Delayed Development of Coronary Artery Dilitation in Suspected Severe Acute Respiratory Syndrome Coronavirus 2 Multisystem Inflammatory Syndrome: More Research Needed.

Although significant disease burden in the severe acute respiratory syndrome coronavirus 2 pandemic has been relatively uncommon in children, worldwide cases of a postinfectious multisystem inflammatory syndrome in children and possible atypical Kawasaki-like disease attributing to severe acute respiratory syndrome coronavirus 2 infection have arisen. Original thinking for coronavirus disease-19 disease was that an overwhelming proinflammatory response drove disease pathogenesis. Emerging reports suggest that a robust immune suppression may be more relevant and predominant. Recently reported data on children with multisystem inflammatory syndrome in children have demonstrated a heterogeneity of immune phenotypes among these patients, with concern for a strong initial proinflammatory state; however, data are lacking to support this. Likewise, understanding development of certain clinical findings to changes in the immune system is lacking. CASE SUMMARY: We report a 12-year-old multiracial male with negative coronavirus disease-19 nasopharyngeal RNA polymerase chain reaction testing but positive severe acute respiratory syndrome coronavirus 2 serology, subsequent development of vasodilatory shock with myocardial depression, and subsequent delayed development of coronary artery dilatation after resolution of myocardial depression. Unlike previous reported cases of multisystem inflammatory syndrome in children, he exhibited profound lymphopenia without specific inflammatory cytokines elevations, whereas nonspecific markers (ferritin and C-reactive protein) were increased. He subsequently was discharged on day 12 of hospitalization with complete recovery. CONCLUSION: Our representative case of a patient with coronavirus disease-19-associated multisystem inflammatory syndrome in children without robust hyperinflammation and a delayed finding of coronary artery dilatation compared with reported case series highlights the need for further mechanistic understanding of coronavirus disease-19 disease and subsequent multisystem inflammatory syndrome in children or Kawasaki disease development. This report offers a number of disease mechanisms and clinical evolution considerations for further elucidation to guide development of potential therapies.

Impact of Contaminated Blood Cultures on Children, Families, and the Health Care System.

BACKGROUND: Contaminated blood cultures pose a significant burden. We sought to determine the impact of contaminated peripheral blood cultures on patients, families, and the health care system. METHODS: In this retrospective case-control study from January 1, 2014, to December 31, 2017, we compared the hospital course, return visits and/or admissions, charges, and length of stay of patients with contaminated peripheral blood cultures (case patients) with those of patients with negative cultures (controls). Patients were categorized into those evaluated and discharged from the emergency department (ED) (ED patients) and those who were hospitalized (inpatients). RESULTS: A total of 104 ED case patients were matched with 208 ED control patients. A total of 343 case inpatients were matched with 686 inpatient controls. There was no significant difference between case and control patient demographics, ED, or hospital course at presentation. Fifty-five percent of discharged ED patients returned to the hospital for evaluation and/or admission versus 4% of controls. There was a significant (P < .0001) increase in repeat blood cultures (43% vs 1%), consultations obtained (21% vs 2%), cerebrospinal fluid studies (10% vs 0%), and antibiotic administration (27% vs 1%) in ED patients compared with controls. Each ED patient requiring revisit to the hospital incurred, on average, $4660 in additional charges. There was a significant (P < .04) increase in repeat blood cultures (57% vs 7%), consultations obtained (35% vs 28%), broadening of antibiotic coverage (18% vs 11%), median length of stay (75 vs 64 hours), and median laboratory charges ($3723 vs $3296) in case inpatients compared with controls. CONCLUSIONS: Contaminated blood cultures result in increased readmissions, testing and/or procedures, length of stay, and hospital charges in children.

Pediatric Anaerobic Blood Culture Practices in Industrialized Countries.

BACKGROUND: Routine anaerobic blood culture collection in febrile children is controversial, as clinicians try to account for the severe but relative infrequency of anaerobic bacteremia. Furthermore, clinical and laboratory practice variation among institutions may lead to potentially inaccurate epidemiological data. Our goal was to assess blood culture practices in pediatric patients throughout an international network of hospitals in industrialized countries. METHODS: We conducted a survey of current clinical and laboratory practice patterns in a convenience sample of international institutions participating in 6 pediatric emergency research networks in the US, Canada, Europe, Australia, and New Zealand. A lead clinician at each institution queried institutional practices from the emergency department, pediatric intensive care unit, and oncology medical directors. The microbiology director at each institution completed the laboratory survey. RESULTS: Sixty-five of 160 (41%) invited institutions participated in the survey. Routine anaerobic blood cultures are collected in 30% of emergency departments, 30% of intensive care units, and 48% of oncology wards. Reasons for restricting anaerobic culture collection included concerns regarding blood volume (51%), low pretest probability (22%), and cost-effectiveness (16%). The most common reasons institutions allow for selectively obtaining anaerobic cultures are clinical suspicion (64%) and patients who are immunosuppressed (50%). The microbiology survey showed variation in systems, although most use the BACTEC™ culture system and MALDI-TOF for organism identification. CONCLUSIONS: There is broad variation in anaerobic blood culture practices among a network of pediatric hospitals in industrialized countries.

