Presentation and Outcomes of Kawasaki Disease in Latin American Infants Younger Than 6 Months of Age: A Multinational Multicenter Study of the REKAMLATINA Network.

Objective: To characterize the clinical presentation and outcomes of Kawasaki disease (KD) in infants <6 months of age as compared to those ≥6 months in Latin America. Methods: We evaluated 36 infants <6 months old and 940 infants ≥6 months old diagnosed with KD in Latin America. We compared differences in laboratory data, clinical presentation, treatment response, and coronary artery outcomes between the two cohorts. Results: The majority (78.1%) of infants and children ≥6 months of age were initially diagnosed with KD, as compared to only 38.2% of infants <6 months. Clinical features of KD were more commonly observed in the older cohort: oral changes (92 vs. 75%, P = 0.0023), extremity changes (74.6 vs. 57.1%, P = 0.029), and cervical lymphadenopathy (67.6 vs. 37.1%, P = 0.0004). Whether treated in the first 10 days of illness or after the 10th day, infants <6 months were at greater risk of developing a coronary artery aneurysm compared to KD patients ≥6 months treated at the same point in the course of illness [ ≤ 10 days (53.8 vs. 9.4%, P = 0.00012); >10 days (50 vs. 7.4%, P = 0.043)]. Conclusion: Our data show that despite treatment in the first 10 days of illness, infants <6 months of age in Latin America have a higher risk of developing a coronary artery aneurysm. Delay in the diagnosis leads to larger coronary artery aneurysms disproportionately in these infants. Thus, suspicion for KD should be high in this vulnerable population.

Echocardiographic Follow-up of Perinatally HIV-infected Children and Adolescents: Results From a Single-center Retrospective Cohort Study in Brazil.

BACKGROUND: The effects of HIV and antiretroviral therapy on cardiovascular system of perinatally infected children throughout their development are not fully understood. OBJECTIVES: To determine the prevalence of cardiac abnormalities in a retrospective cohort of perinatally HIV-infected patients and to investigate associations between echocardiographic and clinical data during their follow-up. METHODS: Review of medical records and echocardiogram reports of 148 perinatally HIV-infected patients between January 1991 and December 2015. RESULTS: Four hundred and eighty echocardiograms were analyzed and 46 (31%) patients showed cardiac abnormalities, frequently subclinical and transient. Nadir CD4 count was higher in patients with consistently normal echocardiogram: 263 (4-1480) versus 202 (5-1746) cells/µL, P = 0.021. Right ventricular (RV) dilation was detected in 18.9%, left ventricular (LV) dilation in 21.6%, septal hypertrophy in 12.2%, LV posterior wall hypertrophy in 6%, LV systolic dysfunction in 8% and pulmonary hypertension in 8.7% of patients. Opportunistic infections were associated with RV dilation [odds ratio (OR = 4.34; 1.78-10.53; P < 0.01)], pulmonary hypertension (OR = 8.78; 2.80-27.51; P < 0.01) and LV systolic dysfunction (OR = 5.38; 1.55-18.71; P < 0.01). Longer duration of highly active antiretroviral therapy was associated with reduced risk of LV dilation (OR = 0.91; 0.85-0.97; P < 0.01) and systolic dysfunction (OR = 0.71; 0.59-0.85; P < 0.01). Protease inhibitors use was associated with reduced risk of RV dilation (OR = 0.54; 0.30-0.97; P < 0.05), LV dilation (OR = 0.35; 0.21-0.60; P < 0.01) and LV systolic dysfunction (OR = 0.07; 0.02-0.31; P < 0.01). Higher CD4 count was associated with lower risk of LV systolic dysfunction (OR = 0.82; 0.69-0.98; P < 0.05). CONCLUSIONS: Echocardiograms identified cardiac abnormalities among children with perinatally acquired HIV infection, and data suggest that immunologic status and therapeutic strategies throughout development can influence cardiac disease burden in this population.

Costs and benefits of secrecy: the dilemma experienced by adolescents seropositive for HIV.

This study explored the experiences of the first generation of adolescents who acquired HIV through vertical transmission when disclosing their diagnosis to friends and romantic partners. The study sample was selected by convenience, with 20 patients (13-20 years old) participating in a qualitative investigation using individual interviews (language: Portuguese; duration: 45 minutes). The participants were followed in specialized clinics for the treatment of pediatric AIDS in São Paulo, Brazil. The results suggest that families who live with HIV tend to keep it a secret, and such behavior is learned and accepted unquestioningly as natural. Respect for privacy and the fear of rejection, coupled with the belief that information about their disease will be spread, are the main beliefs with which participants justify their secrecy. In terms of romantic relationships, adolescents were aware that their HIV status should at some point be shared with current or future sexual partners. However, the decision to reveal an HIV diagnosis in romantic relationships is permeated by anxieties, uncertainties about the right time, and fear of abandonment. In any case, telling the truth requires trust, guarantees of the other's love, and, in some cases, probing romantic partners beforehand to learn their perceptions about the disease. Participants who had experiences disclosing their HIV status shared positive and negative results, including emotional support, acceptance, and understanding, along with ostracism, discrimination, and abandonment by family members. The findings of this paper reinforce the challenges of revealing an HIV diagnosis to third parties. It requires understanding the meaning and importance of the secret for each patient, along with the conflict between the right to confidentiality and the responsibility of treating others exposed to the disease. All these aspects should be discussed extensively with this population and incorporated into clinical practice.

[Recommendation of the Brazilian Society of Pediatrics for antibiotic therapy in children and adolescents with community-acquired pneumonia]. / Recomendação da Sociedade Brasileira de Pediatria para antibioticoterapia em crianças e adolescentes com pneumonia comunitária.

