Short-course antibiotic treatment of bone and joint infections in children: a retrospective study at Montpellier University Hospital from 2009 to 2013.

BACKGROUND: Acute haematogenous bone and joint infections (AHBJI) represent a diagnostic and therapeutic emergency in children, with significant potential sequelae in the case of delayed treatment. Although historically the recommendations for treatment have been based on surgery and prolonged antibiotic therapy, recent studies have demonstrated that short-course antibiotic therapy is also effective. OBJECTIVES: We evaluated a short-term antibiotic protocol for both osteomyelitis and septic arthritis in a 6 year retrospective study at the University Hospital of Montpellier. METHODS: This protocol was based on an initial intravenous treatment with a re-evaluation after 48 h and an early switch to oral therapy in the case of a favourable clinical course for a minimum total duration of 15 days. Antibiotics were selected based on local microbiological epidemiology and systematically adapted to bacteriological results. RESULTS: One hundred and seventy-six cases of AHBJI were included, comprising 56 patients with osteomyelitis, 95 with septic arthritis and 25 who had both of these. The aetiological agent was identified in 42% of the cases, with the main pathogens being Staphylococcus aureus (39%) and Kingella kingae (27%). The mean intravenous treatment duration was 4 days, while the total treatment duration was 15 days. There were no treatment failures, mild sequelae occurred in 1% of the cases and the secondary surgical revision rate was 7%. CONCLUSIONS: The results of this study are comparable to those reported for evaluations of prolonged antibiotic therapy protocols, thus indicating that a common short-term antimicrobial therapy for the management of both osteomyelitis and septic arthritis (minimum of 15 days) is a viable option for treating AHBJI in children. Further prospective studies to confirm these findings are hence warranted.

[Post treatment thoracic aorta: CT and MR imaging features]. / Comment je contrôle une aorte thoracique après traitement en scanner ou en IRM?

Follow-up after thoracic aortic repair relies on CT and MR imaging in order to detect complications from the treatment or underlying pathology. Following prosthetic repair of the ascending aorta, peri-prosthetic hematoma and anastomotic complications (leak, false aneurysm, peri-prosthetic circulation) should be excluded. Following treatment with a covered stent, the location of the prosthesis and its skeleton should be evaluated and endo-leaks and wall defects should be excluded. Following treatment of a dissection, there often is persistent flow in the false lumen. The entry points into the false lumen should be identified. The caliber of the aorta at different levels should be assessed. Signs of ischemia (static and dynamic) and acute complications should be excluded in patients with acute chest pain. Atherosclerosis and dysplastic conditions may affect other segments of the aorta (aneurysm, dissection, hematoma). Follow-up is performed with CT, if possible, when high-resolution evaluation is required, of with MRI in other cases. Follow-up is obtained on a yearly basis or twice a year when an evolutive process is identified. It is performed every two to five years when the risk is low. Follow-up should be suggested by the radiologist.

[The association of VAC® therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps in the management of postoperative mediastinitis in an obese and diabetic patient]. / Intérêt de l'association VAC®-thérapie, ostéosynthèse sternale et lambeaux pectoraux d'avancement dans la prise en charge d'une médiastinite postopératoire après chirurgie cardiaque chez une obèse diabétique.

Postoperative mediastinitis is one of the most worrisome complications after heart surgery. Until now there is no universally accepted strategy in the management of this infectious complication. Recently, various novel techniques like negative pressure therapy and titanium plates sternal reconstruction have allowed a dramatic decrease of mortality and morbidity after mediastinitis. We report the case of a diabetic patient suffering from morbid obesity who developed a severe postoperative mediastinitis after a coronary artery bypass; she was successfully treated by combining negative pressure therapy, titanium plates osteosynthesis and bilateral pectoral muscle flaps.

[Turicella otitidis infection: otitis media complicated by mastoiditis]. / Infections àTuricella otitidis: à propos d'un cas d'otite moyenne compliquée de mastoïdite.