Paragonimus kellicotti flukes in Missouri, USA.

Paragonimiasis is an infection caused by lung flukes of the genus Paragonimus. In Asia, P. westermani infections are relatively common because of dietary practices. However, in North America, cases of paragonimiasis, which are caused by P. kellicotti flukes, are rare. Only 7 autochthonous cases of paragonimiasis were reported during 1968-2008. In 2009, we reported 3 new case-patients with paragonimiasis who had been seen at our medical center over an 18-month period. Six additional case-patients were identified in St. Louis, Missouri, USA, and treated at Washington University-affiliated health centers in 2009-2010. We report detailed descriptions of these case-patients, which includes unusual clinical manifestations. We also describe public health interventions that were undertaken to inform the general public and physicians about the disease and its mode of transmission.

Contribution of autolysin and Sortase a during Enterococcus faecalis DNA-dependent biofilm development.

Biofilm production is a major attribute of Enterococcus faecalis clinical isolates. Although some factors, such as sortases, autolysin, and extracellular DNA (eDNA), have been associated with E. faecalis biofilm production, the mechanisms underlying the contributions of these factors to this process have not been completely elucidated yet. In this study we define important roles for the major E. faecalis autolysin (Atn), eDNA, and sortase A (SrtA) during the developmental stages of biofilm formation under static and hydrodynamic conditions. Deletion of srtA affects the attachment stage and results in a deficiency in biofilm production. Atn-deficient mutants are delayed in biofilm development due to defects in primary adherence and DNA release, which we show to be particularly important during the accumulative phase for maturation and architectural stability of biofilms. Confocal laser scanning and freeze-dry electron microscopy of biofilms grown under hydrodynamic conditions revealed that E. faecalis produces a DNase I-sensitive fibrous network, which is important for biofilm stability and is absent in atn-deficient mutant biofilms. This study establishes the stage-specific requirements for SrtA and Atn and demonstrates a role for Atn in the pathway leading to DNA release during biofilm development in E. faecalis.

Adverse effects of tenofovir use in HIV-infected pregnant women and their infants.

BACKGROUND: Data regarding use of tenofovir disoproxil fumarate in HIV-infected pregnant women are limited. OBJECTIVE: To identify adverse effects of tenofovir use during pregnancy in HIV-infected women and their infants. METHODS: In a retrospective case series, the charts of 127 pregnant HIV-infected women who received highly active antiretroviral therapy (HAART) between 2001 and 2005 were reviewed. Those who received tenofovir during pregnancy were selected for this study. Each woman's chart was reviewed for clinical data and adverse events during the pregnancy; each infant's chart was reviewed for growth parameters from birth to 12 months. RESULTS: Fifteen HIV-infected women with limited treatment options were prescribed HAART containing tenofovir during 16 pregnancies. In utero tenofovir exposure was a median of 127 days (range 6-259). Tenofovir was well tolerated by all women throughout pregnancy. There were 15 successful deliveries occurring at a median (range) of 36 weeks (30-40), with a median birth weight of 3255 g (1135-3610). Complications, including 1 spontaneous abortion, occurred in 9 pregnancies and were not attributed to tenofovir. Eleven (73%) women had abnormal laboratory results, including 6 who experienced grade 1 hemoglobin abnormalities; 4 of these women had preexisting anemia. Calculated glomerular filtration rate (calculated by Modification of Diet in Renal Disease equation) remained above 90 mL/min/1.73 m(2) in all women, except one who had a transient decline. Fourteen infants demonstrated normal growth and development for weight and height at birth, as well as during the 12-month follow-up period; no congenital malformations were documented. Mother-to-child transmission of HIV was not observed in this cohort. CONCLUSIONS: Tenofovir was found to be a well-tolerated component of HAART in this small cohort. Longer-term assessment of tenofovir effects on childhood growth and larger prospective studies of tenofovir use in pregnant women are warranted.

Enterococcus faecalis tropism for the kidneys in the urinary tract of C57BL/6J mice.

Enterococcus faecalis is a gram-positive bacterium that can cause a variety of nosocomial infections of which urinary tract infections are the most common. These infections can be exceptionally difficult to treat because of drug resistance of many E. faecalis isolates. Despite their troublesome nature, little is known about the host or bacterial factors necessary for E. faecalis to cause disease in the urinary tract. Using a mouse model of urinary tract infection, we have shown that E. faecalis is capable of persisting in the kidneys of mice for at least 2 weeks. In contrast, bacterial titers from the bladders of the same mice were inconsistent and tended to be much lower than those recovered from the kidney. This preference for the kidney over the bladder is also observed in other clinical E. faecalis strains. Histologic examination of bladder and kidney tissues demonstrated that E. faecalis induced an inflammatory response in the kidney but not in the bladder. This inflammatory response was TLR2 independent and did not induce inflammatory markers typically associated with uropathogenic Escherichia coli. Using a competition assay, we demonstrated that a pyelonephritis clinical isolate had a growth advantage over a laboratory strain of E. faecalis in the kidneys but not in the bladders of mice. Taken together, these results demonstrate that E. faecalis has tropism for the kidneys in the urinary tracts of mice and that this system can be used to study factors involved in the pathogenesis of urinary tract infections.