Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses

Dengue fever as a cause of hemophagocytic lymphohistiocytosis

Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropodborne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome

Acute Hemorrhagic Edema of Infancy: an unusual diagnosis for the general pediatrician

Acute Hemorrhagic Edema of Infancy (AHEI) is a rare leukocytoclastic vasculitis, clinically characterized by the classical triad: palpable purpuric skin lesions, edema and fever, and is commonly misdiagnosed as Henoch-Schönlein purpura. In addition to its sudden onset, AHEI is also characterized by its self-limited course with complete and spontaneous recovery occurring between 1 and 3 weeks. Because of the scarcity of studies on therapy with corticosteroids, the conservative approach is usually recommended. The authors report an unusual case of an one-year-old boy who presented with typicalcutaneous rash of AHEI and orchitis, the latter showing complete resolution after less than 24 hours of prednisolone therapy. The authors call attention to this entity mainly as a differential diagnosis of Henoch-Schönlein purpura and to the importance of new studies to establish the benefits of corticosteroid therapy for AHEI

Dengue fever as a cause of hemophagocytic lymphohistiocytosis

Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropodborne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in São Paulo, Brazil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in children's nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.Os vírus respiratórios são reconhecidos como os mais frequentes patógenos do trato respiratório inferior para lactentes e crianças de idade reduzida em países desenvolvidos, mas o conhecimento sobre este fato é menor nos países em desenvolvimento.Os autores realizaram um estudo prospectivo para avaliar a ocorrência, os padrões clínicos e a sazonalidade das infecções virais entre as crianças hospitalizadas com doença do trato respiratório inferior (grupo A). A presença de vírus respiratórios na nasofaringe das crianças foi avaliada à admissão em uma enfermaria de pediatria. A cultura celular e a imunofluorescência foram utilizadas para identificação viral. Exames complementares incluiram culturas de sangue e líquido pleural para detecção de bactérias. Dados clínicos e exames radiológicos foram anotados na admissão e durante o período de internação. Para avaliar adequadamente os resultados foi constituído um grupo sem doença respiratória para comparação. Com início em fevereiro de 1995, durante um período de 18 meses, 414 crianças foram incluídas - 239 no grupo A e 175 no grupo B. No grupo A, 111 crianças (46,4%) tinham vírus enquanto somente 5 (2,9%) apresentavam vírus no grupo B. O Vírus Respiratório Sincicial foi detectado em 100 crianças do grupo A (41,8%), o Adenovírus em 11 (4,6%), o vírus Influenza em 2 (0,8%), e o Parainfluenza em uma criança (0,4%). No grupo A as bactérias foram encontradas em 14 casos (5,8%). O Vírus Respiratório Sincicial estava associado a outro vírus ou bactéria em seis casos. Ocorreram dois surtos de Vírus Respiratório Sincicial, com pico em maio e junho. Todas as crianças acometidas por este vírus tinham idade inferior a 3 anos, na sua maior parte menos de um ano de idade. O acometimento bronquial episódico e difuso e/ou a condensação alveolar focal, foram os padrões clínicos mais frequentemente associados aos casos de infecção pelo Vírus Respiratório Sincicial. Todas as crianças do grupo A sobreviveram. Em conclusão, foi observado que o Vírus Respiratório Sincicial foi o patógeno mais frequentemente encontrado em crianças hospitalizadas por doença respiratória grave. As crianças afetadas eram predominantemente lactentes do sexo masculino com bronquiolite e pneumonias focais. De modo similar ao que ocorre em outras regiões subtropicais os surtos do vírus têm pico no outono, extendem-se ao inverno, e se acompanham de um aumento nas internações hospitalares por doença respiratória

Otomastoiditis caused by Sphingomonas paucimobilis: case report and literature review

Sphingomonas paucimobilis is an aerobic Gram-negative bacillus that, although rare in humans, most commonly infects immunocompromised and hospitalized patients. Among the 59 pediatric cases of S. paucimobilis infection reported in the literature, the most common diagnosis involves isolated bacteremia. These cases are related to sporadic or epidemic infections. Death related to this infection occurred in only one case. The authors report a case of an 11-year-old boy with the diagnosis of Sphingomonas paucimobilis otomastoiditis and a thorough review of the literature on this infection in pediatrics. The patient presented a 20-day history of fever, otalgia, otorrhea, and progressive retroauricular swelling with protrusion of the left ear; despite 15 days of amoxicillin regimen. His past medical history included chronic bilateral otitis media, but no cause of immunosuppression was found. A brain computed tomography scan showed left otomastoiditisassociated with a large circumscribed fluid collection with deep involvement of the soft tissues of the temporal region, including the subperiosteal space. Blood tests showed neutrophilia and elevated C-reactive protein. Surgical manipulation of the cited collection drained a large amount of a fetid purulent secretion. Ceftazidime and clindamycin were empirically initiated. The outcome was favorable, with fever defervescence and resolution of the scalp deformation. Culture of the drained secretion was positive for S. paucimobilis. Ciprofloxacin was scheduled for a further 10 days after discharge. The follow-up showed complete recovery. As far as we know, this is the first case of S. paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. The authors call attention to the increasing number of reports on S. paucimobilis infection over the years, and therefore to the importance of this pathogen, which was previously underestimated

