Management of septic shock by pediatric residents: An area for quality improvement.

BACKGROUND: Compliance with sepsis guidelines has been shown to be linked to better outcomes in patients with septic shock; however, adherence to these guidelines is not consistent among pediatric healthcare providers. In Tunisia, the management of children with septic shock is initiated by the pediatric resident on call. METHODS: This study assessed the compliance of Tunisian pediatric residents with the 2020 "Surviving Sepsis Campaign" guidelines and identified factors that could improve compliance. We conducted a cross-sectional national study based on an online survey (SurveyMonkey) presenting a clinical pediatric case of septic shock. The survey was sent to the 200 residents registered in the Tunisian pediatric residency program. RESULTS: The response rate was 72%, with 144 residents replying to the survey. Up to 72.9% of the residents had good compliance with the 1-h bundle: obtaining blood cultures prior to antibiotics, early administration of intravenous (IV) antibiotics, IV fluid expansion, and vasopressor for fluid-refractory septic shock. Factors independently associated with good compliance were a pediatric intensive care unit rotation (odds ratio [OR]: 5.17, 95% confidence interval [CI]: 1.44-18.58; p = 0.012), availability of a written protocol (OR: 9.09, 95% CI: 2.67-30.97; p<0.001), an on-call senior supervisor on site (OR: 6.76, 95% CI: 2.24-20.40; p = 0.001), and European Pediatric Advanced Life Support (EPALS) certification (OR: 13.47, 95% CI: 3.05-59.31; p = 0.001). CONCLUSION: These factors could be considered in the process of a quality improvement strategy that ultimately better promotes performance in pediatric sepsis management and may improve patient outcomes.

c-ANCA-associated vasculitis with predominant CNS demyelination after COVID-19.

COVID-19 infection may trigger the presentation or exacerbation of autoimmune diseases. c-Antineutrophil cytoplasmic antibody (c-ANCA)-associated vasculitis after COVID-19 mainly involves the kidneys and lungs, and is rarely reported. We describe the case of a 13-year-old girl with a history of chronic immunologic thrombocytopenic purpura who presented with transverse myelitis and central nervous system demyelination, and was subsequently diagnosed with c-ANCA-associated vasculitis following COVID-19. The patient's condition improved after pulse therapy with methylprednisolone and rituximab. To our knowledge, this is the first reported pediatric case of ANCA-associated vasculitis with predominant central nervous system involvement after COVID-19 infection.

Evaluation of a 14.5 kDa-Fasciola gigantica fatty acid binding protein as a diagnostic antigen for human fascioliasis.

The aim of the present study was to evaluate the efficiency of 14.5 kDa-Fasciola gigantica fatty acid binding protein (FABP) as a diagnostic antigen for human fascioliasis. 14.5 kDa FABP was isolated from the crude extract of adult F. gigantica worms by ion exchange chromatography followed by gel filtration chromatography and then analyzed by sodium dodecyl sulfate polyacrylamide gel electrophoresis under reducing condition. Anti-FABP IgG polyclonal antibody (pAb) was generated in rabbits and purified by using sequential use of ammonium sulfate, caprylic acid, and then ion exchange chromatography. Conjugation of purified rabbit anti-FABP IgG with horse reddish peroxidase (HRP) was conducted and used in detecting the coproantigen in the stool and the circulating Fasciola antigen (CA) in the sera of Fasciola-infected patients using sandwich enzyme-linked immunosorbent assay (ELISA). The sensitivities of sandwich ELISA test were 96.43% and 94.74%, while the test specificities were 94.87% and 84.62% for the detection of coproantigen and CA, respectively. The parasitological diagnosis using the Kato-Katz technique revealed 64.29% sensitivity with 100% specificity. The diagnostic efficacy of sandwich ELISA was 95.52% for coproantigen and 87.93% for CA detection. In contrast, the diagnostic efficacy of Kato-Katz technique was 85.07%. It was concluded that 14.5 kDa FABP represented a valuable antigen for the immunodiagnosis of human fascioliasis using sandwich ELISA.

Therapeutic hypothermia in children: Which indications remain in 2018?

Experimental studies on therapeutic hypothermia in acute brain injury reported positive outcomes and identified two potential benefits, namely, reduction in seizure incidence and in intracranial pressure. Translating this evidence to humans is challenging, especially for conditions in pediatric patients, such as cardiac arrest, traumatic brain injury, and status epilepticus, among others. This narrative review aimed to discuss the current indications and benefits of therapeutic hypothermia in acute brain injury in the pediatric population (i.e., beyond the neonatal period) by analyzing the neurologic outcome and mortality data obtained from previous studies.

[Steroid therapy for hydrocephalus due to acute cerebellitis in a child]. / Cérébellite aiguë sévère compliquée d'une compression du tronc cérébral et d'hydrocéphalie d'évolution favorable sous corticothérapie.

Severe acute inflammatory cerebellitis is a rare but life threatening disease. We report the case of a 8-year-old boy presenting with cerebellitis and acute cerebellar swelling complicated by brain stem compression and hydrocephalus. Outcome was good on steroid therapy.

