ahora son más los niños en riesgo al añadirse procesos médicos predisponentes como los debidos al cáncer, principalmente neoplasias malignas hematológicas, trasplantes de médula ósea o de progenitores hematopoyéticos (TPH), tratamientos inmunosupresivos, neutropenias prolongadas e inmunodeficiencias de células T. Entre las infecciones por hongos, fusariosis y feohifomicosis (hongos dematiáceos) están siendo comunicadas con más frecuencia en este grupo de pacientes.Para tratar con éxito estas desafiantes infecciones es prioritario que pediatras y subespecialistas se mantengan informados sobre el diagnóstico oportuno y óptimo y así como de las opciones terapéuticas. Al contrario que otras micosis más frecuentes que causan enfermedad en humanos, no hay disponibilidad de pruebas diagnósticas simples antigénicas o serológicas para detectar estos microorganismos en sangre o tejidos(AU)

En pacientes neutropénicos y en receptores de trasplantes, el pronóstico de estas infecciones fúngicas diseminadas y a menudo refractarias es particularmente malo por lo que se requiere un tratamiento precoz y agresivo. Por desgracia no existen guías o protocolos que esbocen la elección más óptima del tratamiento de las infecciones fúngicas invasivas pediátricas y por otro lado hay pocas referencias disponibles que permitan comparar los diversos agentes antifúngicos en niños con sospecha probable o probada infección fúngica invasiva. Las opciones de tratamiento se basan principalmente en algunas guías de adultos donde se comenta el tratamiento de estos hongos emergentes, poco frecuentes e importantes en niños. A pesar de esta insuficiente disponibilidad de estudios clínicos sobre el tratamiento y el mal pronóstico, las opciones terapéuticas de las infecciones fúngicas invasivas han aumentado con el desarrollo de nuevos agentes antifúngicos de mejor tolerancia y mayor espectro de actividad.La epidemiología, manifestaciones clínicas, diagnóstico y tratamiento de la fusiariosis y feohifomicosis (hongos dematiáceos) se revisan en este artículo(AU)

The frequency and diversity of invasive fungal infections has changed over the last 25 years. The emergence of less common, but medically important fungi has increased, and the children at risk has expanded, with the inclusion of medical conditions such as cancer, mainly haematological malignancy or stem cell transplant, immunosuppressive therapy, prolonged neutropenia, and T-cell immunodeficiency. Among mould infections, fusariosis and phaeohyphomycosis (Dematiaceous fungi) have been increasingly reported in this group of patients.To successfully manage these challenging infections, it is imperative that paediatricians and sub-specialists remain aware of the optimal and timely diagnosis and therapeutic options. Unlike other common mycoses that cause human disease, there no simple antigen or serological tests available to detect these pathogens in tissue or blood.The outcome for these disseminate, and often refractory fungal infections in neutropenic patients and transplant recipients remains extremely poor, requiring early and aggressive therapy. Unfortunately there are no guidelines outlining the choices for optimal therapy in the treatment of paediatric invasive fungal infections do not exist, and on the other hand are limited paediatric data available comparing antifungal agents in children with proven, probable or suspected invasive fungal infection. The options for treatment rest mainly on some adult guidelines that comment on the treatment of these emerging and uncommon important fungi in children. Despite the sparse clinical trials available on treatment and its poor outcome, options for treatment of invasive fungal infections have increased with the advance of new antifungal agents, with improved tolerability and increased range of activity.The epidemiology, clinical manifestations, diagnosis and treatment of fusariosis and phaeohyphomycosis are discussed in this article(AU)

Infección pulmonar por "Micobacterium scrofulaceum" en huésped inmunocompetente / Pulmonary infection due ti "Mycobacterium scrofulaceum" in an immunocompetent host

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Child malaria treatment practices among mothers in the district of Yanfolila, Sikasso region, Mali.

We studied child malaria treatment practices among mothers living in the District of Yanfolila in southern Mali. For sampling, we first chose five of 13 health areas with probability proportional to size. Then villages, compounds and mothers with at least one child aged 1-5 years were randomly chosen. We assessed the spleen size of one 1-5 year-old child of each mother, collected a thick blood film and recorded the body temperature of every child whose mother thought he/she was sick. 399 mothers in 28 villages were interviewed with a structured questionnaire divided into two parts. If the child had had soumaya (a term previously associated with uncomplicated malaria) during the past rainy season, we asked about signs and symptoms, health-seeking behaviour (who the mother consulted first) and treatment. If not, information about knowledge of the disease and treatment to be given was collected. 86% of the mothers interviewed stated that their child had been sick and almost half of them had had soumaya. All mothers named at least one sign by which they recognized the disease. Vomiting, fever and dark urine/yellow eyes/jaundice were the three most common signs mentioned. 75.8% managed their child's disease at home and used both traditional and modern treatment. The most common anti-malarial drug was chloroquine, often given at inappropriate dosage. The sensitivity and specificity of the mothers' diagnosis was poor, although this might be explained by the large percentage of children who had already been treated at the time of the interview. The results of our survey call for prompt educational action for the correct treatment of uncomplicated malaria/soumaya, particularly for mothers and possibly for shopkeepers. The high spleen rate (58.1%) among randomly selected children confirms that malaria is a common disease in this area. Improved case-management at home could only be beneficial.

Ectopic production of ACTH by Wilms' tumor.

The authors present the 2nd documented case of Wilms' tumor associated with the "ectopic ACTH syndrome'. This is a 7 1/2-year-old girl who, on examination at the time of admission, had the classical cushingoid appearance. A large hard mass was palpable in the right side of the abdomen. Hormonal assays were consistent with Cushing's syndrome; the serum ACTH levels were extremely high. After surgical removal of the mass, we suspected a stage I Wilms' tumor; this was confirmed by histopathological studies. After surgery, the girl quickly lost her cushingoid appearance and weight excess. Postoperative serum ACTH levels were normal. Ectopic hormone syndromes associated with tumors in childhood are discussed as well as the possible mechanism involved in the ectopic production of ACTH.