Serum angiotensin-converting enzyme has low diagnostic value for pediatric sarcoid uveitis.

PURPOSE: Sarcoid uveitis is rare in the pediatric population. Early diagnosis is challenging and is crucial, due to more severe complications. Diagnosis relies on various criteria, including elevated angiotensin-converting enzyme (ACE) levels. The objective of this study was to evaluate the diagnostic value of serum ACE levels in the diagnosis of pediatric sarcoid uveitis. METHODS: This was an observational retrospective multicenter study of chronic, severe pediatric uveitis between 2013 and 2019 in two French tertiary referral centers. RESULTS: An ACE assay result was available for 105 patients. Nine patients were diagnosed with sarcoid uveitis. The diagnostic values were as follows: sensitivity=22.2%, specificity=87.5%, positive predictive value=14.3%, negative predictive value=92.3%, positive likelihood ratio=1.8, and negative likelihood ratio=0.9. CONCLUSION: The diagnostic performance of ACE in pediatric sarcoid uveitis was found to be poor. NPV exceeded 90% but was based on a significant number of false negatives, indicating a high risk of misdiagnosis. Likelihood ratios confirmed the limited diagnostic value of ACE. Considering age groups and clinical manifestations may enhance precision but requires larger studies. Serum ACE used as a diagnostic marker in pediatric sarcoid uveitis warrants caution and should be interpreted alongside other factors.

[Immunosuppressive therapy in severe or chronic pediatric uveitis: Review of the literature]. / Les immunosuppresseurs dans les uvéites pédiatriques sévères ou chroniques : revue de la littérature.

Immunosuppressants are prescribed for pediatric uveitis in cases of severe involvement affecting the prognosis for vision or life, in cases of recurrent or chronic uveitis to achieve corticosteroid sparing, or in cases of corticosteroid resistance. Immunosuppressants used in children include antimetabolites (methotrexate, mycophenolate mofetil, azathioprine), cyclosporine, tacrolimus, and biologics, including infliximab, adalimumab, anakinra, canakinumab, and tocilizumab. The mechanisms of action and indications of the various immunosuppressants are described in this review.

Real-life study of the role of high-flow nasal cannula for bronchiolitis in children younger than 3 months hospitalised in general pediatric departments.

We aimed to describe the real-life role of high-flow nasal cannula (HFNC) for bronchiolitis in infants under 3 months of age admitted to three general pediatric departments during the 2017-2018 epidemic period. We retrospectively assessed the clinical severity (Wang score) for every 24-h period of treatment (H0-H24 and H24-H48) according to the initiated medical care (HFNC, oxygen via nasal cannula, or supportive treatments only), the child's discomfort (EDIN score), and transfer to the pediatric intensive care unit (PICU). A total of 138 infants were included: 47±53 days old, 4661±851.9 g, 70 boys (50.7%), 58 with hypoxemia (42%), Wang score of 6.67±2.58, 110 (79.7%) staying for 48 consecutive hours in the same ward. During the H0-H24 period, only patients treated with HFNC had a statistically significant decrease in the severity score (n=21/110; -2 points, P=0.002) and an improvement in the discomfort score (n=15/63; -3.8 points, P<0.0001). There was no difference between groups during the H24-H48 period. The rate of admission to the PICU was 2.9% for patients treated for at least 24 h with HFNC (n=34/138, 44% with oxygen) versus 16.3% for the others (P=0.033). Early use of HFNC improves both clinical status and discomfort in infants younger than 3 months admitted for moderately severe bronchiolitis, whatever their oxygen status.

Non accidental repeated lithium poisoning in a child: The role of hair analysis.

Non accidental intoxication due to child abuse is rare and its frequency is likely underestimated because it is difficult to diagnose. Here, we report a case of voluntary repeated exposure to lithium in an infant, for whom the clinical manifestations were convulsions. Toxicological analysis was very helpful for documenting lithium exposure during the assumed period of time. Interpreting the results of hair analysis, a simple and minimally invasive examination, is tricky at this age, but it can facilitate the differentiation of acute versus chronic exposure. Although infrequent and underestimated, lithium should be considered as a cause of intoxication in a previously healthy child with acute seizure.

[Congenital tuberculosis in preterm neonate: a case report]. / Tuberculose congénitale chez le nouveau-né prématuré : à propos d'un cas.

