The importance of SARS-CoV-2 testing in pediatric population

Pediatric population associates multiple peculiarities in terms of SARS-CoV-2 regarding the differences of symptoms in comparison to adults, but also the higher incidence of asymptomatic cases. The aim of these case reports is to underline the importance of SARS-CoV-2 testing in pediatric patients. The first case describes the case of a 2-year and nine-month-old child admitted to the Pediatrics Clinic I Targu Mures for involuntary ingestion of toxic substance. The clinical exam pointed out a mild hyperemia of pharynx and small lymph nodes under the mandibula, on the side area of the neck and above the clavicula; and the laboratory tests pointed out leukocytosis, thrombocytosis and one of the liver transaminases above the normal limit. In spite of the presentation concerns, the patient was tested for SARS-CoV-2 infection, with positive result. The evolution was favorable during the admission. The second case describes a 3-year and 8-month-old male patient brought in the emergency department with the suspicion of foreign body aspiration, but the bronchoscopy revealed only purulent secretion in the trachea and bronchia. The RTPCR test for SARS-CoV-2 infection was negative on the admission day, but due to the slowly favorable evolution, the patient was retested on the 5th day of admission, with positive result. The testing of pediatric patients independently of the symptoms and the clinical setting might carry a higher importance in limiting the viral transmission

Mycoplasma pneumoniae pneumonia – challenges related to diagnosis and treatment in children

Introduction. Pneumonia is a common infectious disease among children, very familiar to pediatricians and a major cause of hospitalization worldwide. Mycoplasma pneumoniae (M. pneumoniae) - atypical pathogen, is estimated to be responsible for approximately 30-40% of community-acquired pneumonias. The aim of the paper was to underline the diagnostic and treatment difficulties in a case of pneumonia with M. pneumoniae in a school-aged boy, with multiple presentations in the Emergency Service for respiratory difficulties. Material and method. We present the case of a 7 years and 10-month-old male patient, admitted to our clinic for wheezing, cough and dyspnea. Results. The clinical exam at admission pointed out influenced general status, wheezing, thoraco-abdominal swing, intercostal draft, sibilant and crackles, oxygen saturation 89%, tachycardia 134 beats/minute. The blood tests revealed mild leukocytosis, with neutrophilia, slightly increased inflammatory biomarkers. Considering the general status and the presence of functional respiratory syndrome, steroid and symptomatic anti-inflammatory treatment is initiated. However, the general condition remains stable, which required the widening of the spectrum of investigations with the performance of a chest CT noticing a pneumonic condensation with an air bronchogram located at the level of the right upper lobe. Considering the stationary respiratory functional syndrome and the radiological appearance of the pneumonia as well as the age, we performed serology for atypical germs and identified a positive titer of Ig M antibodies for M. pneumoniae by instituting Azithromycin po, but after 3 days, the evolution remains stationary, thus we changed the treatment with intravenous Levofloxacin, with a favorable subsequent evolution. Conclusions. Pneumonia with atypical pathogens such as M. pneumoniae is a well-defined and well-known pathology in the literature, but it still remains a condition that imposes multiple difficulties related to the diagnosis and therapeutic management of pediatric cases

THE UTILITY OF CONTRAST-ENHANCED ULTRASONOGRAPHY IN DIAGNOSING CHILD’S VESICOURETERAL REFLUX – A CASE REPORT AND A REVIEW OF THE LITERATURE

Vesicoureteral reflux represents the reflow of bladder content in the ureter and pelvicalyceal system with their subsequent dilation. Most of the cases of urinary tract infections in child are associated with vesicoureteral reflux. We present the case of a 3-year-old female patient, with a history of multiple symptomatic urinary tract infections, who was admitted in our clinic for specialty investigations and establishment of an adequate therapy. The clinical exam and the laboratory tests did not point out any pathological elements. The native abdominal ultrasound was without pathological modifications, while the contrast-enhanced ultrasonography revealed bilateral vesicoureteral reflux. The renal scintigraphy with DMSA showed impaired renal function on the right side, of 39% with duplicity of the collector system and moderate dilation of the superior pelvis, and normal function of the left kidney. The recommendations consisted in long-term antibiotic prophylaxis, contrast-enhanced ultrasonography once a year and nephrologist consult every 6 months. The particularity of the case consists in diagnosing a bilateral vesicoureteral reflux by contrast-enhanced ultrasonography in a female patient with a history of multiple urinary tract infections, in whom the native renal ultrasound did not point out any pathological elements

