Pediatric severe factor XI deficiency: A multicenter study.

BACKGROUND: Factor XI (FXI) deficiency is a rare autosomal recessive bleeding disorder. Only scarce publications address its clinical features in children. The increased prevalence of FXI deficiency in Israel enabled data collection for this large multicenter cohort study. OBJECTIVE: Some hemostatic challenges may be unique or more common in children, such as bleeding in the neonatal period or trauma-related injury. The current study was designed to explore the potential impact of these differences in children with severe FXI deficiency. METHODS: Medical files of all children with FXI level under 15% followed at five tertiary centers were evaluated. The retrieved data comprised demographic and clinical characteristics, including bleeding episodes, surgical interventions, treatment strategies, as well as laboratory features. RESULTS: Sixty children, whose median age at diagnosis was 4.2 years and their median FXI level was 4%, were included. Three children experienced triggered intracranial hemorrhage (ICH) and two children had major bleeds. No bleeding complications occurred in surgeries in which hemostatic treatment consisting mostly of tranexamic acid or fresh frozen plasma was applied (n = 45). In contrast, excessive bleeding was noted in 25% of surgical procedures performed without hemostatic preparation (p = .002). CONCLUSION: This study's findings confirm the generally favorable outcome of this rare bleeding disorder, with no spontaneous bleeds or cases of perinatal ICH. Nonetheless, proper diagnosis and adequate hemostasis in the surgical setting are imperative. Unlike previous studies in adults, our pediatric study suggests an association between the severity of FXI deficiency and bleeding tendency.

The etiologic, microbiologic, clinical and outcome characteristics of immunocompetent young children <2 years of age hospitalized with acute neutropenia.

BACKGROUND: To describe the etiologic, microbiologic, clinical and outcome characteristics of acute neutropenia (absolute neutrophil count, ANC, <1.5 × 109/L) in hospitalized immunocompetent children. METHODS: Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, alveolar pneumonia, Brucellosis and Rickettsiosis. RESULTS: 431/671 (64.2%) healthy infants and children hospitalized with acute neutropenia were <2 years of age; 176 (40.8%), 167 (38.8%) and 88 (20.4%) patients were aged 0-3, 4-12 and 13-24 months, respectively. There were 19 (4.4%), 53 (12.3%), 140 (32.5%) and 209 (50.8%) patients with ANC count <200, 200-500, 501-1000 and 1001-1500 × 109 cells/L, respectively. Severe neutropenia (<500 × 109/L) was recorded in 72 (16.7%) patients. Fever >38 °C was present in 208/431 (48.3%) patients. Blood cultures were positive in 10 (2.3%), with Brucella melitensis, Staphylococcus aureus and Enterobacter spp. identified in 4, 3 and 2 patients, respectively; 5/10 patients with positive blood cultures were <3 months of age. Overall, 55/431 (12.7%) and 65/431 (15.1%) patients were diagnosed with SBIs and bacterial infections, respectively. Nasal washings-PCR for respiratory viruses was positive in 139/293 (47.4%) patients tested. An infectious etiology (bacterial and/or viral) was diagnosed in 190/431 (44.1%) patients. Three patients were diagnosed with acute lymphocytic leukemia. Resolution of neutropenia was achieved in 111/208 (53.4%) evaluable patients (63%, 50.6% and 48% of patients aged 0-3, 4-12 and >12 months, respectively and 56.8%, 53.5% and 52% of patients with severe, moderate and mild neutropenia, respectively). CONCLUSION: Acute neutropenia is common in immunocompetent children <2 years of age and is frequently associated with viral infections. We showed a substantial involvement of bacterial infections and particularly SBIs in the etiology of acute neutropenia. After a 1-month follow-up, resolution of neutropenia occurred in half of the patients, without association with age subgroups and with neutropenia severity.

Factor VII Deficiency in Patients Receiving Chronic Packed Cell Transfusions.

Acquired factor VII deficiency is a rare coagulopathy that has not been reported in transfusion-dependent patients so far. In this study, we reviewed files of 26 transfusion-dependent patients for coagulation profiles, factor V levels, factor VII levels, possible environmental factors influencing factor VII levels, and bleeding history. In 26 of 29 patients (89.6%), we found mild factor VII deficiency (<60%) with levels ranging between 35% and 56%. Bleeding history was unremarkable. We concluded that transfusion-dependent patients may have mild factor VII deficiency with no bleeding tendency under physiologic conditions.

