Diagnóstico de la tuberculosis en la edad pediátrica. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Neumología Pediátrica (SENP) / Diagnosis of tuberculosis in pediatrics. Consensus document of the Spanish Society of Pediatric Infectology (SEIP) and the Spanish Society of Pediatric Pneumology (SENP)

La tuberculosis continúa siendo uno de los problemas sanitarios más importantes en el mundo. En países desarrollados se está asistiendo a un aumento de casos, incluidos los niños, por diferentes motivos. El más determinante parece ser la inmigración procedente de zonas con elevada endemia de tuberculosis. Es prioritario que se establezcan las medidas necesarias para optimizar el diagnóstico precoz y adecuado de las distintas formas clínicas de tuberculosis en niños. Para ello, la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Neumología Pediátrica (SENP), ambas pertenecientes Asociación Española de Pediatría, han decidido realizar el presente documento de consenso con el objetivo de unificar los criterios de actuación diagnóstica en la edad pediátrica (AU)

Tuberculosis is one of the most important health problems worldwide. There are an increased number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration coming from high endemic areas. Measures to optimize early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Pediatric Association (Spanish Society of Pediatric Infectology and Spanish Society of Pediatric Pneumology) have agreed this Consensus Document in order to homogenize diagnostic criteria in pediatric patients (AU)

Diagnóstico de la tuberculosis en la edad pediátrica / Diagnosis of tuberculosis in paediatrics

La tuberculosis continúa siendo uno de los problemas sanitarios más importantes en el mundo. En países desarrollados se está asistiendo a un aumento de casos, incluidos los niños, por diferentes motivos. El más determinante parece ser la inmigración procedente de zonas con elevada endemia de tuberculosis. Es prioritario que se establezcan las medidas necesarias para optimizar el diagnóstico precoz y adecuado de las distintas formas clínicas de tuberculosis en niños. Para ello, la Sociedad Española de Infectología Pediátrica y la Sociedad Española de Neumología Pediátrica ambas pertenecientes a la Asociación Española de Pediatría, han decidido realizar el presente documento de consenso, con el objetivo de unificar los criterios de actuación diagnóstica en la edad pediátrica (AU)

Tuberculosis is one of the most important health problems worldwide. There are an increasing number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration from highly endemic areas. Measures to optimise early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Paediatric Association (Spanish Society of Paediatric Infectology and Spanish Society of Paediatric Pneumology) have agreed this Consensus Document in order to homogenise diagnostic criteria in paediatric patients (AU)

[Diagnosis of tuberculosis in pediatrics. Consensus document of the Spanish Society of Pediatric Infectology (SEIP) and the Spanish Society of Pediatric Pneumology (SENP)]. / Diagnóstico de la tuberculosis en la edad pediátrica. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y la Sociedad Española de Neumología Pediátrica (SENP).

Tuberculosis is one of the most important health problems worldwide. There are an increased number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration coming from high endemic areas. Measures to optimize early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Pediatric Association (Spanish Society of Pediatric Infectology and Spanish Society of Pediatric Pneumology) have agreed this Consensus Document in order to homogenize diagnostic criteria in pediatric patients.

[Diagnosis of tuberculosis in paediatrics]. / Diagnóstico de la tuberculosis en la edad pediátrica.

Tuberculosis is one of the most important health problems worldwide. There are an increasing number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration from highly endemic areas. Measures to optimise early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Paediatric Association (Spanish Society of Paediatric Infectology and Spanish Society of Paediatric Pneumology) have agreed this Consensus Document in order to homogenise diagnostic criteria in paediatric patients.

Púrpura fulminante posvaricelosa: potencialmente mortal / Post-varicella purpura fulminans: Potentially fatal

Aunque la varicela suele ser una enfermedad benigna, algunas complicaciones pueden ser mortales, como la púrpura fulminante posvaricelosa. Su mecanismo fisiopatogénico se explica por la producción de anticuerpos para las proteínas C y S de la cascada de la coagulación, lo que puede tener consecuencias funestas con la producción de coagulopatía de consumo en personas con déficits parciales de estas proteínas. El tratamiento es sintomático y consiste básicamente en la administración de plasma fresco congelado (para suplir las proteínas que se consumen), de antitrombina III y heparinización (para tratar la producción de trombos) y de antiinflamatorios, como los corticoides; sin embargo, se están introduciendo tratamientos nuevos, como la prostaglandina E1 intravenosa y la prostaciclina (AU)

Although varicella is usually a benign disease, some of its complications, such as post-varicella purpura fulminans, can be fatal. Its pathophysiological mechanism is caused by the production of antibodies to protein C and protein S in the coagulation cascade. This could have fatal consequences for those patients with partial deficiency of these proteins that develop disseminated intravascular coagulation. Treatment is symptomatic: fresh frozen plasma to treat protein depletion, antithrombin III and heparinization against thrombus formation, and anti-inflammatory drugs (steroids). However, new therapies, such as prostaglandin E1 IV and prostacyclin, are being introduced (AU)

[Post-varicella purpura fulminans: potentially fatal]. / Púrpura fulminante posvaricelosa: potencialmente mortal.

