Role of the Egami score to predict immunoglobulin resistance in Kawasaki disease among a Western Mediterranean population.

Kawasaki disease is an acute self-limited systemic vasculitis common in childhood. Intravenous immunoglobulin (IVIG) is an effective treatment, and it reduces the incidence of cardiac complications. Egami score has been validated to identify IVIG non-responder patients in Japanese population, and it has shown high sensitivity and specificity to identify these non-responder patients. Although its effectiveness in Japan, Egami score has shown to be ineffective in non-Japanese populations. The aim of this study was to apply the Egami score in a Western Mediterranean population in Catalonia (Spain). Observational population-based study that includes patients from all Pediatric Units in 33 Catalan hospitals, both public and private management, between January 2004 and March 2014. Sensitivity and specificity for the Egami score was calculated, and a logistic regression analysis of predictors of overall response to IVIG was also developed. Predicting IVIG resistance with a cutoff for Egami score ≥3 obtained 26 % sensitivity and 82 % specificity. Negative predictive value was 85 % and positive predictive value 22 %. This low sensitivity implies that three out of four non-responders will not be identified by the Egami score. Besides, logistic regression models did not found significance for the use of the Egami score to predict IVIG resistance in Catalan population although having an area under the ROC curve of 0.618 (IC 95 % 0.538-0.698, p < 0.001). Although regression models found an area under the ROC curve >0.5 to predict IVIG resistance, the low sensitivity excludes the Egami score as a useful tool to predict IVIG resistance in Catalan population.

Tuberculosis in pediatric patients treated with anti-TNFα drugs: a cohort study.

BACKGROUND: Adult patients receiving anti-TNFα drugs are at increased risk of tuberculosis (TB), but studies in pediatric populations are limited, and the best strategy for latent tuberculosis infection (LTBI) screening in this population remains controversial. We describe the prevalence of LTBI prior to anti-TNFα therapy and the long-term follow-up after biological treatment initiation in a cohort of children and adolescents. METHODS: Cohort observational study in children and adolescents receiving anti-TNFα agents in a tertiary-care pediatric hospital. LTBI was ruled out prior to the implementation of anti-TNFα drugs by tuberculin skin test (TST), and, from March 2012 on, QuantiFERON Gold-In Tube test (QTF-G). During anti-TNFα treatment, patients were evaluated every 6 months for TB with history and physical examination. TST/QTF-G were not repeated unless signs or symptoms consistent with TB arose or there was proven TB contact. RESULTS: The final cohort consisted of 221 patients (56.1% female; 261 treatments), of whom 51.7%/30.0%/17.3% were treated with etanercept/adalimumab/infliximab, respectively, for a variety of rheumatic diseases (75.6%), inflammatory bowel disease (20.8%), and inflammatory eye diseases (3.6%). The median (IQR) age at diagnosis of the primary condition was 6.8 years (2.7-11.0) and the duration of the disease before implementing the anti-TNFα agent was 1.8 years (0.6-4.2). LTBI was diagnosed in 3 adolescent girls (prevalence rate: 1.4%; 95% CI: 0.4-4.2) affected with juvenile idiopathic arthritis: TST tested positive in only 1, while QTF-G was positive in all cases (including 2 patients already on etanercept). They all received antiTB chemoprophylaxis and were later (re)treated with etanercept for 24-29 months, without incidences. No incident cases of TB disease were observed during the follow-up period under anti-TNFα treatment of 641 patients-year, with a median (IQR) time per patient of 2.3 years (1.4-4.3). CONCLUSIONS: In our study, the prevalence of LTBI (1.4%) was similar to that reported in population screening studies in Spain; no incident cases of TB disease were observed. In low-burden TB settings, initial screening for TB in children prior to anti-TNFα treatment should include both TST and an IGRA test, but systematic repetition of LTBI immunodiagnostic tests seems unnecessary in the absence of symptoms or known TB contact.

Efficacy and safety of TNF-alpha antagonists in children with juvenile idiopathic arthritis who started treatment under 4 years of age.

The aims of the study were to assess efficacy and safety of TNF-alpha antagonists (anti-TNF) in a cohort of patients with juvenile idiopathic arthritis (JIA) who began treatment under 4 years old and to assess relapse rate after methotrexate and/or anti-TNF withdrawal. We made a retrospective charts review of our non-systemic JIA patients treated with anti-TNF under 4 years of age between January 2006 and April 2013. Demographics, epidemiologic, clinical, laboratory data and rate of relapse after treatment withdrawal due to clinical remission were collected. Efficacy and safety end points included side effects (SE) and time to achieve clinical remission. We included 27 patients, 23 received etanercept and 4 adalimumab with a median age of 3.01 (range 0.88-3.97) years at anti-TNF beginning and 1.94 (range 0.18-5.44) and 2.39 (range 0.18-7.24) years of treatment and follow-up, respectively. All patients had previously received disease-modifying antirheumatic drugs at optimal dose. Nineteen patients reached clinical remission on treatment in a median time of 9.1 (range 6.23-21.17) months. Four of those relapsed during treatment. Six developed mild SE, mostly mild infections. No serious SE were described. Eleven patients who reached clinical remission relapsed after treatment withdrawal. None achieved clinical remission off treatment. Most patients reached clinical remission on anti-TNF. In our cohort of patients, etanercept and adalimumab were safe, with mostly mild infections and no serious SE. We observed a high relapse rate during treatment withdrawal.