[PEDIATRIC ANIMAL-RELATED INJURIES IN THE JEWISH AND ARAB POPULATION IN SOUTHERN ISRAEL].

INTRODUCTION: Annually in the US, about 2 million patients who are animal-related casualties go to the Emergency Medicine Department (ER), which accounts for 0.5-1.5% of the ER visits; 25% of these casualties are children. Similar numbers are also seen in Europe and the UK. In a single-center study in Israel, it was found that the percentage of ER visits for animal injuries was about 2.1%. Soroka University Hospital is the only Level I trauma center in the Negev, serving a population of over 1,250,000, and as such it treats about 175,000 ER visits each year, of which about 27% are pediatric visits. The population treated in our hospital is diverse in terms of socioeconomic origin and status, and includes Jewish patients mainly situated in urban settlements and Arab-Bedouin population living in familiar and unfamiliar villages (the Bedouin diaspora). In light of this, in the present study, we have tried to investigate animal injuries in children, emphasizing scorpion bites which are common in our area. METHODS: We retrospectively reviewed the medical records of all children aged 0-17 years during an 18-month study period - from January 2009 until the end of June 2010 - to identify children who have been referred to the ER at the Soroka Hospital due to animal injury. Demographics, characteristics of the injury, incidence times and referral to treatment, and data on the course of assessment and treatment of the injury and hospitalization were recorded. Data was typed and processed using Microsoft Excel 2007 software and we used SPSS 23.0 for Windows for the statistical analysis. RESULTS: A total of 729 pediatric injuries caused by animals were reported, which accounted for about 1% of the total number of children's visits to the pediatric ER during the study period. Twenty-six cases were omitted because they did not meet the inclusion criteria in the study. Of the remaining 703 referrals, 66.1% of the patients were boys, the peak age was in the 6-8-year age group (26%); 44.1% lived in a Jewish settlement, 31.2% in an unrecognized Arab-Bedouin settlement and 24% in a recognized Arab-Bedouin settlement. In both forms of Bedouin settlements, the most frequent injuries were dog bites n = 166, (23.60%), yellow scorpion bites = 163 (23.2%) and black scorpion bites n = 44 (6.25%); 97 of the children were admitted (13.8%), of whom 44 were admitted to the ICU, with 84.1% of those admitted to the intensive care unit (ICU) were treated due to yellow scorpion injury. The 2-5-year age group was the most prevalent among inpatients, accounting for 32. DISCUSSION: Pediatric animal injuries are a common cause of ER visits and even hospitalization. A relatively high percentage of hospitalizations were in the ICU. The most common cause of animal injury seen in our cohort was dog bites, but yellow scorpion bites resulted in most hospitalizations, especially in the pediatric ICU. The incidence of yellow scorpion injuries was significantly higher in the Arab-Bedouin population and even more so in those living in unrecognized settlements, and 87% of the pediatric hospitalizations were seen in Arabic-Bedouin children. Animal-related injuries are a serious health problem in the Arab-Bedouin population and in the unrecognized villages in particular, and there is room to emphasize the prevention of these injuries in this impoverished sector.

Positive Outcomes of Denosumab Treatment in 2 Patients With Cherubism.

Cherubism is a rare autosomal dominant disease whose severity ranges widely, from asymptomatic to life-threatening. Bilateral symmetrical painless expansion of the mandible and maxilla resulting in a typical appearance of the face resembling a cherub, are the highlighted features of the condition. In most cases, cherubism-induced lesions in the jaws appear around the age of 3 years and tend to expand and increase in numbers until puberty. Treatment options for cherubism range from observation to surgical correction and various pharmacologic therapies. Given the excess sensitivity of cherubism osteoclasts to RANKL (receptor activator of nuclear factor κB ligand) and the positive effects of denosumab (XGEVA; Amgen, Thousand Oaks, CA) treatment in patients with giant cell granuloma, we have designed a treatment based on denosumab for 2 cherubism patients that achieves what we consider promising results.

Comparison of the etiologic, microbiologic, clinical and outcome characteristics of febrile vs. non-febrile neutropenia in hospitalized immunocompetent children.