[Pneumococcal meningitis mortality in children. Prognostic factors in a series of 73 cases]. / Mortalité par méningites à pneumocoque chez l'enfant. Facteurs pronostiques à propos d'une série de 73 observations.

OBJECTIVE: Despite advances in antibiotic therapy strategies and pediatric intensive care, prognosis of Streptococcus pneumoniae meningitis remains very poor. To determine the factors associated with hospital mortality of children with pneumococcal meningitis. METHODS: We conducted a retrospective study of 73 cases of childhood pneumococcal meningitis admitted in 4 teaching hospitals in the center of Tunisia during a 8-year period (1995-2002). RESULTS: Hospital mortality was 13.7% (10 of 71 patients), and neurologic sequela were observed in 34.5% of survivors. Based on univariable analysis, five variables were associated with the outcome: Pediatric Risk of Mortality score (p < 0.001), coma (p=0.0009), use of mechanical ventilation (p=0.0001), convulsions (p = 0.0449), and shock (p=0.0085). In multivariable analysis, only 2 factors were independently associated with in-hospital mortality: Pediatric Risk of Mortality score and the use of mechanical ventilation. 11.8% of pneumococcal isolates were intermediate and resistant to penicillin. Non-susceptible pneumococcus strains to penicillin and the use of steroids were not associated significantly with the mortality rate. CONCLUSIONS: Pneumococcal meningitis remains a devastating childhood disease. Two variables were independently associated with the in-hospital death in our series (high Pediatric Risk of Mortality score, and the use of mechanical ventilation). According to these data we may recommend the inclusion of vaccination against streptococcus pneumonia in the children's immunization program in Tunisia.

Continuous insulin infusion in hyperglycaemic very-low-birth-weight infants receiving parenteral nutrition.

Continuous infusion of insulin was used to improve glucose tolerance in 30 premature (26.4+/-1.4 weeks) very-low-birth-weight (750+/-211.3 g) hyperglycaemic infants receiving parenteral nutrition. Infusion of insulin was started at 159.1+/-67 h of life; while glycaemia was 12.1+/-3.3 mmol/l. Normoglycaemia was restored within 31.4h (range 2-134 h). A maximum insulin dose of 0.4 (range 0.07-4.2)IU/kg/h was required to control the blood glucose, the mean cumulative doses of insulin required was 3.27 IU/kg (range 0.09-18.1). The mean glucose infusion rate during insulin treatment was 20.3+/-1.7 g/kg/day; lipid was 4.6+/-1.1 g/kg/day and non-protein caloric intake 121.7+/-16.5 kcal/kg/day. Infants reach 85 kcal/kg/day of non-protein energy intake at 179.5+/-71.2 h after birth. During continuous insulin infusion, enteral feeding was started in all infants at 124.9+/-75.8 h of life. Insulin was continued for 317.7+/-196.6 h. Only two infants lost weight during the first week of treatment, the remaining infant gained weight steadily. In conclusion, continuous insulin infusion can rapidly and safely improve intravenous glucose tolerance, allowing higher caloric intake and growth in very-low-birth-weight infants who develop hyperglycaemia during total parenteral nutrition.

[Medullary arteriovenous malformations in children]. / Les malformations artérioveineuses médullaires chez l'enfant.

UNLABELLED: Spinal arteriovenous malformations are rare lesions in children but may produce serious functional disorders and residual handicaps. CASE REPORT: We report the case of a 10-year-old patient who had weakness in his left leg with intermittent urinary incontinence. Neurological examination showed a spastic paraparesis of both legs, more obvious in the left leg. MRI led to the diagnosis of a spinal vascular malformation, which was confirmed by angiography. The patient underwent a session of embolization, which resulted in a significant clinical improvement. CONCLUSION: The importance of MRI in such a case is emphasized as is therapeutic management with embolization.

[Ischemic colitis and hemophagocytosis complicating Kawasaki disease]. / Colite ischémique et syndrome d'hémophagocytose compliquant une maladie de Kawasaki.

UNLABELLED: Gastrointestinal manifestations of Kawasaki disease are usually limited to stomatitis, paralytic ileus, and hydrops of the gallbladder. We report a case of Kawasaki disease complicated with hemophagocytosis and ischemic colitis. CASE REPORT: A 5-year-old girl with Kawasaki disease presented with hemophagocytosis that responded to gamma-globulin therapy. On day 4 she had abdominal pain and diarrhea. CT scan showed features suggesting ischemic colitis. Symptoms resolved on total parenteral nutrition. CONCLUSION: Ischemic colitis and hemophagocytosis are potential severe complications of Kawasaki disease.

[Severe Reye syndrome: report of 14 cases managed in a pediatric intensive care unit over 11 years]. / Syndrome de Reye sévère: à propos de 14 cas pris en charge dans une unité de réanimation pédiatrique pendant 11 ans.

