Role of dexamethasone in controlling the proinflammatory cytokine cascade in the first episode of paediatric acute pyelonephritis.

AIM: Febrile urinary tract infection is a common bacterial infection in childhood. The kidney damage after acute pyelonephritis (APN) could be related to the stimulation of the proinflammatory response. We aimed to investigate the role of inflammatory cytokines and the effect of dexamethasone after a first episode of APN. METHODS: Subanalysis of the DEXCAR RCT in which children with confirmed APN (1 month-14 years) were randomly assigned to receive a 3 days course of either intravenous dexamethasone or placebo. Urinary cytokine levels at diagnosis and after 72 h of treatment were measured. RESULTS: Ninety-two patients were recruited. Younger patients, males and those with abnormalities in the ultrasound study or vesicoureteral reflux showed higher values of urinary cytokines. Patients with severe APN had higher Tumour Necrosis Factor (TNF)α levels (81.0 ± 75.8 vs. 33.6 ± 48.5 pg/mg creatinine, p = 0.015). Both intervention groups showed similar basal clinical characteristics, including urinary cytokine levels. Treatment reduced urinary cytokine levels irrespective of dexamethasone administration. Neither the intervention group nor the urinary cytokine levels modulated the development of kidney scars. CONCLUSION: Basal urinary cytokines were associated with age, abnormal ultrasound and vesicoureteral reflux. Patients with severe APN had higher TNFa urinary levels. Administration of dexamethasone in children with APN does not improve the control of the proinflammatory cytokine cascade.

Dexamethasone to prevent kidney scarring in acute pyelonephritis: a randomized clinical trial.

BACKGROUND: Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children. METHODS: Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed. RESULTS: Ninety-one participants completed the follow-up and were finally included (dexamethasone n = 49 and placebo n = 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups, p = 0.907). Renal damage severity in the early DMSA (ß = 0.648, p = 0.023) and procalcitonin values (ß = 0.065 p = 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (ß = 0.545, p = 0.054), but dexamethasone treatment showed no effect. CONCLUSION: Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014. "A higher resolution version of the Graphical abstract is available as Supplementary information."

Implicación de la infección por enterovirus en la hospitalización pediátrica de un hospital general / Implication of enterovirus infection on paediatric hospitalisation in a general hospital

Introducción. Los enterovirus originan un 80% de los casos de meningitisen niños y son causa frecuente de hospitalización por fiebreen menores de tres meses de edad.Objetivo. Evaluar la implicación de este agente etiológico en lahospitalización pediátrica en nuestro centro y describir las característicasclínicas.Método. Revisión retrospectiva de las historias clínicas de niños ingresadosen que se detectó genoma de enterovirus por reacciónen cadena de la polimerasa (PCR) entre abril de 2000 y diciembrede 2006.Resultados. Se obtuvieron 83 muestras (líquido cefalorraquídeo(LCR), heces, frotis faríngeo y sangre) de 62 pacientes. La edad mediafue de 8 meses (entre 5 días y 12 años). El 50% eran lactantesmenores de 3 meses. El principal motivo de consulta fue la fiebreseguida de cefalea y vómitos y el 29% presento signos meníngeos.La PCR por enterovirus en LCR resultó positiva en 27 casos, solamente17 tenían pleocitosis y en 5 también se detectó en heces yfrotis faríngeo. Se diagnosticó una infección bacteriana concomitanteen 13 pacientes. La estancia media en el hospital fue de 8días (DE=4,08).Conclusiones. 1. Los enterovirus son agentes frecuentemente implicadosen la hospitalización pediátrica por fiebre en menores detres meses de edad y son responsables de la mayoría de meningitisasépticas en los niños de nuestra serie. 2. En recién nacidos y lactantesel síntoma principal es la fiebre con irritabilidad, mientrasque en los escolares la fiebre se asocia a cefalea y signos meníngeos.3. La detección de enterovirus por PCR en LCR no siempre seacompaña de pleocitosis. 4. El resultado de la PCR más precoz podríareducir la utilización de antibióticos y la estancia hospitalaria(AU)

Introduction. Enterovirus is the cause of 80% of meningitis cases in children and is also a frequent cause of admission to hospital in infants under 3 months old with fever. Objective. To review the implication of this etiologic agent in children admitted to our centre and to describe the clinical characteristics. Method. Retrospective review of children's clinical records with positive detection of enterovirus genome by polymerase chain reaction (PCR) in the period between April 2000 and December of 2006. Results. Enterovirus genome was detected in 83 samples (cerebrospinal fluid (CSF), stools, throat culture, and blood) of 62 patients. The average age was 8 months (from 5 days to 12 years). 50% were nursing infants less than 3 months old. The most frequent symptom was fever, then headache and vomiting, and 29% with meningeal signs. Enterovirus was detected by PCR in CSF in 27 cases, 17 had pleocytosis, and in five the enterovirus was also positive in throat culture and stools. Bacterial infection was detected in 13 cases. The average hospital stay was eight days (SD=4.08). Conclusions. 1. Enterovirus is a common agent involved in patients younger than 3 months old with fever and is the most commonlyidentified cause of aseptic meningitis in our study. 2. In newborns and infants, the main symptoms are fever and irritability, while in school-age children, the fever is associated with headache and meningeal signs. 3. Enterovirus detection in CSF is not always accompanied by biochemical alteration. 4. Earlier enterovirus PCR result might decrease the length of hospital stays and unnecessary use of antibiotics(AU)

Retrobament amb la febre tifoide a Catalunya al segle XXI. Comentaris clínics i al tractament / No disponible

Fonament. La febre tifoide va ser una malaltia freqüental nostre país fins a la dècada dels vuitanta del segle XX. En l’actualitat el pediatre no està acostumat al diagnòstic clínic d’aquesta malaltia.Objectiu. Revisar els casos diagnosticats els darrers 6anys, a la vegada que revisar els aspectes més actuals de la malaltia i el seu tractamentMètode. Revisió retrospectiva dels casos diagnosticatsdurant el segle XXI amb l’anàlisi demogràfica, epidemiològica i clínica, les dades de laboratori, l’evolució i el tractamentResultats. S’han diagnosticat 10 casos entre el 2002-2006, només 2 van ser d’infants autòctons; els altres, excepte 1, havien arribat a Catalunya entre 2 i 15 dies abans. La febre, únic símptoma present en tots els casos, s’havia instaurat entre 3 i 15 dies abans. El diagnòstic es va fer per la positivitat de l’hemocultiu. Els microorganismes aïllats en 2 casos presentavenresistències. Es van tractar amb cefalosporines de3a generació iv o orals en 8 casos, 1 amb amoxicil·lina -àcid clavulànic i 1 amb azitromicina. L’apirèxia es va presentar entre els 3 i 15 dies amb una mitjana de 6.3 dies.Les complicacions, amb bona evolució: 4 hepatitis, 3 colecistitis alitiàsica, 1 coagulopatia, anèmia (que va necessitar transfusió) i pancreatitis. 1 recaiguda als 15 dies.Conclusions. a) El fet que en cap cas es pensa clínicament en aquest diagnòstic, excepte en la recaiguda. b) L’ajut que ofereix l’ecografia en el seguiment de possibles complicacions abdominals. c) L’actualització dels tractaments

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