Congenital tuberculosis is a rare but severe disease. Diagnosis is often delayed, especially in preterm neonates. We report a premature infant born after 27 weeks of gestation and in vitro fertilization. Tuberculosis was suspected after 112 days of life in view of sepsis, respiratory distress, and the discovery of maternal tuberculosis. Mycobacterium tuberculosis was isolated in endotracheal aspirates, gastric aspirates, and stools. The infant initially received four antitubercular antibiotics over 3 months, then two antibiotics over 9 months. A wide screening for a possible nosocomial transmission from this index case was set up. At the chronological age of 2 years, the baby is healthy without after-effects and no secondary cases were diagnosed. This article recalls the difficulty diagnosing congenital tuberculosis, particularly in preterm neonates. It also underlines the need to raise and eliminate the diagnosis of tuberculosis in an infertile woman.

[New blood tests for diagnosis of infection with Mycobacterium tuberculosis]. / Les nouveaux tests diagnostiques de la tuberculose.

INTRODUCTION: A major challenge in tuberculosis (TB) control is the diagnosis and the treatment of latent tuberculosis infection. STATE OF THE ART: At the time, the diagnosis is based on tuberculin skin test (TST). TST is not specific, has poor sensitivity and is not easy to perform. PERSPECTIVES: Two interferon-based tests for the diagnosis of tuberculosis have just been licensed. These tests have some advantages on TST. They require only a blood sample and their results are not dependent on the examinator. Their specificity is higher than TST because they don't cross-react with BCG vaccination and with most of the environmental Mycobacterium species. Their sensitivity is higher for the diagnosis of active tuberculosis too. For latent tuberculosis, the interferon-gamma assays show a better correlation with the exposure to Mycobacterium tuberculosis than TST. The ability to detect TB of the two tests seem to be reduced in immunocompromised patients, specially in medically ones. CONCLUSIONS: Interferon-gamma assays seems to be useful tools in TB detection, but these good results have to be confirmed in larger studies with unselected patients.

[Treatment of visceral leishmaniasis in children]. / Le traitement de la leishmaniose viscérale infantile.

Visceral Leishmania infantum leishmaniasis is endemic in the south of France. For many years the mainstay for treatment of infected children was pentavalent antimony: meglumine antimoniate (Glucantime) or sodium stibogluconate (Pentostam). However these drugs are poorly tolerated and resistance similar to that observed in the treatment of Indian visceral Leishmania donovani leishmaniasis has been reported. Currently liposomal amphotericin B is being used instead of antimony for treatment of visceral leishmaniasis in children in France. In addition to being well tolerated, liposomal amphotericin B is almost 100% effective. It can be administered in six intravenous injections of 3-4 mg/kg each (days 1 to 5 then day 10). A two-day protocol (10 mg/kg/d) that would reduce overall cost by shortening the duration of hospitalization is now being studied. Another oral drug, i.e., miltefosine, has been successfully used for treatment of visceral leishmaniasis in India. However it has not been evaluated for treatment of Mediterranean visceral leishmaniasis.

[Chest X-ray and acute bronchiolitis: Are these indications decreasing?] / Radiographie de thorax et bronchiolite aiguë : des indications en diminution ?

OBJECTIVE: A management protocol for infants hospitalized for acute bronchiolitis, established after the study conducted in our unit in 2012, recommends a chest X-ray when the clinical course is unusual or if a differential diagnosis is suspected. The goal of this study was to evaluate professional practices after the introduction of this new management protocol. STUDY DESIGN: Retrospective descriptive study in two pediatric units from October 2013 to March 2015, including infants (0-23 months) hospitalized for their first episode of acute bronchiolitis without any underlying chronic condition. RESULT: Overall, 599 infants were included (median age, 3.7 months, 54 % boys). Nearly six out of ten (n=355, 59.3 %) had at least one chest radiograph (38.5 % fewer than in 2012). It was abnormal in 96.3 % of cases, revealing distension and/or bronchial wall thickening (56.7 %), focal opacity (23.5 %), or atelectasis (19.5 %). An X-ray was performed out of the recommendations in 42.5 % of cases. The chest X-ray result led to management changes in 52 infants with prescription of antibiotics for pneumonia (86.5 %) and allowed the diagnosis of heart disease in one case (0.2 %). Management of acute bronchiolitis (X-ray and antibiotics) was statistically different between the two pediatric units. DISCUSSION: This protocol led to a significant decrease in the number of chest X-rays. However, many are still performed out of the recommendations, resulting in an increase of antibiotic use for pneumonia. CONCLUSION: The decrease in use of chest X-rays in acute bronchiolitis for hospitalized infants was significant but remains insufficient.