Rapunzel Syndrome—An Extremely Rare Cause of Digestive Symptoms in Children: A Case Report and a Review of the Literature

Rapunzel syndrome is an extremely rare condition seen in adolescents or young females with psychiatric disorders consisting of a gastric trichobezoar with an extension within the small bowel. The delays in diagnosis are common since in its early stages, it is usually asymptomatic. We report the case of a 13-year-old girl admitted in our clinic for abdominal pain, anorexia, and weight loss. The clinical exam pointed out diffuse alopecia, a palpable mass in the epigastric area, and abdominal tenderness at palpation, the patient weighing 32 kg. The laboratory tests showed anemia. The abdominal ultrasound showed a gastric intraluminal mass with a superior hyperechoic arc. The upper digestive endoscopy revealed a mass formed by hair, mucus, and food occupying the gastric cavity with the extension into the duodenum confirming the diagnosis of Rapunzel syndrome. The giant trichobezoar of 511 g, measuring 17 × 7 × 6.5 cm with a tail of approximately 3 cm, was successfully removed through laparotomy. Although rare, Rapunzel syndrome must never be forgotten as a differential diagnosis for digestive symptoms since its early detection hinders the occurrence of further complications

A RARE CASE OF URINARY TRACT INFECTION WITH BURKHOLDERIA CEPACIA IN A MALE CHILD

Introduction. Burkholderia cepacia is an aerobic, glucose-non-fermenting, gram negative bacillus that mainly affects immunocompromised and hospitalized patients. Urinary tract infections (UTI) caused by this aggressive pathogen are rarely described in the literature. Patients who associate predisposing risk factors such as post renal transplant, vesico-ureteral reflux (VUR), neurogenic bladder, bladder irrigation, or use of contaminated medical devices, are susceptible to B. cepacia UTI. Case presentation. We report the case of a 5-year-old boy, admitted in the Pediatrics Clinic, for fever, cloudy and malodorous urine. His personal history revealed surgery for myelomeningocele, ventriculo-peritoneal shunt for congenital hydrocephalus, lower limb paraplegia, and bilateral hydronephrosis grade III, neurogenic bladder and recurrent UTI. The laboratory tests performed on the day of admission revealed increased inflammatory biomarkers, leukocytosis and anemia. The urine test revealed pyuria and the urine culture, obtained by bladder catheterization, was positive for multiple drug resistant B. cepacia. Antibiotic therapy was initiated with Meronem and symptomatic drugs. After 10 days of hospitalization the patient was discharged in general good status with the recommendations of chemoprophylaxis. Conclusions. Despite the very low incidence of B. cepacia UTI in children, we present the case of a patient who associate predisposing factors such as neurogenic bladder, hydronephrosis and recurrent UTI who lead to an aggressive infection with this opportunistic pathogen

SEPSIS WITH STREPTOCCOCUS PNEUMONIAE IN A CHILD WITH NEPHROTIC SYNDROME

Introduction. Nephrotic syndrome is one of the most frequent glomerular pathologies encountered in pediatric ages, with an incidence of 4.7 cases in 100,000 children. The most frequent infectious complication of nephrotic syndrome is bacterial peritonitis caused most of the times by Streptococcus pneumoniae, a microorganism responsible by a high number of pneumonia, otitis media and sepsis episodes among children. Case report. We present the case of a 4.7-year-old male patient, diagnosed with nephrotic syndromes with 2 recurrences and transitory hypertension, admitted in our clinic for: diffuse abdominal pain, vomiting, diarrhea, fever and right otalgia. The laboratory tests on the day of admission pointed out elevated inflammatory biomarkers, leukocytosis, anemia and combined dyslipidemia. The urinary exam showed massive proteinuria. The blood culture was positive for Streptococcus Pneumoniae. The abdominal ultrasound revealed mild ascites, the thoracic radiography ruled out a pneumonia, and the ENT exam pointed out erythematous and bulged tympanic membrane. We initiated empirical therapy with Ceftriaxone, steroids and symptomatic drugs. After 3 weeks of hospitalization, the patient is discharged in good general status, with remission of nephrotic syndrome. Conclusions. Congestive acute otitis media can lead in case of immunosuppressed patients to a severe sepsis with Streptococcus pneumoniae. Thus, anti-pneumococcal vaccination is mandatory, especially in case of high risk patients