UNLABELLED: Turicella otitidis is a nonfermentative, Gram-positive bacillus, which is almost exclusively isolated from the ear. Few cases of infection caused by T. otitidis have been reported in the literature, but the pathogenic potential of this little-known bacterium remains controversial, particularly in acute and chronic otitis media. CLINICAL OBSERVATIONS: A retrospective study of T. otitidis isolated in the University Hospital of Montpellier in 2004 found T. otitidis in 13 patients. Among them, a 3-year-old girl had presented with acute and perforated otitis media and mastoiditis caused by T. otitidis, thereby confirming the pathogenic effect of this bacterium. CONCLUSION: T. otitidis is relatively frequently isolated from middle ear samples in healthy patients. However, T. otitidis has been implicated in serious cases of infection and should be considered an opportunistic pathogen. Its clinical significance can be difficult to establish and each case should be carefully interpreted. From a bacteriological point of view, T. otitidis should be precisely identified to obtain more information regarding its role in clinical pathology.

[Hereditary angioedema causing colocolic intussusception]. / Oedème angioneurotique héréditaire compliqué d'invagination colocolique.

Hereditary angioedema is a rare, autosomal dominant disease inherited. The cause is a quantitative or qualitative congenital deficit in C1 inhibitor. Various clinical symptoms, in particular of sub-cutaneous, upper airways and digestive origin, have been described. Life threatening conditions may be observed. Little information is available on digestive tract localization corresponding to intestinal intussusception associated with hereditary angioedema in children. We report a case of hereditary angioedema observed in a 15-years-old girl who presented such features. We propose a review of the literature and discuss the curative treatment of digestive crisis in children with hereditary angioedema.

[Hypertension in the absence of renal involvement during childhood Henoch-Schönlein purpura]. / Hypertension artérielle sans atteinte rénale au cours d'un purpura rhumatoïde de l'enfant.

Henoch-Schönlein purpura (HSP) is an IgA mediated vasculitis that affects small vessels. In this condition, arterial hypertension is most often linked with renal involvement, but it can also occur in the absence of urinary abnormalities. We report the case of a 12-year-old girl who presented with HSP and hypertension in the absence of renal involvement. Hypertension responded to oral therapy with nicardipine, and disappeared after healing of the disease. In the case of hypertension during HSP in the absence of renal involvement, other causes of childhood's arterial hypertension have to be ruled out.

Non-conform diagnostic management of pulmonary embolism suspected patients is responsible for a higher risk of thrombotic event occurrence.

The aim of this 3-month follow-up prospective pragmatic study was to evaluate the implementation of a pulmonary embolism (PE) diagnostic strategy in clinical practice. One thousand and one hundred thirty-four consecutive in- and outpatients with clinically suspected PE were enrolled into a sequential diagnostic algorithm in which vascular medical unit plays a pivotal role in advising physicians and suggesting the most appropriate tests according to the diagnostic algorithm. In this observational study, patients that followed the proposed work-up were attributed to a so-called "conform group". Patients in whom diagnostic work-up was not according to protocol were attributed to a "non-conform group". Nine hundred and ninety-seven patients (87.9%) had a conform work-up, and 137 patients a non-conform work-up according to the proposed diagnostic algorithm. The non-conform work-up directly increased in relation to the age of the referred patients. PE was ruled out in 907 (80%) patients of whom 787 (86.8%) were in the conform group. Of the 797 patients who did not receive anticoagulant drugs, follow-up was obtained in 792 (99.4%). Among these patients, the incidence of acute thromboembolic events during the 3-month follow-up period was different in the group of patients that had a conform work-up (1%, [95% CI, 0.5-2.1%]) from the non-conform group patients (4.5%, [95% CI, 2-10.2%]. Therefore patients from the non-conform group have an independent increased risk to develop a thromboembolic event during the follow-up, adjusted odds ratio 3.3 [1.1-10, 95% CI]. Therefore we demonstrated that a non-conform diagnostic management strategy is associated with a higher risk of thrombotic event occurrence.

