Haemophilus influenzae Type b Vaccine Failure in Portugal: A Nationwide Multicenter Pediatric Survey.

BACKGROUND: Despite the high effectiveness of the Haemophilus influenzae type b (Hib) vaccine in preventing invasive disease (ID) in children, Hib vaccine failures (VFs) cases may still occur. This study aimed to characterize the Hib-VF cases in Portugal in a 12-year period and trying to identify the possible associated risk factors. METHODS: Prospective descriptive nationwide surveillance study. Bacteriologic and molecular studies were performed at the same Reference Laboratory. Clinical data were collected by the referring pediatrician. RESULTS: Hib was identified in 41 children with ID and 26 (63%) were considered VF. Nineteen (73%) cases occurred in children less than 5 years old; 12 (46%) occurred before the Hib vaccine booster dose at 18 months of age. Comparing the first and the last 6-year periods of the study, the incidence rate of Hib, VF and total H. influenzae (Hi) ID significantly raised ( P < 0.05). VF cases corresponded, respectively, to 13.5% (7/52) and 22% (19/88) of total Hi-ID cases ( P = 0.232). Two children died due to epiglottitis and 1 acquired sensorineural hearing loss. Only 1 child had an inborn error of immunity. The immunologic workup performed in 9 children revealed no significant abnormalities. All 25 Hib-VF strains analyzed belonged to the same clonal complex 6. CONCLUSIONS: In Portugal, more than 95% of children are vaccinated against Hib, but severe Hib-ID cases still occur. No predisposing factors were clearly identified to justify the increased number of VF in recent years. Along with continued Hi-ID surveillance, Hib colonization and serologic studies should be implemented.

Immune thrombocytopenia in the setting of acute SARS-CoV-2 infection.

Immune thrombocytopenia (ITP) is an immune-mediated event, characterised by the destruction of platelets by autoantibodies resulting in isolated thrombocytopaenia (platelets <100 x109/L). In children, most cases are preceded by a viral infection. Cases of ITP in the setting of SARS-CoV-2 infection have been described. We describe a previously healthy boy, who presented with an extensive frontal and periorbital haematoma, petechial rash on the trunk and coryza. He had suffered a minor head trauma, 9 days before admission. Blood tests revealed a platelet count of 8000/µL. The remainder study was unremarkable, except for a positive SARS-CoV-2 PCR. Treatment comprised a single dose of intravenous immunoglobulin, with increase in platelet count and no recurrence. We made a working diagnosis of an ITP concurrent with a SARS-CoV-2 infection. Although few cases have been described, SARS-CoV-2 might be considered as a trigger for ITP.

Transient symptomatic zinc deficiency in an exclusively breastfed infant.

A 3-month-old, full term female infant, adequate for gestational age, and exclusively breastfed, was admitted with a 10 day history of generalised scaling erythematous dermatitis, affecting the face (perinasal, nasolabial folds and periauricular), acral and intertriginous areas, with irritability and failure to thrive. Her mother had been treated with isoniazid since the third trimester because of family contact with tuberculosis. Based on a diagnosis of suspected impetiginised eczema, the infant was treated with flucloxacillin and prednisolone, and maternal isoniazid was suspended, with no improvement. Investigations found low serum zinc levels in the infant (33 µg/dL; normal range (NR) >60 µg/dL), normal plasma zinc levels in the mother (111.3 µg/dL; NR 68-120 µg/dL) and lower than the normal range of zinc levels in breast milk (270µg/L; NR 1000-2500 µg/L), suggesting acrodermatitis caused by zinc deficiency. Oral zinc supplementation (3 mg/kg/day) was started with a marked improvement in skin lesions, as well as good weight gain. At the age of 6 months, after food diversification, supplementation was suspended, without any recurrence of symptoms.

Metatarsal Salmonella enteritidis osteomyelitis in a healthy child.

Non-typhoidal Salmonella osteomyelitis in healthy children is a very rare condition. A previously healthy 7-year-old boy presented with foot pain following a small injury. Local inflammatory signs of the foot were observed, with a normal radiograph. Two weeks before, he had had gastroenteritis. Assuming cellulitis, flucloxacillin was began. Early during admission, surgical subcutaneous abscess drainage was performed and Salmonella enteritidis was identified. According to bacterial susceptibility, antibiotherapy was changed to ceftriaxone. A foot radiograph and an MRI scan, performed on the 9th and the 12th days, revealed findings suggestive of osteomyelitis of the metaphysis of the fifth metatarsal. Clinical worsening persisted and surgical extensive debridement was needed. A 6-week antibiotic treatment was completed, with a good outcome. Osteomyelitis with a poor evolution in children with risk factors (prior gastrointestinal illness, warm weather and previous exposure to antibiotics) can raise the possibility of a non-typhoidal Salmonella infection.