[Necrotizing cellulitis complicating varicella in two children given nonsteroidal anti-inflammatory drugs]. / Dermo-hypodermite nécrosante compliquant la varicelle chez l'enfant sous anti-inflammatoires non stéroïdiens: à propos de 2 cas.

We report two cases of fasciitis with necrotizing hypodermitis of the foot and arm which complicated varicella in immunocompetent children given nonsteroidal anti-inflammatory drugs. The skin barrier and immune function are weakened by the varicella zoster virus. Exposure to nonsteroidal anti-inflammatory drugs further favors necrotizing cutaneous infections caused by group A beta hemolytic streptococci. MRI can confirm the presence of superficial aponevrosis necrosis defining necrotizing fasciitis but should not retard surgical management which is always indicated for necrotizing fasciitis and sometimes for necrotizing dermo-hypodermitis.

[Extrapulmonary infections due to Mycoplasma pneumoniae]. / L'infection extrapulmonaire à Mycoplasma pneumoniae.

Pneumonia is the main site of infection with Mycoplasma pneumoniae in paediatric age. Nevertheless it can also give rise to other manifestations, with or without respiratory involvement. In the present review are described some unusual clinical features of M. pneumoniae in children. Encephalitis and meningoencephalitis is the most frequent neurological manifestation, but cases of meningitis, myelitis, and polyradiculitis, have been reported. Cardiac involvement is potentially severe, including pericarditis and myocarditis. Cold agglutinin haemolytic anaemia is the most frequent haematologic manifestation. Skin, renal, gastro-intestinal, osteoarticular, and other manifestations have also been reported in the literature. The pathogeny of these extrapulmonary infections is not fully elucidated and the treatment remains partly controversial. Extrapulmonary complications can occur as a result of direct invasion and/or autoimmune response.

[Mefloquine versus halofantrine in children suffering from acute uncomplicated falciparum malaria]. / Méfloquine versus halofantrine dans le traitement de l'accès simple à Plasmodium falciparum de l'enfant voyageur.

AIM OF THE STUDY: To evaluate mefloquine versus halofantrine in children suffering from acute uncomplicated falciparum malaria. MATERIAL AND METHODS: Prospective non randomized study in hospitalized children during one year. Acute falciparum malaria was defined by fever and a positive thin and/or thick smear. Malaria was presumed to have been contracted in Comoros archipelago and/or Madagascar 6 months previously. Patients were excluded, when quinine had to be used, according to World Health Organization's severity criteria. RESULTS: Forty-nine children were included: 29 were treated with halofantrine and 20 with mefloquine. Patients features in the two groups of treatment were identical, with exception for the mean time between first clinical signs and diagnosis (shorter in mefloquine group). Fever's and hospitalization's duration under treatment were similar. An increase in QTc interval was frequently observed in patients treated with halofantrine (56 versus 0%), although patients with mefloquine experienced vomiting (45 versus 0%). Relapses seemed to be more frequent with halofantrine (14 versus 0%). DISCUSSION: Halofantrine and mefloquine are efficient for falciparum malaria treatment in our pediatric series, despite a high rate of adverse events. Mefloquine's tolerance may probably be improved with changes in regimen and dose. Relapses are more frequent with a single first treatment of halofantrine, than with mefloquine. Unfortunately, features of a second halofantrine treatment are not defined.

[First-line liposomal amphotericin B for pediatric visceral leishmaniasis in southern France]. / Amphotéricine B liposomale en première intention dans la leishmaniose viscérale infantile en région Provence-Alpes-Côte-d'Azur-Corse.