We compared the etiologic, microbiologic, clinical, and outcome picture among febrile and non-febrile immunocompetent children hospitalized during 2013-2015 with acute neutropenia (absolute neutrophil count < 1.5 × 109/L). Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, pneumonia, brucellosis, and rickettsiosis. Overall, 664 children < 18 years of age were enrolled; 407 (62.2%) had fever > 38.0 °C and 247 (37.8%) were non-febrile at admission. There were 425 (64.0%), 125 (18.8%), 48 (7.2%), and 66 (9.9%) patients aged 0-24 months, 2-6, 7-12, and > 12 years, respectively. No differences were recorded in the distribution of febrile vs. non-febrile patients among the age groups nor among the 3 neutropenia severity groups (< 0.5, 0.5-1.0 and 1.0-1.5 × 109/L). SBI infections were diagnosed in 98 (14.8%) patients, with higher rates among febrile patients vs. non-febrile patients (16.8% vs. 11.5%, P = 0.06). Brucellosis and rickettsiosis were diagnosed in 15.4% and 23.1% tests performed, respectively. 295/688 (42.9%) virologic examinations returned positive. Among patients < 24 months, more febrile ones had viral infectious compared with afebrile patients (P = 0.025). Acute leukemia was diagnosed in 6 patients. Neutropenia resolved in 163/323 (50.5%) patients during a 1-month follow-up. No differences were recorded in neutropenia resolution between febrile and non-febrile children among all 3 severity groups. Severe neutropenia was rare and occurred mainly in very young patients. SBIs were more common among febrile patients compared with non-febrile patients, but there was no association between severity of neutropenia or its resolution and the presence or absence of fever at diagnosis.

Treatment of transfusion-dependent congenital dyserythropoietic anemia Type I patients with pegylated interferon alpha-2a.

OBJECTIVE: Pegylated IFN-α2a has been reported in two case reports as being efficacious in treating CDA-I patients. This study aims to assess its efficacy on a series of CDA-I patients. METHODS: Study sample consisted of seven CDA type 1 transfusion-dependent patients. They received pegylated interferon alpha-2a at an initial dose of 90-180 µg once a week, tapered according to clinical response and side effects. Good response was defined as Hb ≥ 10 g/dL for ≥3 months, partial response was defined as 7 ≤ Hb<10 g/dL for ≥3 months, and no response was defined as HB < 7 g/dL for over 3 months on treatment. Time to response was defined as the time needed to achieve hemoglobin levels ≥ 10 g/dL without transfusion. Patients were evaluated periodically by abdominal ultrasounds to rule out liver adenomas. RESULTS: Five patients (71%) had a good response to treatment. One patient stopped treatment due to side effects. One patient had partial response. One patient, with more severe phenotype and poor compliance, had poor response to treatment. No abnormal findings were found in ultrasound examination. No effect on serum ferritin level could be established. CONCLUSION: Pegylated interferon α2a therapy is efficacious in CDA-I patients with a reasonable safety profile.

Septic arthritis in children: Updated epidemiologic, microbiologic, clinical and therapeutic correlations.

BACKGROUND: Septic arthritis (SA) is an infection characterized by significant epidemiologic and microbiologic differences between developed and developing regions and between age groups. OBJECTIVES: To determine the epidemiologic, clinical, microbiologic and therapeutic aspects of pediatric SA in Southern Israel. METHODS: A retrospective case-series study based on the records of children <16 years of age admitted with SA at Soroka Medical Center, Beer-Sheva, during 2006-2013. RESULTS: 189 patients were enrolled. There were 119 (63%) Bedouin and 70 (37%) Jewish children. The knee (39.7%), hip (28%) and ankle (13.8%) were the most commonly involved joints. Blood and/or synovial fluid cultures were positive in 48 (25.4%) patients. Overall SA incidence among children <16 years and <5 years was 11.7 and 25.4/100,000, respectively, without changes throughout the study period. SA incidence among Bedouin children was higher than among Jewish children (15.4 vs. 8.3/100,000 cases). Staphylococcus aureus was the most commonly isolated pathogen (18, 19.5% of all patients), followed by Kingella kingae (10, 5.3%)-(37.5% and 20.8% among culture-positive patients, respectively). The number of children with culture-positive SA that required surgery was higher than those with culture-positive SA treated conservatively (P < 0.001). Hospitalization was longer in children treated surgically than in those treated conservatively (P < 0.001). CONCLUSION: This study is the largest single-center series on pediatric SA published in the last five years and provided an updated picture on incidence and the microbiologic, clinical and therapeutic aspects of pediatric SA in Southern Israel. The study supports a regional presentation pattern of SA and may guide its therapeutic management.