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in São Paulo, Brazil Padrões clínicos e sazonalidade das hospitalizações causadas pelo vírus respiratório sincicial em São Paulo, Brasil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations. The authors conducted a prospective study to evaluate the occurrence, clinical patterns, and seasonal trends of viral infections among hospitalized children with lower respiratory tract disease (Group A). The presence of respiratory viruses in children's nasopharyngeal was assessed at admission in a pediatric ward. Cell cultures and immunofluorescence assays were used for viral identification. Complementary tests included blood and pleural cultures conducted for bacterial investigation. Clinical data and radiological exams were recorded at admission and throughout the hospitalization period. To better evaluate the results, a non- respiratory group of patients (Group B) was also constituted for comparison. Starting in February 1995, during a period of 18 months, 414 children were included- 239 in Group A and 175 in Group B. In Group A, 111 children (46.4%) had 114 viruses detected while only 5 children (2.9%) presented viruses in Group B. Respiratory Syncytial Virus was detected in 100 children from Group A (41.8%), Adenovirus in 11 (4.6%), Influenza A virus in 2 (0.8%), and Parainfluenza virus in one child (0.4%). In Group A, aerobic bacteria were found in 14 cases (5.8%). Respiratory Syncytial Virus was associated to other viruses and/or bacteria in six cases. There were two seasonal trends for Respiratory Syncytial Virus cases, which peaked in May and June. All children affected by the virus were younger than 3 years of age, mostly less than one year old. Episodic diffuse bronchial commitment and/or focal alveolar condensation were the clinical patterns more often associated to Respiratory Syncytial Virus cases. All children from Group A survived. In conclusion, it was observed that Respiratory Syncytial Virus was the most frequent pathogen found in hospitalized children admitted for severe respiratory diseases. Affected children were predominantly infants and boys presenting bronchiolitis and focal pneumonias. Similarly to what occurs in other subtropical regions, the virus outbreaks peak in the fall and their occurrence extends to the winter, which parallels an increase in hospital admissions due to respiratory diseases.<br>Os vírus respiratórios são reconhecidos como os mais frequentes patógenos do trato respiratório inferior para lactentes e crianças de idade reduzida em países desenvolvidos, mas o conhecimento sobre este fato é menor nos países em desenvolvimento.Os autores realizaram um estudo prospectivo para avaliar a ocorrência, os padrões clínicos e a sazonalidade das infecções virais entre as crianças hospitalizadas com doença do trato respiratório inferior (grupo A). A presença de vírus respiratórios na nasofaringe das crianças foi avaliada à admissão em uma enfermaria de pediatria. A cultura celular e a imunofluorescência foram utilizadas para identificação viral. Exames complementares incluiram culturas de sangue e líquido pleural para detecção de bactérias. Dados clínicos e exames radiológicos foram anotados na admissão e durante o período de internação. Para avaliar adequadamente os resultados foi constituído um grupo sem doença respiratória para comparação. Com início em fevereiro de 1995, durante um período de 18 meses, 414 crianças foram incluídas - 239 no grupo A e 175 no grupo B. No grupo A, 111 crianças (46,4%) tinham vírus enquanto somente 5 (2,9%) apresentavam vírus no grupo B. O Vírus Respiratório Sincicial foi detectado em 100 crianças do grupo A (41,8%), o Adenovírus em 11 (4,6%), o vírus Influenza em 2 (0,8%), e o Parainfluenza em uma criança (0,4%). No grupo A as bactérias foram encontradas em 14 casos (5,8%). O Vírus Respiratório Sincicial estava associado a outro vírus ou bactéria em seis casos. Ocorreram dois surtos de Vírus Respiratório Sincicial, com pico em maio e junho. Todas as crianças acometidas por este vírus tinham idade inferior a 3 anos, na sua maior parte menos de um ano de idade. O acometimento bronquial episódico e difuso e/ou a condensação alveolar focal, foram os padrões clínicos mais frequentemente associados aos casos de infecção pelo Vírus Respiratório Sincicial. Todas as crianças do grupo A sobreviveram. Em conclusão, foi observado que o Vírus Respiratório Sincicial foi o patógeno mais frequentemente encontrado em crianças hospitalizadas por doença respiratória grave. As crianças afetadas eram predominantemente lactentes do sexo masculino com bronquiolite e pneumonias focais. De modo similar ao que ocorre em outras regiões subtropicais os surtos do vírus têm pico no outono, extendem-se ao inverno, e se acompanham de um aumento nas internações hospitalares por doença respiratória