[Paravertebral streptococcal myositis complicated by an epidural abscess in a 5-year-old girl]. / Myosite paravertébrale à Streptococcus pyogenes A beta hémolytique compliquée d'un abcès épidural chez une enfant.

CASE REPORT: A 5-year-old girl was hospitalised for fever, abdominal and lumbar pain, associated with general impairment state and a whitlow. One of the blood cultures and CSF grew A beta haemolytic Streptococcus, muscular echography and MRI showed paravertebral myositis, which was complicated by an epidural abscess. The outcome was good with medical treatment alone. DISCUSSION: Streptococcal myositis is a rare and severe skeletal muscle infection caused by A beta haemolytic Streptococcus. It is characterized by a muscle necrosis, without abscess formation. It has to be distinguished from pyomyositis, usually caused by Staphylococcus aureus, where a muscle abscess occurs, which must be treated by surgical drainage and antibiotics. Prognosis of this infection is poorer than other muscle infections such as pyomyositis, with a high mortality rate. The diagnosis is difficult and often delayed. Practitioners should keep in mind this diagnosis, even if symptoms are non specific, in front of an undetermined infectious syndrome associated with pain, and make an echography or nuclear magnetic resonance imaging to confirm the diagnosis.

[Quality of life in HIV-infected children and adolescents under highly active antiretroviral therapy: change over time, effects of age and familial context]. / Evolution de la qualité de vie des enfants et adolescents infectés par le virus de l'immunodéficience humaine (VIH) sous multithérapie antirétrovirale: effet de l'âge et du contexte familial.

OBJECTIVE: To evaluate Quality of life (QoL) of HIV-infected children under highly active antiretroviral therapies, and its change over 18 months. MATERIALS AND METHODS: QoL was evaluated by self-administred questionnaires (french versions of AUQUEI, OK-ado, and compilation of both) in 23 young living with HIV/AIDS (6-15 yrs), under antiretroviral multitherapies, and re-evaluated 18 months later in 19 of them. RESULTS: At baseline, QoL in HIV-infected children-adolescents was relatively good. The answers given to each items and the mean score from infected children were similar to those obtained in uninfected healthy children. Moreover, infected adolescents distinguished definitly from healthy adolescents, describing higher QoL. The mean satisfaction score from the whole group decreased between M0 and M18 (mainly in the youngests), and mainly concerned 3 fields (self-esteem, health and school) while their somatic health remained stable or improved. An effect of the familial context was also observed for these 3 fields. CONCLUSION: The progressive decline of QoL in HIV-infected children, and the surprising high and steady level of satisfaction over-time provided by the adolescents, underlined the frailty of this population and the need for a psychologic management associated to the medical follow-up. Such a multidisciplinary approach should take into account the preoccupations and difficulties of each age-class, those linked to the diagnosis itself, and to the familial or scolar contexts, in order to preserve QoL of this pediatric population, as far as possible, in a long term.

[Imaging benign tumors of the pleura]. / Imagerie des tumeurs bénignes de la plèvre.

Five percent of pleural tumors are benign. Solitary fibrous tumors are the most frequent. We recall the clinical and pathological features and present the radiographic, computed tomographic and magenetic resonance imaging results obtained for the main types of benign tumors of the pleura.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France.

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

[Pleural empyema in children: Montpellier's experience]. / Les pleurésies purulentes de l'enfant: expérience montpelliéraine.