Although varicella is usually a benign disease, some of its complications, such as post-varicella purpura fulminans, can be fatal. Its pathophysiological mechanism is caused by the production of antibodies to protein C and protein S in the coagulation cascade. This could have fatal consequences for those patients with partial deficiency of these proteins that develop disseminated intravascular coagulation. Treatment is symptomatic: fresh frozen plasma to treat protein depletion, antithrombin III and heparinization against thrombus formation, and anti-inflammatory drugs (steroids). However, new therapies, such as prostaglandin E1 IV and prostacyclin, are being introduced.

Documento de consenso sobre el tratamiento de la exposición a tuberculosis y de la infección tuberculosa latente en niños / Treatment of tuberculosis exposure and latent tuberculosis infection in children

Introducción La pobreza, la infección por el virus de la inmunodeficiencia humana (VIH), la resistencia a fármacos y la diseminación a partir de pacientes con infección latente son las causas más importantes de la pandemia actual de tuberculosis. En los países industrializados, la población inmigrante procedente de países en desarrollo y la falta de programas eficaces de control son las causas principales del incremento de la enfermedad. La situación de los niños es todavía más grave por ser más vulnerables a la enfermedad que los adultos. El mayor riesgo de contraer tuberculosis lo tienen los niños autóctonos que conviven con adultos que tienen factores de riesgo de tuberculosis y los niños inmigrantes y adoptados del tercer mundo. A pesar de que los niños desarrollan la enfermedad no son prácticamente nunca bacilíferos, el tratamiento adecuado de la exposición a tuberculosis bacilífera y de la infección tuberculosa latente en niños contribuye a crear una vigilancia estrecha de los núcleos familiares que asegura un riguroso estudio de contactos y contribuye a evitar formas graves de tuberculosis, más frecuentes en el niño. Objetivo El objetivo de este segundo documento de consenso del Grupo de Trabajo de Tuberculosis de la Sociedad de Infectología Pediátrica (SEIP) es unificar criterios para el tratamiento de las situaciones de exposición a tuberculosis e infección tuberculosa latente en niños y sensibilizar a las autoridades sanitarias acerca de la necesidad de acometer programas muy estrictos de detección de tuberculosis en población de riesgo

Introduction The most important causes of the current tuberculosis pandemic are poverty, HIV infection, drug resistance, and the spread of infection by patients with latent tuberculosis infection. In industrialized countries, the main reasons for the increase of this disease are immigration from developing countries and the lack of effective surveillance programs. The situation of children is even more serious as they are more vulnerable to the disease than adults. The children most at risk are those who live with adults at risk for tuberculosis, immigrant children, and adoptees from developing countries. Although children are bacilliferous only exceptionally, the appropriate management of bacilliferous tuberculosis exposure and latent tuberculosis infection in children contributes to the creation of close surveillance of nuclear families and rigorous study of contacts. Moreover, it could prevent serious forms of the disease, which are more frequent in children. Objective The principal objective of this second consensus document of the Spanish Society of Pediatric Infectious Diseases (Sociedad Española de Infectología Pediátrica [SEIP]) is to unify the criteria for the treatment of tuberculosis exposure and latent tuberculosis infection in children. A further aim is to increase awareness of the need for strict detection measures in high-risk populations among health authorities

[Neonatal morbidity associated with meconial amniotic fluid]. / Morbilidad neonatal asociada a líquido amniótico meconial.