AIMS OF THE STUDY: First, to describe liposomal amphotericin B (AmBisome use as first line treatment of pediatric visceral leishmaniasis and secondly, to evaluate the incidence of the disease in southern France (Provence - Alpes - Côte d'Azur - Corse). MATERIAL AND METHODS: Retrospective chart review of children referred for visceral leishmaniasis from 1996 to 2003. RESULTS: Thirty-two children under 15 years of age and suffering from visceral leishmaniasis were treated with liposomal amphotericin B as first line treatment. Clinical and biological features were usual: age <5 years, no immunodeficiency, spleen enlargement and fever, cytopenia. In this population, treatment effectiveness was evaluated to 97% (one relapse). Under treatment, patients quickly improved. Drug regimens varied from 18 to 24 mg/kg (day 1 to 5, and day 10). Four other children were not treated with first-line liposomal amphotericin B during the period. Thus, the incidence of pediatric visceral leishmaniasis was evaluated to be 0.61/100,000 children <15 years/year in the region (2.74 in the Alpes-Maritimes department, French Riviera, and 0.6 in the Bouches-du-Rhône department, Marseilles area). CONCLUSION: Liposomal amphotericin B treatment is usual for children referred for visceral leishmaniasis in this region. This treatment may be approved regarding the high level of effectiveness and the low number of adverse events. A two days drug regimen with 20 mg/kg should be evaluated. Moreover, the incidence of the pediatric visceral leishmaniasis in southern France is decreasing, but local variations may be observed.

[Malaria chemoprophylaxis in traveling children]. / La chimioprophylaxie antipaludéenne de l'enfant voyageur.

In France, 4,000 imported malaria cases are reported each year (7,000 to 8,000 estimated). Chemoprophylaxis is essential for prevention in travelers. When malaria is susceptible to chloroquine, this drug (Nivaquine) has to be used. It is given daily in France (1.5 mg/kg per day), from departure to four weeks after return. When low levels of chloroquino-resistance are reported, French authorities recommend the use of chloroquine + proguanil (Savarine) if the body weight is >50 kg or Nivaquine) + Paludrine), if <50 kg), or atovaquone + proguanil (Malarone). Nivaquine) (1.5 mg/kg per day) and Paludrine) (3 mg/kg per day) have to be pursued for one month after return, although Malarone) (1 pediatric tablet/10 kg per day, in children >10 kg weight) may be disrupted after one single week. Adverse events are rarer with atovaquone + proguanil, than with chloroquine + proguanil. When chloroquino-resistance is high, Malarone) or mefloquine (Lariam) are used. Weekly drug regimen is recommended with mefloquine (5 mg/kg per weight) for the travel duration and four weeks after return and the drug tolerance is good in pediatric prophylaxis. Doxycycline is used under conditions in children >8 years of age. New drugs as for tafenoquine, an amino-8 quinoleine, might enhance patients compliance if given monthly.

[Management of cutaneous leishmaniasis in adults and children]. / Traitement des leishmanioses cutanées de l'adulte et de l'enfant.

Cutaneous leishmaniasis can present a variety of clinical features and courses. The causative Leishmania species is an important prognostic factor in immunocompetent patients. Local treatment modalities including topical paromomycin, cryotherapy, localized controlled heat, carbon dioxide laser therapy, or intralesional meglumine antimoniate can be effective against Leishmania major or Leishmania tropica. Oral fluconazole may be a second-line treatment. Parenteral antimonials are useful for persistent or recurrent Old World leishmaniasis. For New World leishmaniasis, parenteral antimonials represent the first-line treatment in all forms except those caused by Leishmania guyanensis in which pentamidine is preferable. Liposomal amphotericin B appears to be effective for treatment of cutaneous leishmaniasis but further study will be needed. Results using oral Miltefosine are promising against Indian kala-azar (Leishmania donovani) but disappointing against South American leishmaniasis.

[Imported malaria at the Marseilles Hôpital-Nord, France: a prospective study on 352 cases between 2001 and 2003]. / Le paludisme d'importation à l'Hôpital-Nord de Marseille en 2001-2003: étude prospective de 352 cas.