OBJECTIVES AND METHOD: To assess the management of pleural empyema in pediatric from a medical and surgical experience and a review of the literature. STUDY: Fifty-eight cases were reviewed from January 98 to December 2003. 62.6% have already received antibiotherapy. Forty-three percent of cases were less than three years old. Initial cultures identified Streptococcus pneumoniae in 39%, Streptococcus pyogenes in 5.6%, Mycoplasma pneumoniae and Staphylococcus aureus in only one case and were negative in 47%. A primitive or second-line thoracoscopy were used for drainage in two-third of the cases and mainly 6.95 days after admission. Located pleural empyema and major collected volume were the main indications for thoracoscopy. Three cases have been converted into open thoracotomy. One death occurred in an immunocompromised child. All patients were well at last follow-up. DISCUSSION: The frequency of parapneumonic empyema has increased since ten years. Progress of echography and endoscopy changed their management. Antibiotics have to be effective against pneumococcal infection. Chest tube drainage is necessary to assure the lung reexpansion in case of fibropurulent collection. The difficulty is to optimise the time of video-assisted thoracoscopy (VAT) using predictive criteria as loculations and pneumatoceles. VAT allowed the aspiration of pleural fluid and removing of fibrinous loculations. Moreover VAT achieved optimal adhesiolysis and the irrigation or decortication of the pleural cavity. VAT minimized duration of stay, of chest tube drainage and the indications of thoracotomy.

[Epidemiology of Human Metapneumovirus in respiratory tract diseases of children: preliminary results]. / Epidémiologie du métapneumovirus humain dans les infections respiratoires de l'enfant: résultats préliminaires.

BACKGROUND: Human metapneumovirus (hmpv) is a newly identified agent responsible for respiratory tract infections in children, especially before one year of age. A prospective epidemiological study is underway to better define the spectrum of the disease in France. PATIENTS AND METHODS: From November 2003 to November 2004, rhinopharyngeal aspirates were obtained from all children under five years of age admitted to the hospital with upper or lower airway symptoms. Viral identification was made using gene amplification. RESULTS: Among 355 evaluable samples to date, 34 were positive for hmpv genome. Mean age of infected children was 6.4 months, 20.5% were prematurely born infants. The prognosis is usually good. CONCLUSION: Our preliminary results are consistent with the available literature data. Further studies are needed to better define the exact frequency and morbidity of this newly recognized infection, both in hospital and community settings.

[Salmonella infections in children: a retrospective study over a four-year period]. / Les infections à salmonelles chez l'enfant: étude retrospective sur quatre ans.

OBJECTIVES: Epidemiological state of salmonella infections in Languedoc-Roussillon (France) and discussion of therapeutic indications. MATERIAL AND METHOD: Retrospective study over a four-year period of paediatric salmonella infections requiring hospitalisation in Montpellier University Hospital. Analysis of clinical, bacteriological, laboratory and therapeutic data. RESULTS: One hundred and sixty nine cases of paediatric salmonella infections have been investigated. The clinical triad consisted of diarrhea, abdominal pain and fever. Six severe cases have been observed and seemed to have been independent of patient's background. Laboratory findings showed inconstantly hyperleucocytosis and increase in CRP levels. Stool analysis remained the reference laboratory test to detect salmonella. Two major strains of salmonella have been identified: Salmonella enterica subsp. enterica serovar Typhimurium and Enteriditis. Treatments have been essentially symptomatic but 20% of the children (n=34) required antibiotic therapy. A favourable outcome was observed in all the children. DISCUSSION: Incidence of salmonella infections is increasing in France, particularly in the Languedoc-Roussillon area. Diagnosis of mild forms is generally easy but certain patient background seems to expose to severe forms. Treatment of salmonella infections is mainly symptomatic, only severe or specific cases (young age, immunodepression...) requiring antibiotic treatment. The growing antibiotic use and the increasing of resistance are currently the main problems in the management of salmonella infections. Those infections remain a public health problem in Languedoc-Roussillon.

Mucosal relapse of visceral leishmaniasis in a child treated with anti-TNFα.

Visceral leishmaniasis is an enzootic parasitosis present across the Mediterranean Basin. Some consider it an opportunistic parasite. We report the case of a girl treated with anti-tumour necrosis factor alpha (anti-TNFα) for juvenile idiopathic arthritis who had previously presented with visceral leishmaniasis. Two and a half years later, she presented a tumour-like mass in the nasal mucous membrane caused by Leishmania parasites. Leishmania infantum is classically responsible for visceral leishmaniasis, but pure mucocutaneous leishmaniasis has also been described. To our knowledge, this is the first observation of a recurrence of visceral leishmaniasis in the mucocutaneous form. The occurrence of atypical forms and presentations in those on anti-TNF therapy should be considered.