BACKGROUND: The significance of meconium-stained amniotic fluid (MSAF) is discussed, both in regards to obstetric and pediatric management. The primary concerns regarding MSAF have been its significance as a sign of fetal distress/perinatal asphyxia and the prevention of associated morbidity such as meconium aspiration syndrome. The objectives of our study were: (1) To know the incidence and type of MSAF, (2) to study the associated morbidity in newborns with MSAF admitted to the Neonatal Care Unit (NCU), and (3) to analyze the perinatal differences between newborns with moderate versus thick MSAF. PATIENTS AND METHODS: A retrospective study was performed to know the incidence of MSAF in all of the deliveries in our hospital during a 4 year period. The consistency of meconium was classified into 3 classes, thin (light), moderate or thick (heavy). On the other hand, a prospective analysis was undertaken to determine the morbidity of all meconium-stained neonates admitted to our NCU during this period, mainly in relation to perinatal asphyxia, pulmonary, gastrointestinal and infectious pathology and neonatal mortality. RESULTS: The presence of MASF complicates 18% of all of our deliveries with it being mild in 10.8%, moderate in 4.4% and severe in 2.8%. Of all newborns with MSAF, one third were admitted to the NCU, mainly for two reasons, association with perinatal asphyxia (124 cases) and observation of a risk of meconium aspiration syndrome (85 cases). The main neonatal morbidities associated with MSAF in our populations were perinatal asphyxia in 56.1% (32 cases of severe perinatal asphyxia and 92 non-severe), pulmonary pathology in 34% (meconium aspiration syndrome in 32 cases and other respiratory abnormalities in 43) and gastrointestinal pathology in 30.5% (transitory feeding intolerance in all cases). Four cases of meconium-stained neonates were exitus. The neonatal morbidity is significantly more frequent in relation to thick meconium and also if perinatal asphyxia is associated to MSAF. CONCLUSIONS: Although the relationship between MSAF and perinatal asphyxia is controversial, their association increases neonatal morbidity. In accordance with our results, thick meconium is implicated as a risk factor influencing the well being during the intrapartum and postpartum periods.

[Usefulness of renal scintigraphy in the assessment of the first febrile urinary infection in children]. / Utilidad de la gammagrafía renal en la valoración de la primera infección urinaria febril en la edad pediátrica.

OBJECTIVE: The objective of this study was to compare the findings of renal ultrasonography and 99mTc-DMSA renal scintigraphy in children with their first acute febrile urinary tract infection to determine which method is better in detecting patients at risk of renal injury or reflux. PATIENTS AND METHODS: Thirty-three children between 0.2 and 12.3 years of age with their first acute febrile urinary tract infection were studied by means of clinical and laboratory assessment, renal ultrasonography and 99mTc-DMSA renal scintigraphy. In 24 patients (72.7%) a voiding cystourethrography was made. The patients were divided into two groups, those under 2 years of age (n = 14) and those over 2 years old (n = 19). RESULTS: Cortical scintigraphy showed renal changes in 23 patients (69.7%) and ultrasonography showed renal changes in 2 (6.1%; p < 0.05). Children over 2 years of age had a higher incidence of renal lesions than did younger children (84.2% vs 50%; p < 0.05). There were no differences between girls and boys. Reflux was demonstrated in 13 patients (54.2%). Among those kidneys which presented abnormal cortical scintigraphy, vesicoureteral reflux was present in 76.5% of the studies. Furthermore, of those with abnormal ultrasonography vesicoureteral reflux was present in 17.6%. CONCLUSIONS: We found a high incidence of renal involvement in children with their first acute febrile urinary tract infection. The cortical scintigraphy is more sensitive than ultrasonography in detecting renal changes. The incidence of vesicoureteral reflux in febrile urinary tract infection is high. When there is a renal cortical defect the risk of reflux is higher. This suggests that cortical scintigraphy should be added to the initial examination of children with their first acute febrile urinary tract infection and this could be supplemented by voiding cystourethrography alone, with ultrasonography having a secondary role.

[Sensitivity of the clonidine and guanfacine tests (alpha-2-adrenergic agonists) as pharmacologic stimulants of growth hormone. Effects on plasma cortisol]. / Sensibilidad del test de clonidina y test de guanfacina (agonistas alpha-2-adrenérgicos) como estímulos farmacológicos de la hormona de crecimiento. Efectos sobre el cortisol plasmático.

OBJECTIVE: The effects of two pharmacological alpha-2-adrenergic stimuli (clonidine and guanfacine) on GH and cortisol concentrations in the blood in a group of non-growth-hormone-deficient children with short stature was compared. PATIENTS AND METHODS: Seventeen children (10 males and 7 females) with short stature (height standard deviation score: -2.3 +/- 0.5) were studied. The mean age was 9.4 +/- 2.5 years. The GH response to the clonidine or guanfacine test was positive (> 10 ng/ml) in all subjects. RESULTS: Oral clonidine test: In 14 cases (82.4%) the GH response was positive (peak value: 17.2 +/- 6.3 ng/ml) and in 3 cases (17.6%) the GH response was negative (false negatives). A significant decrease in plasma cortisol concentration was noted, from a basal level of 17.0 +/- 8.0 to 5.9 +/- 3.8 micrograms/ml at 120 minutes (p < 0.05). Blood pressure decreased significantly (p < 0.05), but without symptoms of hypotension. Somnolence was noted in 16 cases (94.1%). Oral guanfacine test: In 8 cases (47%) the GH response was positive (peak value: 14.2 +/- 3.7 ng/ml) and in 9 cases (52.9%) the GH response was negative (false negatives). A significant decrease in plasma cortisol concentration was noted, from a basal level of 14.2 +/- 6.4 to 7.2 +/- 3.7 at 90 minutes (p < 0.05). Blood pressure did not change and none of the patients had somnolence during the test. CONCLUSIONS: The alpha-2-adrenergic agonists, clonidine and guanfacine, appear to be reliable agents for testing of the growth hormone reserve of the pituitary gland. Plasma cortisol levels decreased significantly with either stimuli. The clonidine test is more sensitive than the guanfacine test and can be recommended as a definitive test for the diagnosis of classical growth hormone deficiency.