Pediatric Carbon Monoxide Poisoning in Southern Israel: A Cross-Sectional Study.

OBJECTIVES: This study aimed to describe the epidemiology and clinical burden of unintended carbon monoxide (CO) poisoning among children in the Negev region of southern Israel. METHODS: This was a cross-sectional retrospective study of CO poisoning patients admitted to Soroka University Medical Center in 2011 through 2015. RESULTS: Overall, 43 cases of CO poisoning were recorded among children younger than 18 years. Five patients died, all upon admission. Poisoning due to smoke "per se" and due to CO emitted from heating devices were responsible for 28 (65.1%) and 14 (32.6%) cases, respectively. Eight (18.6%) patients suffered from convulsions, and 13 (43.3%) of 30 evaluable patients complained of headaches. Twenty-two (51.2%) were found unconscious in the field, and 7 (16.3%) were unconscious at examination at the emergency department. The average carboxyhemoglobin level on admission was 10.5% ± 10.4% (level ranging from 0.1% to 46.2%). Treatment included oxygen in 34 patients (79%) and hyperbaric oxygen therapy in 8 patients (19%). No differences were found between Bedouin and Jewish children in sex, age, residence area, source of CO poisoning, symptoms severity, and need for hyperbaric oxygen therapy. More patients with exposure to water heating devices were older than 4 years, lived in villages, and were diagnosed as having loss of consciousness in the field compared with those exposed to smoke inhalation. CONCLUSIONS: Carbon monoxide poisoning in children is frequent in southern Israel. Education about prevention, implementation of safer standards for home heating systems, and government supervision are required management strategies to decrease the CO poisoning incidence in southern Israel.

Mucormycosis in children with haematological malignancies is a salvageable disease: a report from the Israeli Study Group of Childhood Leukemia.

Mucormycosis has emerged as an increasingly important cause of morbidity and mortality in immunocompromised patients, but contemporary data in children are lacking. We conducted a nationwide multicentre study to investigate the characteristics of mucormycosis in children with haematological malignancies. The cohort included 39 children with mucormycosis: 25 of 1136 children (incidence 2·2%) with acute leukaemias prospectively enrolled in a centralized clinical registry in 2004-2017, and an additional 14 children with haematological malignancies identified by retrospective search of the databases of seven paediatric haematology centres. Ninety-two percent of mucormycosis cases occurred in patients with acute leukaemias. Mucormycosis was significantly associated with high-risk acute lymphoblastic leukaemia (OR 3·75; 95% CI 1·51-9·37; P = 0·004) and with increasing age (OR 3·58; 95% CI 1·24-9·77; P = 0·01). Fifteen patients (38%) died of mucormycosis. Rhinocerebral pattern was independently associated with improved 12-week survival (OR 9·43; 95% CI 1·47-60·66; P = 0·02) and relapsed underlying malignancy was associated with increased 12-week mortality (OR 6·42; 95% CI, 1·01-40·94; P = 0·05). In patients receiving frontline therapy for their malignancy (n = 24), one-year cumulative mucormycosis-related mortality was 21 ± 8% and five-year overall survival was 70 ± 8%. This largest paediatric population-based study of mucormycosis demonstrates that children receiving frontline therapy for their haematological malignancy are often salvageable.

Factors Associated With Single and Recurrent Bacteremia in Childhood Brucellosis.