OBJECTIVE: To standardize the use of antibiotics to treat community-acquired pneumonia in children and adolescents in Brazil. METHODS: The following data sources were utilized: the Medline and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde) bibliographic databases; World Health Organization and Pan American Health Organization documents published between 1980 and 2002; Internet materials in Portuguese, Spanish, or English located using the search terms "pneumonia, child, adolescent, etiology, treatment"; and interviews with renowned experts in the field. RESULTS: Hospitalization is always required for children younger than 2 months of age. That age group should be treated with ampicillin and aminoglycosides or third-generation cephalosporins. Children older than 2 months must be hospitalized if there is severe pneumonia. Tachypnea should be used as the criterion to distinguish between acute respiratory infection and pneumonia. Pneumonia is considered to be very severe when there are seizures, sleepiness, stridor at rest, severe malnutrition, no ingestion of fluids, or signs of respiratory failure such as central cyanosis. Children who are 2 months of age or older may receive outpatient treatment with amoxicillin or penicillin G procaine. In the case of inpatient treatment, crystalline penicillin or ampicillin may be used for severe cases, and oxacillin and chloramphenicol or ceftriaxone for very severe cases. A macrolide, preferably erythromycin, should be employed when the etiologic agent is suspected to be Chlamydia trachomatis, C. pneumoniae, Mycoplasma pneumoniae, or Bordetella pertussis. CONCLUSIONS: The diagnosis of pneumonia and the need for hospitalization can be based on clinical assessment. The main antibiotics to be used are amoxicillin, penicillin, erythromycin, ampicillin, oxacillin, chloramphenicol, ceftriaxone, and aminoglycosides, depending on the age of the patient and the severity of the disease.

Recomendação da Sociedade Brasileira de Pediatria para antibioticoterapia em crianças e adolescentes com pneumonia comunitária / Recommendation of the Brazilian Society of Pediatrics for antibiotic therapy in children and adolescents with community-acquired pneumonia

OBJETIVO: Padronizar o uso dos antibióticos no tratamento das crianças e adolescentes com pneumonia comunitária no Brasil. MÉTODOS: Foram utilizados os dados das bases de dados Medline e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); documentos da Organização Mundial da Saúde e Organização Pan-Americana da Saúde, de 1980 a 2002; busca na Internet, em português, espanhol e inglês, utilizando-se as palavras-chave "pneumonia, criança, adolescente, etiologia, tratamento"; e questionamentos a pesquisadores com reconhecido saber sobre o assunto. RESULTADOS: As crianças com menos de 2 meses devem ser hospitalizadas sempre e receber tratamento com ampicilina associada a aminoglicosídeo ou a cefalosporina de terceira geração. As crianças maiores de 2 meses devem ser hospitalizadas se apresentarem pneumonia grave (pneumonia e tiragem subcostal). Recomenda-se utilizar taquipnéia como critério para distinguir entre infecção respiratória aguda e pneumonia. Considera-se a pneumonia muito grave quando associada a convulsões, sonolência, estridor em repouso, desnutrição grave, ausência da ingestão de líquidos ou sinais de insuficiência respiratória grave, como cianose central. As crianças com 2 meses ou mais podem ser tratadas ambulatorialmente com amoxicilina ou penicilina procaína. Quando o tratamento for hospitalar, podem ser utilizadas penicilina cristalina ou ampicilina para os casos graves ou oxacilina associada a cloranfenicol ou ceftriaxona para os casos muito graves. Sempre que houver a suspeita de a etiologia ser C. trachomatis, C. pneumoniae, M. pneumoniaeou B. pertussis deve-se utilizar um macrolídeo, preferencialmente a eritromicina. CONCLUSÕES: O diagnóstico de pneumonia pode ser baseado em avaliação clínica, assim como a indicação de hospitalização. Os principais antibióticos a serem utilizados são amoxicilina, penicilina, eritromicina, ampicilina, oxacilina, cloranfenicol, ceftriaxona e aminoglicosídeos, conforme a faixa etária e a gravidade.

Hyperlipidaemia a risk factor for femoral head osteonecrosis (Legg-Calv -Perthes-like disease) in children with AIDS: case report.

Although treatment of children infected with HIV with protease inhibitors has improved the survival of these patients, various adverse side effects have been reported, including metabolic abnormalities, such as hyperlipidaemia. We describe a case of hip osteonecrosis in an adolescent with AIDS who was being treated with protease inhibitors. There is a possible relation with hyperlipidemia. F.M.G., white, 11 years old, AIDS A2, started to receive AZT and DDI when he was 7 years old. In April 1999, the patient had a significant increase in viral load and so the antiretroviral therapy was switched to d4T, 3TC and Ritonavir. Triglyceride plasma levels reached 460mg/dl after this switch and were always above the reference value. In December 1999, the patient complained of pain in the right hip. On physical examination, he had limited movement of this joint. Magnetic resonance imaging of the right hip showed flattening, deformity and fragmentation of the femoral head, compatible with osteonecrosis. Few cases of femoral head osteonecrosis have been associated with HIV infection, in the absence of the classic risk factors for osteonecrosis. Metabolic risk factors include hypertriglyceridaemia. The immunological disorders that occur in the HIV infection may predispose the patient to avascular osteonecrosis and metabolic disorders, particularly hypertriglyceridemia, while the use of protease inhibitors, may be considered an additional risk factor for osteonecrosis. Given the importance of premature diagnosis and to avoid complications of osteonecrosis, we recommend evaluation of musculoskeletal symptoms in children receiving protease inhibitors.