Q fever in children.

OBJECTIVE: To describe clinical profiles of Q fever in children. DESIGN: Retrospective study. SETTING: Tertiary teaching hospital. PARTICIPANTS: Thirteen children aged 2 to 14 years, with a mean +/- SD age of 9.6 +/- 3.6 years. SELECTION PROCEDURES: Review of the medical records of all children with Q fever admitted from 1986 to 1990. The diagnosis was made by detection of phase II antibodies to Coxiella burnetii by the complement fixation test. MEASUREMENTS/MAIN RESULTS: Clinical profiles consisted of a self-limited illness characterized by high fever (mean +/- SD, 39.9 degrees C +/- 0.66 degrees C) of 5 to 10 days' duration (mean +/- SD, 7.4 +/- 1.6 days), constitutional symptoms, and mild liver dysfunction. Eleven patients had gastrointestinal manifestations (vomiting and/or abdominal pain). Respiratory symptoms were not prominent. Most patients had normal or low white blood cell counts, and seven showed a relative increase of band forms. Their erythrocyte sedimentation rates ranged from 8 to 23 mm/h. All patients did well without specific therapy for C burnetii. CONCLUSION: In children with the symptoms described above, tests to detect antibodies to C burnetii should be performed.

[High frequency ventilation in the newborn. Study of 27 cases]. / Ventilación de alta frecuencia en el recién nacido. Estudio de 27 casos.

The clinical histories of 27 neonates ventilated with high frequency respirators (Volumetric Diffusive Respirator VDR-2) have been analyzed in order to evaluate the efficiency of this type of ventilation in neonatal pathology. The average gestational age of these patients was 32 +/- 4 weeks. Most of them (70%) presented respiratory distress due to hyaline membrane disease. Of the remaining cases, three (11%) presented with congenital diaphragmatic hernia, two with pulmonary hypertension, two with meconium aspiration syndrome, one with Group B Streptococal sepsis/shock and one with case diaphragmatic agenesia. Between two and six hours after initiation of high frequency ventilation (HFV), pH, paCO2 and pO2 improved significantly in relationship to former values (p < 0.05- p < 0.001), reaching values in the normal range at 6.5 +/- 14 hours regarding pH, 30 +/- 50 hours regarding paCO2 and 6.5 +/- 10 hours regarding paO2. No hemodynamic modification could be attributed to this procedure. The principal complications were ectopic air (62%) and necrotizing tracheobronchitis (TBN) (25%). Bronchopulmonary dysplasia (BDP) was diagnosed in 20% of the cases, ductus (DAP) in 33% of the cases and intracraneal hemorrhage in 25% of the cases. Mortality was 70%. High frequency ventilation is an alternative procedure to conventional ventilation in this group of neonates. It produces an important number of favorable responses, but has complications that can not be overlooked.

PIP: Clinical records of 27 newborns treated with high frequency ventilation in a hospital neonatal service in Madrid were retrospectively studied. High frequency ventilation is a technique with specific indications that has recently been applied in some neonatal pathologies as an alternative to conventional ventilation. The respirators, model 2 Volumetric Diffusive Respirators, were used in 24 of the 27 cases because of failure of conventional ventilation. The 27 newborns weighed an average of 1850 +or- 944 g and ranged from 900 to 4000 g. Their average gestational age was 32 +or- 4 weeks, and the range was 26-42 weeks. 19 had respiratory difficulties stemming from hyaline membrane disease, 3 had congenital diaphragmatic hernias, 2 had pulmonary hypertension, and one each had meconium aspiration syndrome, septic shock from group B streptococcus, and diaphragmatic agenesia. 66% were delivered by cesarean. The pH, paCO2, and paO2 improved significantly between 2 and 6 hours after initiation of HFV treatment. Values in the normal range were reached at 6.5 +or- 14 hours for pH, 30 +or- 50 hours for paCO2, and 6.5 +or- 10 hours for paO2. No hemodynamic modifications were attributed to HFV. The most significant complications were ectopic air (62%) and necrotizing tracheobronchitis (25%). Broncopulmonary dysphasia was diagnosed in 20%, ductus in 33%, and intracraneal hemorrhage in 25%. The case fatality rate was 70%. Ten newborns improved definitively with HFV and proceeded to conventional ventilation. Two later succumbed to other causes. The study showed that HFV can lead to serious complications and should be applied with great prudence despite it great potential benefit.