BACKGROUND: Data regarding risk factors of bacteremic brucellosis, and specifically recurrent bacteremia, are scarce. We assessed patients with childhood brucellosis, differentiating between those having culture-negative, single-bacteremic, and recurrent-bacteremic episodes. METHODS: The medical files of pediatric brucellosis patients, from 2005 through 2014, were reviewed retrospectively. Univariate and multivariate analyses were performed to compare demographic and clinical characteristics of culture-negative, single-bacteremic, and recurrent-bacteremic (≥30 days between positive cultures) episodes. RESULTS: Of all 436 brucellosis cases, 22% were culture-negative, 72% were single-bacteremic, and 6% were recurrent-bacteremic. In a univariate analysis, single-bacteremic episodes were associated with fever (90% vs 65% and 40% in culture-negative and recurrent bacteremia, respectively) and elevated glutamic oxaloacetic transaminase (GOT) levels. Recurrent-bacteremic episodes were associated with anemia (26% vs 14% and 9% in single bacteremia and culture negative, respectively), elevated GOT, low immunoglobulin M (IgM) titers (56% vs 89% and 99%, respectively), and lower levels of adequate treatment (74% vs 94% and 86%, respectively). In multivariate analyses, single bacteremia was associated with fever (odds ratio [OR], 3.595, compared with culture negative), while recurrent bacteremia was inversely associated with IgM titers ≥1:160 (OR, 0.022 and 0.226 compared with culture negative and single bacteremia, respectively) and fever (OR, 0.108 compared with single bacteremia). CONCLUSIONS: Brucellosis episodes are commonly complicated with bacteremia. Single-bacteremic episodes were associated with high-grade fever and elevated liver enzymes, possibly indicating high bacterial virulence. Recurrent-bacteremic episodes were associated with poor treatment at initial diagnosis, along with low rates of fever, low IgM titers, and high anemia rates, possibly indicating impaired host response. Physicians should consider treatment modifications for suspected recurrent-bacteremic brucellosis, including monitoring treatment adherence, and possibly administering prolonged treatment.

Central venous catheter-associated bloodstream infections in children diagnosed with intestinal failure in Southern Israel.

OBJECTIVES: To study the clinical, epidemiological, and microbiological associations between intestinal failure (IF) and central line-associated infections (CLABSI) in patients with central vein catheters (CVCs) during 2005-2016. METHODS: We compared retrospectively CLABSI rates according to background disease, type of line access, pathogen distribution, and antibiotic susceptibilities. RESULTS: One hundred and fourteen children (64.1% < 4 years) were enrolled. Main diagnoses were persistent diarrhea (20, 17.5%), short bowel syndrome (13, 11.4%), continuous-TPN w/o diarrhea (11, 9.7%), very early-onset inflammatory bowel disease (VEO-IBD, 8, 7%), Hirschsprung's disease (3, 2.6%), non-oncologic hematologic conditions (13, 11.4%), and other diseases (46, 40.4%). 152.749 catheter days were recorded; 71.1% had Hickman's catheters. Two hundred and nine CLABSI episodes were recorded in 58 patients (82% with IF, 13.7 and 8.2/1000 catheter days in IF, and non-gastrointestinal conditions, P = 0.09). More CLABSI were recorded in continuous TPN vs. VEO-IBD or persistent diarrhea (38.8 vs.15.8 and 12.8/1000 catheter days, P < 0.004). Among patients with Hickman in jugular vein, highest CLBSI incidence was in continuous TPN, VEO-IBD, and persistent diarrhea (29.9, 15.84, and 12.49 episodes/1000 catheter days, respectively). CVCs were removed in 38.8% CLABSI. Two hundred and thirty-five pathogens were isolated (Enterobacteriaceae spp. in 39% of IF patients, mostly in persistent diarrhea and short bowel syndrome patients, 47.6% and 34.8%, respectively). Coagulase-negative Staphylococcus was the commonest pathogen in continuous TPN, VEO-IBD, and Hirschsprung's (71.4%, 55.6% and 46.1%, respectively). CONCLUSIONS: CLABSI rates in IF patients were among the highest reported. We reported a "hierarchy" in CLABSI incidence among patients with IF and showed that CLABSI incidence and etiology were different as function of background diseases and CVC insertion site.

[IS THERE STILL A PLACE TO USE ERYTHROCYTE SEDIMENTATION RATE IN THE 21ST CENTURY?]

INTRODUCTION: Erythrocyte sedimentation rate (ESR) is a simple test that is not without limitations but is still widely used. Dysfunction is used as a diagnostic test on the one hand and as a follow-up test on the other, where many physicians attribute normal results of this test to the absence of disease. Therefore, the question remains: Is there still room for continued ESR in the 21st century? And are there other tests with higher sensitivity and specificity that can replace the ESR? The purpose of the current review is to acquaint the reader with this test, its advantages and limitations, and to expand the scope of alternative tests and their effectiveness in comparison to ESR. It seems to us that the development of technology and research has strongly discouraged the use of ESR, but there are still quite a few instances where this test is still cost-effective. In most cases, especially during the diagnosis of life-threatening diseases, other tests are needed, or there is a need for a combination of the ESR with additional tests.