Malalties de transmissió sexual a urgències pediàtriques / Enfermedades de transmisión sexual en urgencias pediátricas / Sexually transmitted diseases in pediatric emergency care

Objectiu: determinar les característiques dels pacients diag-nosticats de malalties de transmissió sexual (MTS) a urgències i establir la freqüència en què són degudes a abús sexual. Mètode: estudi retrospectiu fet entre el gener del 2007 i eldesembre del 2011. S'inclouen els pacients menors de 18anys diagnosticats a urgències d'MTS -infecció per Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, virus d'immunodeficiència humana (VIH), virus del papil•loma humà (VPH) i virus herpes simple tipus 2 (VHS-2)-. Resultats: s'han trobat 28 pacients (6 casos / 100.000 vi-sites); mediana d'edat 15,9 anys (p. 25-75: 13,9-17,5); tots adolescents excepte 4, menors de 7 anys; 23 (82,1%)de sexe femení. Els motius de consulta són: 8 (28,6%)lesions cutànies, 6 (21,4%) secreció vaginal/uretral, 6(21,4%) dolor abdominal, 1 (3,6%) febre, 1 (3,6%) promiscuïtat, 1 (3,6%) nàusees i vòmits i 5 (17,9%) infecció asimptomàtica. En 8 casos (28,6%) el motiu incloïa la sospita d'abús sexual (3 remesos pel pediatre i 5 per manifestació del menor). Tretze casos (46,4%) són valorats conjuntament amb Ginecologia, 6 (21,4%) amb Dermatologiai 11 (39,3%) amb la Unitat Funcional d'Abús al Menor de l'Hospital. Es diagnostiquen microbiològicament 10(35,7%) infeccions per N. gonorrhoeae, 6 (21,4%) per C.trachomatis, 6 (21,4%) per VPH, 3 (10,7%) per VIH, 2(7,2%) per VHS-2 i 2 (7,2%) per T. pallidum. Una adoles-cent amb malaltia inflamatòria pèlvica presenta coinfeccióper N. gonorrhoeaei C. trachomatis. Finalment es diagnostiquen d'abús sexual 10 pacients (35,7%). Conclusions: els diagnòstics d'MTS a Urgències es donenbàsicament en adolescents; en infants petits cal sospitarabús. Malgrat que són molt poc freqüents, és importantconèixer els signes guia per poder fer un diagnòstic precoçi minimitzar-ne les conseqüències

Objetivo. Determinar las características de los pacientes diagnosticados de enfermedad de transmisión sexual (ETS) en urgencias y establecer la frecuencia en que son debidas a abuso sexual. Metodología. Estudio retrospectivo entre enero de 2007 y diciembre de 2011. Se incluyen los pacientes menores de 18 años diagnosticados de ETS -Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, virus de inmunodeficiencia humana (VIH), virus de papiloma humano (VPH) y virus herpes simple tipo 2 (VHS-2)-. Resultados. Se han encontrado 28 pacientes (6 casos / 100.000 consultas a urgencias), mediana de edad de 15,9 años (p. 25-75: 13,9-17,5); todos adolescentes excepto 4, menores de 7 años; 23 (82,1%) de sexo femenino. Los motivos de consulta son: 8 (28,6%) lesiones cutáneas, 6 (21,4%) secreción vaginal/uretral, 6 (21,4%) dolor abdominal, 1 (3,6%) fiebre, 1 (3,6%) promiscuidad, 1 (3,6%) náuseas-vómitos y 5 (17,9%) presentan infección asintomática. En 8 casos (28,6%) el motivo de consulta incluía la sospecha de abuso sexual (3 remitidos por el pediatra y 5 por manifestación del menor). Trece casos (46,4%) son valorados conjuntamente con Ginecología, 6 (21,4%) con Dermatología y 11 (39,3%) con la Unidad Funcional de Abuso al Menor del Hospital. Se diagnostican microbiológicamente 10 (35,7%) infecciones por N. gonorrhoeae, 6 (21,4%) por C. trachomatis, 6 (21,4%) por VPH, 3 (10,7%) por VIH, 2 (7,2%) por VHS-2 y 2 (7,2%) por T. pallidum. Una adolescente con enfermedad inflamatoria pélvica presenta coinfección por N. gonorrhoeae y C. trachomatis. Finalmente, se diagnostican de abuso sexual a 10 pacientes (35,7%). Conclusiones. Los diagnósticos de ETS en urgencias se dan básicamente en adolescentes; en niños pequeños, se debe sospechar abuso sexual. Pese a ser muy poco frecuentes, es importante conocer los signos guía de las ETS para poder realizar un diagnóstico precoz y minimizar sus consecuencias (AU)