Polytraumatism and solid organ bleeding syndrome: The role of imaging.

In multiple injuries, features of bleeding from solid organs mostly involve the liver, spleen and kidneys and may be treated by embolization. The indications and techniques for embolization vary between organs and depend on the pathophysiology of the injuries, type of vascularization (anastomotic or terminal) and type of embolization (curative or preventative). Interventional radiologists should have a full understanding of these indications and techniques and management algorithms should be produced within each facility in order to define the respective place of the different treatment options.

A method for the characterization of the echostructures of normal and pathological breast tissues.

Since a valid macroscopic investigation fundamentally cannot exist without its basis in microscopy, we are seeking to identify characteristic echo structures by means of acoustical microscopy at frequencies of 600 MHZ and 1 GHZ in order to better understand ultrasonography in everyday practice and to determine reliable and specific imaging characteristics of the different components of breast tissues. We have studied slices of mammary tissue 5-10 microns thick which had been removed during surgery. Acoustical imaging has to be performed in transmission mode as well as reflection mode. The intrinsic acoustic contrast is more than sufficient to obtain good visualization of different tissue components of the mammary gland. We noted, however, that even if the microscopic acoustic images were of good quality--often as good as light microscopy--certain tissue components such as the epithelium are irregularly visualized. It appears that the effective visualization of a structure depends entirely upon this acoustical environment.

Breast pathology in MRI. First results.

The authors present the first results of the assessment of MRI (0.35 T) with adapted surface reel in the exploration of mammary pathology in 90 cases. On a morphological level, MRI permits a new analysis of signs of dystrophy. As far as MRI is concerned, no specific sign of mammary neoplasia seems to exist. A classification is suggested, taking into account morphology and parameters of relaxation.

Ideal imaging in MR: contrast-enhancing pharmaceuticals. Evaluation of tempo carboxylic acid as nitroxide diagnostic agent.

The meglumine salt of TCA, a piperidinyl nitroxide stable free radical derivative, was tested as an NMR contrast enhancer. This report of its use in animals indicates its usefulness in the enhancement of signal intensity of the kidney and bladder.

[Family socioeconomic deprivation and vulnerability in the pediatric emergency room: evaluation and management]. / Précarité et vulnérabilité familiale aux urgences pédiatriques: évaluation et prise en charge.

OBJECTIVE: The aim of this study was to evaluate the importance of socioeconomic deprivation and other forms of vulnerability in families attending the pediatric emergency unit (PEU). It was based on a five-level classification of family types and an analysis of responses provided by the French healthcare system. METHOD: The prospective study involved 150 families admitted to the PEU on the basis of open-response interviews that analyzed demographic and socio-economic characteristics, motivations for consultation, the child's quality of life, family problems experienced by the parents, and their support network. RESULTS: Five categories of families were defined as follows: complete destitution necessitating immediate social measures (0.7%); acknowledged and well-managed economic deprivation (13.3%), unacknowledged and/or complex economic deprivation with a significant deterioration in the quality of life (22.2%), familial psychological vulnerability without economic deprivation (30.4%), and families without any apparent problems (33.7%). Consultation at the PEU appears to be a multifactorial phenomenon motivated by socioeconomic, psychological and cultural factors. This phenomenon is connected with the present-day imbalance in the healthcare system, which does not adequately respond to the needs of vulnerable families. CONCLUSION: This survey contributes to the current reflection on the integration of psychosocial factors in child healthcare at both the hospital and local community level. The method described herein has determined the factors of vulnerability and the risks of economic deprivation. It can contribute to the development of improved communication and cooperation between practitioners, the hospital and local social workers.