Clinical and Laboratory Findings in Jewish and Bedouin Patients in Southern Israel Who Were Diagnosed with Factor VII Deficiency.

BACKGROUND: Congenital factor VII deficiency is a rare recessive autosomal bleeding disorder with a wide spectrum of clinical manifestations. OBJECTIVES: To compare the clinical and laboratory findings in Jewish and Bedouin patients with factor VII deficiency. METHODS: The clinical and laboratory findings of patients with factor VII deficiency treated at Soroka Medical Center, a tertiary hospital in Israel, from 2005 to 2015 were analyzed regarding blood factor levels, illness severity, treatment administration, and disease outcome. RESULTS: Seventy-eight patients were enrolled (1:13,000 of the population in southern Israel) of whom 26 were diagnosed with severe factor VII deficiency (1:40,000). Sixty (76.9%) patients were Jewish and 18 (23.1%) were Bedouin. In univariable analysis, Bedouin patients exhibited a more severe illness, with significantly higher complication and fatality rates, and required more preventive treatment than the Jewish patients. CONCLUSIONS: The prevalence of congenital factor VII deficiency (including severe deficiency) in the Jewish and Bedouin populations of southern Israel is higher than previously reported. The clinical spectrum of the disease was found to be more severe in the Bedouin population.

Purpuric rash and fever among hospitalized children aged 0-18 years: Comparison between clinical, laboratory, therapeutic and outcome features of patients with bacterial versus viral etiology.

BACKGROUND: The evaluation of children with purpuric rash and fever (PRF) is controversial. Although many of them have viral infections, on occasion such patients may be infected with Neisseria meningitidis. We described all children aged 0-18 years with PRF in southern Israel during the period 2005 ̶ 2016 and compared their microbiologic, laboratory, clinical and outcome characteristics in relation to various etiologies of this syndrome. METHODS: Data were summarized from electronic patient and microbiology files. Viral diagnoses were made by serology and/or PCR. RESULTS: Sixty-nine children with PRF were admitted; 30 (43.48%), 9 (13.04%) and 30 (43.48%) had a syndrome of bacterial, viral or non-established etiology, respectively. N. meningitidis infection was diagnosed in 16/69 (23.19%) patients and in 16/30 (53.33%) patients with bacterial etiology; 14/30 (46.67%) patients suffered from a non-invasive bacterial disease (9 with Rickettsial disease). Adenovirus and Influenza B (3 and 2 cases, respectively) represented the most frequent etiologic agents among patients with viral etiology. More patients with PRF of bacterial etiology were older, of Bedouin ethnicity, looked ill on admission, had higher rates of meningitis and were treated more frequently with antibiotics compared with patients with non-bacterial PRF. Fatality rates among patients with bacterial, viral and non-established etiology were 5/30 (16.7%), 0% and 2/39 (5.1%). CONCLUSIONS: Although PFR was uncommon, high rates of meningococcal infections were recorded in children with PRF, which was associated with high fatality rates. Rickettsial infections were frequent, emphasizing the need for a high index of suspicion for this disease in endemic geographic areas.

Urinary tract infection in young infants discharged from the emergency room with normal urinalysis.

AIM: We describe the clinical, microbiologic, therapeutic, and outcome characteristics of infants under three months of age with a positive urine culture reported after discharge from emergency department with normal urinalysis. METHODS: We enrolled all infants with a urine culture obtained during an emergency room visit during 2004-2012, discharged without antibiotic therapy and subsequently reported with a positive urine culture. RESULTS: Three hundred and ninety-three positive urine cultures were reported; 46/393 (11.7%, 42 in patients under two months of age) had positive urine cultures following normal urinalysis at first visit. Fifteen (33%) had positive urine cultures at second visit; 11/15 (73%) infants with second positive urine culture were under one month of age, eight were asymptomatic and seven had mild symptoms at second visit. Pathogens isolated in all 15 infants were identical between first and second visit. All 27 infants re-examined at second visit at the emergency room were hospitalised, completed sepsis work/up and received antibiotic treatment. None developed serious bacterial infections. CONCLUSION: We propose a new management approach for young infants with normal urinalysis and positive urine culture and suggest restricting the management option including hospitalisation, sepsis work/up and antibiotic treatment at second visit only to infants under one month of age.