OBJECTIVE: The authors had for aim to study epidemiological, clinical, and parasitological characteristics, as well as regimen received, of imported malaria cases hospitalised at the North University Hospital, in Marseilles, France. DESIGN: The patients presenting with imported malaria included in this study were hospitalised in the infectious and tropical diseases unit and in the pediatrics unit at the North University Hospital, from January 1, 2001 to December 31, 2003. Variables were prospectively collected and recorded. RESULTS: 352 patients including 240 adults and 112 children were included. Most of them (67% of the adults and 92% of the children) were contaminated during a trip to the Comoros Islands. Plasmodium falciparum was the most common species identified. 97.5% of adult and 98% of child patients back from Comoros did not take any chemoprophylaxis against malaria or took inadequate regimens. Halofantrin was the most commonly used drug for children to treat uncomplicated P. falciparum malaria. In adults, atovaquone-proguanil was used as a first line drug in the absence of vomiting, and a 3-day intravenous regimen of quinine-clindamycin in case of vomiting. CONCLUSION: The specificity of imported malaria in Marseilles is the high proportion of Comorian patients who go back home periodically to visit friends and relatives. A better education of the Comorian population in Marseilles, regarding malaria risks and prophylaxis, needs to be implemented.

[Acute epiglottitis due to group A ß-hemolytic streptococcus in a child]. / Épiglottite aigüe à streptocoque ß-hémolytique du groupe A.

Acute epiglottitis has become an exceptional observation in pediatrics. The introduction of Haemophilus influenzae type B vaccine changed the morbidity, mortality, and microbiology of this disease. We report the case of an 11-month-old infant with acute epiglottitis due to group A ß-hemolytic streptococcus.

[Bronchiectasis revealing triple A syndrome]. / Une dilatation de bronches révélant un syndrome du triple A.

We report on the case of a 3-year-old child presenting bilateral bronchiectasis due to recurrent pneumonia with esophageal achalasia. The final diagnosis was triple A syndrome. This presentation is particularly atypical and rare at this age.

[Juvenile dermatomyositis and new autoantibodies: Cases and review]. / Dermatomyosite juvénile et nouveaux auto-anticorps : à propos de quatre observations.

Juvenile dermatomyositis (JDM) is the most common inflammatory myopathy in children. Its diagnosis is usually made on a clinical basis following the criteria of Bohan and Peter (1975). Recently, the presence of myositis-specific autoantibodies (MSAs) have started to be associated with specific outcome in adult patients; the diagnosis and prognosis value of these autoantibodies remains to be identified in children. We report four cases of JDM with MSAs focusing on clinical, biological, and radiological manifestations, and then we describe associated treatment. The cohort comprises four girls with an average age of 8.5 years. The time to diagnosis was 1 week to 4 months. For these patients, the immunologic study found one patient positive for the MDA5 antibody (or CADM 140), one positive for the TIF1γ antibody (or p155/140), and two patients positive for the NXP2 antibody (or p140/MJ). Each patient showed specific and characteristic cutaneous manifestations. For example, the girl positive for the TIF1γ antibody presented the most severe skin disease with urticaria, face edema, and vascularity of the neck and shoulders. However, regarding muscular features, proximal weakness was present in most of the cohort, except for the child positive for the MDA5 antibody, who presented no sign of muscular disease at the beginning with low CK levels. Importantly, acute pancreatitis also affected this patient. Concerning radiological indications, muscular MRI evidenced hyperinflammation, a sign of diffuse myositis, in all these patients. Treatments consisted in corticosteroids together with methotrexate or mycofenolate mofetil associated or not with intravenous immunoglobulin therapy. This report highlights the importance of systematic detection and analysis of MSA in diagnosis and characterization of JDM, and describes a new approach that would allow more focused treatments and be a useful predictor of clinical complications and prognosis in JDM-affected subjects.

[Disseminated BCG disease revealing a partial deficiency in receptor 1 interferon gamma]. / Bécégite disséminée révélatrice d'un déficit partiel en récepteur 1 de l'interféron gamma.

We report on a case of disseminated BCGitis with an unusual presentation in a 4-month-old infant revealing a syndrome of Mendelian susceptibility to mycobacteria due to a partial dominant mutation of the interferon gamma receptor 1 gene.

[Which prophylaxis for the travelling child?]. / Quelle prophylaxie pour l'enfant voyageur?

Protection against malaria can never be totally effective: chemoprophylaxis may not prevent infection with multidrug-resistant Plasmodium. Drug tolerance may vary. Antimalarial drugs are often not well adapted for infants. Mechanical prophylaxis is essential in childhood: devices as insecticide impregnated bednets or repellents are the most efficient protection against mosquito bites and in fine against infection.