Objective. To determine the characteristics of patients diagnosed with sexually transmitted diseases (STDs) in the Emergency Department (ED) and to estimate their association with child abuse. Method. Retrospective review of patients under 18 years seen in an ED between January 2007 and December 2011 with a diagnosis of STD, including Neisseria gonorrheae, Chlamydia trachomatis, Treponema pallidum, Human immunodeficiency virus (HIV), Human papillomavirus (HPV), and Herpes simplex virus type 2 (HSV2) infection. Results. 28 patients (82.1% females) (6 cases/100,000 consultations) were included. The median age was 15.9 years (p. 25-75: 13.9-17.5); all cases were teenagers except for four children who were under seven years of age. Reasons for medical consultation were skin lesions in eight cases (28.6%), vaginal/urethral discharge in six (21.4%), abdominal pain in six (21.4%), and fever, sexual promiscuity, and nausea/vomiting in one case each; in five cases the infection was asymptomatic. In eight patients (28.6%) the reason for consultation included suspicion of sexual abuse (three cases were referred by the primary care pediatrician, and in five cases the abuse was disclosed by the patient). Thirteen cases (46.4%) were evaluated in conjunction with gynecology, six (21.4%) with dermatology, and 11 (39.2%) with the Functional Unit of Child Abuse from the hospital. Ten patients (35.7%) were diagnosed with N. gonorrheae infection, six (21.4%) with C. trachomatis, six (21.4%) with HPV, three (10.7%) with HIV, two (7.2%) with HSV-2, and two (7.2%) with T. pallidum. An adolescent who presented pelvic inflammatory disease was diagnosed with a co-infection of N. gonorrheae and C. trachomatis. Ten patients (35.7%) were diagnosed with sexual abuse. Conclusions. Diagnosis of STD is not common in pediatric ED, and more commonly occurs in female teenagers. It is important to know their leading signs and symptoms in order to do an early diagnosis and treatment and to minimize long-term effects (AU)

Infección bacteriana potencialmente grave en los lactantes de 1 a 3 meses de edad con fiebre sin foco / Serious bacterial infections in1 to 3 month ol infants with fever without a source

Fundamento. Es habitual la realización de exploraciones complementarias a los lactantes de corta edad con fiebre sin foco (FSF) para identificar a aquellos con alto riesgo de infección bacteriana potencialmente grave (IBPG). Objetivo. Conocer la prevalencia y la etiología de la IBPG en los lactantes de 1 a 3 meses de edad con FSF. Método. Estudio retrospectivo de los lactantes de 1 a 3 meses de edad atendidos en urgencias de un hospital pediátrico de tercer nivel por FSF durante un año (diciembre 2009 - diciembre 2010). Se excluyeron los pacientes a los que no se había realizado hemocultivo (HC) y/o urocultivo (UC). Resultados. Se incluyeron 275 pacientes (61,1% de sexo masculino), con una mediana de edad de 57 días (P25-75: 42-74 días). La mediana de evolución de la fiebre fue de 8 horas (P25-75: 3-13,25) y 117 (47,6%) acudieron con fiebre de menos de 6 horas de evolución. Presentaban un triángulo de evaluación pediátrica alterado 16 pacientes (5,8%). Cincuenta y un lactantes (18,5%) fueron diagnosticados de una IBPG, siendo la infección urinaria la principal entidad responsable (90,2%) y Escherichia coli el principal microorganismo aislado. Seis pacientes (2,2%) presentaron un HC positivo. A diferencia de los parámetros analíticos, la anamnesis y la exploración física no fueron útiles en la identificación de los pacientes con IBPG. Conclusiones. La prevalencia de IBPG, especialmente la infección urinaria, en los lactantes febriles de corta edad es significativa. La poca utilidad de los signos clínicos obliga a la realización de exploraciones complementarias(AU)

Background. It is common practice to order diagnostic tests to febrile young infants in order to identify those at greater risk for serious bacterial infection (SBI). Objective. To determine the prevalence and etiology of SBI in 1 to 3- month-old infants who present with fever without a source (FWS). Method. Retrospective study of all infants aged 1 to 3 months who presented to the emergency department of a tertiary pediatric hospital with FWS from December 2009 through December 2010. Patients on whom blood or urine cultures were not obtained were excluded. Results. 275 infants (61.1% males), with a median age of 57 days (P25-75; 42-74) were included. The median duration of the fever was 8 hours (P25-75; 3-13.25) and 117 (47.6%) children were seen within the first 6 hours. Sixteen patients (5.8%) were not well appearing. Fifty-one infants (18.5%) were diagnosed with SBI, being urinary tract infection (UTI) the main diagnosis (90.2%) and Escherichia coli the most commonly isolated organism. Six patients (2.2%) had a positive blood culture. In contrast to the laboratory data, clinical features were not useful in the identification of those patients with SBI. Conclusions. The rate of SBI, and more notably UTI, was significant among our young febrile infants. Because of the non-specific clinical signs, it is necessary to perform additional diagnostic studies to better identify those patients at risk for SBI(AU)