Hematologic Manifestations of Brucellosis in Children.

BACKGROUND: Brucellosis is a common zoonosis in the Bedouin population of southern Israel. Limited data exist for the rate and risk factors of hematologic complication of brucellosis in children. We assessed anemia, leukopenia, thrombocytopenia and pancytopenia in childhood brucellosis in southern Israel. METHODS: Our medical center is the sole hospital in southern Israel. All medical files of brucellosis, 2005-2014, identified through positive blood cultures or International Classification of Diseases 9th revision coding with positive serology, were reviewed retrospectively. RESULTS: Overall, 511 brucellosis episodes were identified; 42% (N = 214) with ≥1 cytopenia, including 13% (N = 68) anemia, 28% (N = 144) leukopenia, 14% (N = 74) thrombocytopenia and 2% (N = 9) pancytopenia. Overall, 99.8% of episodes were in Bedouin children and 70% in males. In 79% of episodes, blood culture was positive for Brucella melitensis. Acute infections comprised 84% of all episodes. In univariate analysis, older age (10.49 ± 4.81 vs. 9.25 ± 4.89 years), fever (92% vs. 78%), positive blood culture (84% vs. 75%) and IgM ≥1:640 levels (50% vs. 39%) were associated with cytopenia. In contrast, arthralgia was associated with noncytopenic episodes. In multivariate analyses, older age (odds ratio = 1.063) and fever (odds ratio = 3.127) were associated with cytopenia. CONCLUSIONS: Brucellosis is commonly presented with cytopenia, especially in bacteremic episodes with fever. However, pancytopenia is uncommon and its finding should alert the physician to look for other possible etiologies.

The Infectious and Noninfectious Etiology, Clinical Picture and Outcome of Neutropenia in Immunocompetent Hospitalized Children.

BACKGROUND: Acquired neutropenia in immunocompetent children is common, and its differential diagnosis ranges from benign causes to life-threatening diseases. We described the etiology, clinical picture and outcome of new-onset neutropenia in immunocompetent children assessed in the emergency department and hospitalized at our medical center. METHODS: Previously healthy children admitted with neutropenia (absolute neutrophil count <1.5 × 10(9)/L) were included. Serious bacterial infections were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, pneumonia, Brucellosis and Rickettsiosis. RESULTS: A total of 601 patients (5 days-202 months old) were enrolled; 3 (0.5%), 48 (8%), 165 (27.5%) and 385 (64%) had absolute neutrophil counts <0.2, 0.2-0.5, 0.5-1.0 and 1.0-1.5 × 10(9)/L, respectively. Associated leukopenia and thrombocytopenia were diagnosed in 186 (39%) and 71 (11.8%) patients. Three hundred sixteen of 601 (52.6%) and 519 of 601 (86.4%) were <2 or 36 months of age, respectively. Fever at admission was present in 27.6% patients. Serious bacterial infections were diagnosed in 106 (17.6%) patients. Brucellosis and rickettsiosis were diagnosed in 8 of 52 (15.4%) and 9 of 39 (23.1%) tests obtained. Respiratory syncytial virus was diagnosed in 17 of 33 (51.5%) nasal washes. An infectious etiology was determined in 171 (28.5%) patients. Acute leukemia was diagnosed in 6 patients. A significant correlation was found between resolution of neutropenia and patient age, infectious etiology and severity of neutropenia. CONCLUSIONS: (1) Severe neutropenia was rare; (2) More than half of patients were <2 months of age; (3) An infectious etiology was diagnosed in a high number of patients, and serious bacterial infections were frequent and (4) Brucella spp. and rickettsial infections were frequent etiologies associated with neutropenia in our setting.

Group A streptococcal brain abscess in children: two case reports and a review of the literature.

Brain abscesses caused by group A Streptococcus (GAS) are infrequently encountered in children. We present two cases of brain abscess (one cerebellar and one located in the temporal lobe) due to GAS infection occurring in close temporal proximity in previously healthy young children living in different geographic areas of southern Israel. The relevant literature since 2000, in the context of recent epidemiological data reporting an increase in the incidence of invasive GAS infections, is reviewed.