New insights regarding Helicobacter pylori infection in children

Helicobacter pylori (H. pylori) are one of the most common infections during childhood, and if left untreated it might persist lifelong resulting in severe complications such as gastric malignancies. The epidemiology of this infection has wide variations along the continents, countries and sub-regions being related mainly to the socio-economic status, hygiene and sanitary conditions. Nevertheless, a descending trend of H. pylori prevalence was noticed worldwide during the last decades, fact that might decrease in time the incidence of gastric cancer in adults. The diagnosis of this infection remains tricky in children and the selection of the most effective diagnostic tool is essential in order to early diagnose H. pylori associated gastropathies and extraintestinal manifestations. In spite of the lack of symptoms which occurs especially in pediatric subjects, H. pylori infection might result in severe damage to the gastric mucosa and further complications requiring close monitoring after the eradication regimen. Therefore, multiple non-invasive and invasive methods were designed to identify properly the presence of this bacterium within the individual’s stomach and for enabling the clinician to use to most adequate method based on its sensitivity and specificity, but also based on the specific clinical situations. Aside from the well-known standard triple therapy used for the eradication of this infection, multiple other regimens were lately proposed in order to prevent failure of eradication. Moreover, probiotics were recently proved to improve the eradication rate, and at the same time to decrease the side effects of the antibiotics therapy. The proper eradication of H. pylori infection during childhood remains the cornerstone in preventing gastric cancer during adulthood

A RARE CASE OF INFERIOR VENA CAVA AGENESIS ASSOCIATED WITH DEEP VENOUS THROMBOSIS

Inferior vena cava (IVC) agenesis is an extremely rare malformation, most times diagnosed randomly, representing an important risk factor in the development of spontaneous deep venous thrombosis (DVT) in children and young adults. We present the case of an 8-year-old male child admitted in our clinic for the following complains: right lumbar pain with paravertebral irradiation. The personal pathological history revealed a recent appendectomy. At the time of admission, an abdominal ultrasound was performed which revealed right nephromegaly, and also raised the suspicion of IVC agenesis. We performed a thoraco-abdominal angio-CT exam with contrast enhancement which confirmed the diagnosis of IVC agenesis and right common iliac vein, venous thrombosis of the right external iliac vein, right common femoral vein and right superficial femoral vein. We excluded a potential antiphospholipid syndrome or a thrombophilia, and the genetic tests ruled out the possibility of a family predisposition. We initiated anticoagulant therapy with close monitoring of the coagulation parameters, the evolution being favorable. Despite the very low frequency of this malformation, the early and correct diagnosis is essential for these patients’ management and prognosis

TYPE I DIABETES MELLITUS – DIAGNOSIS BASED ON COMPLICATIONS

We present you an atypical case of type 1 diabetes mellitus at onset, with multiple abscesses, diagnosis confi rmed afterwards by laboratory tests. This report is of a 14 year-old girl, who presented with abscesses of thighs, hypogastric and inguinal area. The regular investigations performed pointed out hyperglycemia with glucose in the urine, accompanied by weight loss, polyuria and polydipsia. The abscesses were incised and drained. The pathological signs of the clinical examination were: infl uenced general status, decreased skin turgor, dry lips, multiple fi stulized abcesses of the thighs and hipogastric area, hyperemic pharynx and tonsils. The blood tests revealed hyperglycemia (272 mg/dl), leucocytosis with granulocytosis, thrombocytosis, and increased values of hemoglobin. The clinical and paraclinical data were suggestive for type I diabetes mellitus, complicated with abscesses. The treatment consisted in substitutive treatment with insulin associated with antibiotics, antimycotics, analgesics, antipyretics, endovenous perfusions for rehydration. The evolution of the case was favorable under treatment with insulin, the condition of the cutaneous abscesses improved very much after surgical treatment and administration of antibiotics, but they healed only after the equilibration of diabetes mellitus. In conclusion, even though in the specialty literature it is reported that there appear multiple cutaneous infections in patients with diabetes mellitus wrong treated, these are rarely diagnosed at the onset of this disorder in children, this fact being probably explained by the acute onset of the disease at this age