UNLABELLED: Idiopathic Reye syndrome is a rare disease revealed by unexplained encephalopathy and microvesicular liver steatosis. Some clinical and epidemiological studies mainly performed in English speaking countries questioned the reality of Reye syndrome because numerous know inherited metabolic diseases, and some of them unrecognized, could mimick this disorder. We focused in our study on severe forms of Reye syndrome admitted to a pediatric intensive care unit. METHODS: Retrospective study over the last eleven years (1991-2001) included all the pediatric patients admitted to our tertiary referral center with the classical American Reye syndrome criteria (e.g. CDC). Extensive metabolic screening was performed in all cases, except for the ultimately dead patients. RESULT: Fourteen patients (mean age 52 months) were included. Fever always occurred before their admission and aspirin (n = 12) or acetaminophen (n = 7) was prescribed. Median Glasgow scale was 7 on admission. Mean amoniac plasma level was 320 mumol/L and alanine-aminotransferase peak plasma level 1475 +/- 1387 IU/L. Mechanical ventilation was started in ten children and six of them underwent continuous venovenous hemofiltration. Three patients ultimately died and 11 survived with a mean five years follow-up without relapses or neurological impairment. Any of them demonstrated inherited metabolic disease except for one infant with hereditary fructose intolerance. CONCLUSION: Unlike widespread opinion, severe Reye syndrome without identified metabolic disorders seems to not disappear in our country. Reye syndrome remains a potentially life threatening disease and raises for aggressive treatment of brain edema. If aspirin and Reye syndrome association are not formally documented in France, cautiousness must be kept in mind and all the aspirin adverse effects notifications should be addressed to the public drugs survey network.

[Acute rhabdomyolysis disclosing polymyositis in children]. / Rhabdomyolyse aiguë révélatrice d'une polymyosite chez l'enfant.

UNLABELLED: Traumatic and non-traumatic rhabdomyolysis have been mostly reported in adults. Polymyositis rarely leads to rhabdomyolysis. CASE REPORT: We report the case of a 13-year-old girl with rhabdomyolysis. Full recovery was observed after symptomatic treatment. Nine months later she developed polymyositis. CONCLUSION: Long-term follow-up is necessary for rhabdomyolysis, even in those cases with an isolated occurrence caused by viral infection.

[Syndrome of inappropriate macrophage activation associated with infantile visceral leishmaniasis]. / Syndrome d'activation inapropriee des macrophages associe à une leishmaniose viscerale infantile.

Hemophagocytosis has already been in cases of visceral leishmaniasis and thus may complicate search for diagnosis. We report a case of hemophagocytosis in a 20 month-old boy presenting with fever, hepatosplenomegaly, pancytopenia and coagulopathy. An initial diagnosis of kala-azar was refuted because of absence of biological inflammatory syndrome and negativity of bone-marrow aspiration. Specific serology for visceral leishmaniasis become positive. The boy was given stibogluconate for 21 days; he improves gradually with complete remission.

[Vitamin-responsive epilepsies: an update]. / Épilepsies vitamino-sensibles.

Inborn error of metabolism may produce a complex clinical picture in which epilepsy is only one of the various neurologic manifestations including developmental delay/regression, mental retardation, and movement disorders. However, metabolic epilepsies may dominate the clinical presentation. A specific diagnosis of metabolic disorders in epileptic patients may provide the possibility of specific treatments that can improve seizures. In a few metabolic diseases such as vitamin-responsive epilepsies, epilepsy responds to specific treatments based on supplementation of cofactors. Certain rare vitamin-responsive inborn errors of metabolism may present as early encephalopathy with anticonvulsant-resistant seizures. These include pyridoxine-dependent seizures, pyridoxal-phosphate-dependent seizures, folinic acid-responsive seizures, and biotinidase deficiency. This review discusses our current understanding of these vitamin-responsive epilepsies.

Gamma interferon is dispensable for neopterin production in vivo.

Previous studies have indicated that neopterin is synthesized in vitro by human monocyte-derived macrophages and dendritic cells upon stimulation with gamma interferon (IFN-gamma). Neopterin production under specific conditions in vitro has also been obtained upon stimulation with IFN-alpha and/or IFN-beta. However, it is unknown if any IFN-gamma-independent neopterin synthesis is possible in vivo. In the present study we investigated the serum neopterin concentrations in patients affected by the syndrome of Mendelian susceptibility to mycobacterial disease (MSMD). Indeed, this syndrome is characterized by deeply impaired or absent IFN-gamma production or function due to severe mutations in molecules involved in IFN-gamma/interleukin-12 (IL-12)/IL-23-dependent pathway. Serum neopterin levels were measured by an enzyme-linked immunosorbent assay in 27 patients with MSMD. We found that serum neopterin levels are elevated in the complete absence of IFN-gamma activity due either to a complete deficiency of its receptor or to deleterious mutations of IL-12 or its receptor. These data clearly indicate that, as reported from in vitro studies, other stimuli are able to induce neopterin synthesis in vivo. Consequently, neopterin cannot be used as means of diagnosis of MSMD due to IFN-gamma-, IL-12-, and IL-23-dependent pathway defects.