Lipschütz ulcer and group A streptococcal tonsillitis.

Lipschütz ulcers (LU) are non-sexually related genital ulcers, rarely reported. We describe a healthy 11-year-old girl, who presented with fever and a painful vulvar ulcer associated with erythematous tonsillitis. Throat swab test for Group A Streptococcus (GAS) was positive. She was treated with amoxicillin. Further investigation was negative, including Herpes Simplex virus DNA from ulcer swab and serology for Epstein-Barr virus, cytomegalovirus and Mycoplasma pneumoniae Antistreptolysin O titre was high. The ulcer healed in 2 weeks, with no recurrence in a 1 year follow-up period. The association of LU with GAS tonsillitis is very rare.

[Infectious Mononucleosis and Cholestatic Hepatitis: A Rare Association]. / Mononucleose Infeciosa e Hepatite Colestática: Uma Associação Rara.

Infectious mononucleosis is one of the major clinical manifestations of Epstein-Barr virus infection. In this syndrome, elevation of liver transaminase levels is common but cholestasis is rare, with few cases described in the literature. We present the case of a 14-year-old female adolescent, admitted to the Emergency Room with fever, odynophagia and cervical adenomegaly. She was treated with amoxicillin and two days later he presented with jaundice. The analytical evaluation was compatible with cholestatic hepatitis and abdominal ultrasound revealed hepatosplenomegaly without dilatation of the bile ducts. The diagnosis of Epstein-Barr virus infection was confirmed by the presence of serological markers. This case aims to raise awareness of a rare manifestation of a common infectious agent and, consequently, to the inclusion of acute Epstein-Barr virus infection in the differential diagnosis of pediatric cholestatic hepatitis.

A mononucleose infeciosa é uma das principais manifestações clínicas da infeção pelo vírus Epstein-Barr. Nesta síndrome, a elevação das aminotransferases é comum mas a colestase é rara, havendo poucos casos descritos na literatura. Adolescente, 14 anos, sexo feminino, admitida no serviço de urgência por febre, odinofagia e adenomegália cervical. Iniciou tratamento com amoxicilina e dois dias depois iniciou icterícia. A avaliação analítica foi compatível com hepatite colestática e a ecografia abdominal revelou hepatoesplenomegália, sem dilatação das vias bilares. O diagnóstico de infeção pelo vírus Epstein-Barr foi confirmado pela presença de marcadores serológicos. Este caso pretende alertar para uma manifestação rara de um agente infecioso comum e, consequentemente, para a inclusão da infeção aguda a vírus Epstein-Barr no diagnóstico diferencial de hepatite colestática na idade pediátrica.

Epstein-Barr virus-associated cholestatic hepatitis.

Epstein-Barr virus infection is common in children, usually presenting as infectious mononucleosis, including fever, tonsillitis and lymphadenopathy associated with self-resolving increase in transaminases. Cholestasis is rare in children with only a few cases reported but it was described in up to 55% of the adult population affected. We present a case of a 6-year-old boy with fever, vomiting and choluria. The physical examination showed hepatomegaly and jaundice and was otherwise unremarkable. The laboratory studies revealed increased transaminases (aspartate aminotransferase 97 U/L, alanine aminotransferase 166 U/L), hyperbilirubinaemia (total bilirubin 3.2 mg/dL, direct bilirubin 2.89 mg/dL) and increased γ-glutamyl transpeptidase (114 mg/dL). Urine urobilinogen was increased. The abdominal ultrasound showed hepatomegaly. Epstein-Barr viral capsid antibody IgM was positive and IgG was negative. Serological studies for other viruses were negative. We underline the need to consider Epstein-Barr virus in the cholestatic hepatitis differential diagnosis, in order to avoid unnecessary investigations.

[Infective endarteritis complicating clinically silent patent ductus arteriosus]. / Endarterite infecciosa de canal arterial clinicamente silencioso.

Infective Endocarditis is caused by bacteria or fungi involving the heart or the great vessels (Endarteritis). It is a rare and potentially ominous disease, with increasing incidence. Despite technological advances it remains difficult to diagnose and treat, particularly in children below two years. Congenital heart disease is the main risk factor for Infective Endocarditis in children. A patent ductus arteriosus clinically silent is infrequently implied. Over two-month-old Streptococci spp and Staphylococcus aureus are the main agents, responsible for 62-77% of cases. Gram negative rods count for 4-6%, being Klebsiella pneumoniae a rare pathogen. The authors report a case of a previously healthy four-months-old infant, admitted for bronchiolitis. He developed a Klebsiella pneumoniae persistent bacteremia related to Endarteritis of a silent patent ductus arteriosus. After prolonged and successful antibiotic therapy, the ductus arteriosus was surgically closed. He suffered no complication during the disease process and recovered uneventfully.