Bronchiolitis. Analysis of 10 consecutive epidemic seasons

Bronchiolitis is the leading cause of hospitalization in infants under 12 months. Our aims were to analyze epidemiological characteristics of infants with bronchiolitis over 10 consecutive seasons and to evaluate whether there are any clinical differences between infants hospitalized for bronchiolitis during epidemic peak months and infants in non-peak months. We enrolled consecutive enrolled 723 previously healthy term infants hospitalized at the Paediatric Emergency Department, "Sapienza" University of Rome over the period 2004-2014. Fourteen respiratory viruses were detected from nasopharyngeal aspirates by molecular methods. Clinical and demographic data were extracted from clinical charts. Viruses were detected in 351 infants (48.5%): RSV in 234 (32.4%), RV in 44 (6.1%), hBoV in 11 (1.5%), hMPV in 12 (1.6%), co-infections in 39 (5.4%), and other viruses in 11 (1.5%). Analyzing the 10 epidemic seasons, we found higher incidence for bronchiolitis every 4 years with a peak during the months December-January. Infants hospitalized during peak months had lower family history for asthma (P = 0.003), more smoking mothers during pregnancy (P = 0.036), were slightly higher breastfed (0.056), had lower number of blood eosinophils (P = 0.015) and had a higher clinical severity score (P = 0.017). RSV was detected mostly during peak months, while RV was equally distributed during the seasons. We found some variations in bronchiolitis incidence during epidemics, and discriminative characteristics in infants hospitalized for bronchiolitis during peak months and in non-peak months, that might reflect two different populations of children. Pediatr Pulmonol. 2016; 9999:XX-XX. © 2016 Wiley Periodicals, Inc

Modifiable risk factors associated with bronchiolitis

Background: We sought to clarify possibly modifiable risk factors related to pollution responsible for acute bronchiolitis in hospitalized infants. Methods: For this observational study, we recruited 213 consecutive infants with bronchiolitis (cases: median age: 2 months; age range: 0.5-12 months; boys: 55.4%) and 213 children aged <3 years (controls: median age: 12 months; age range: 0.5-36 months; boys: 54.5%) with a negative medical history for lower respiratory tract diseases hospitalized at 'Sapienza' University Rome and IRCCS Bambino Gesù Hospital. Infants' parents completed a standardized 53-item questionnaire seeking information on social-demographic and clinical characteristics, indoor pollution, eating habits and outdoor air pollution. Multivariate logistic regression analyses were run to assess the independent effect of risk factors, accounting for confounders and effect modifiers. Results: In the 213 hospitalized infants the questionnaire identified the following risk factors for acute bronchiolitis: breastfeeding 3/43 months (OR: 2.1, 95% confidence interval [CI]: 1.2-3.6), presence of older siblings (OR: 2.8, 95% CI: 1.7-4.7), 3/44 cohabitants (OR: 1.5, 95% CI: 1.1-2.1), and using seed oil for cooking (OR: 1.7, 95% CI: 1.2-2.6). Having renovated their home in the past 12 months and concurrently being exposed daily to smoking, involving more than 11 cigarettes and two or more smoking cohabitants, were more frequent factors in cases than in controls (p = 0.021 and 0.05), whereas self-estimated proximity to road and traffic was similar in the two groups. Conclusions: We identified several risk factors for acute bronchiolitis related to indoor and outdoor pollution, including inhaling cooking oil fumes. Having this information would help public health authorities draw up effective preventive measures - for example, teach mothers to avoid handling their child when they have a cold and eliminate exposure to second-hand tobacco smoke

Severe pertussis infection in infants less than 6 months of age: clinical manifestations and molecular characterization

We conducted a study to determine the main traits of pertussis among unimmunized infants less than 6&nbsp;months of age. From August 2012 to March 2015, 141 nasopharyngeal aspirates (NPAs) were collected from infants with respiratory symptoms attending 2 major hospitals in Rome. Clinical data were recorded and analyzed. Lab-confirmation was performed by culture and realtime PCR. B. pertussis virulence-associated genes (ptxP, ptxA and prn), together with multilocus variable-number tandem repeat analysis (MLVA), were also investigated by the sequence-based analysis on the DNAs extracted from positive samples. Antibiotic susceptibility with Etest was defined on 18 viable B. pertussis isolates. Samples from 73 infants resulted positives for B. pertussis. The median age of the patients was 45&nbsp;d (range 7–165); 21 infants were treated with macrolides before hospital admission. Cough was reported for a median of 10&nbsp;d before admission and 18&nbsp;d after hospital discharge among infected infants, 84% of whom showed paroxysmal cough. No resistance to macrolides was detected. Molecular analysis identified MT27 as the predominant MLVA profile, combined with ptxP3-ptxA1-prn2 associated virulence genes. Although our data may not be generalized to the whole country, they provide evidence of disease severity among infants not vaccinated against pertussis. Moreover, genetically related B. pertussis strains, comprising allelic variants of virulence associated genes, were identified

Infants hospitalized for Bordetella pertussis infection commonly have respiratory viral coinfections

Background: Whether viral coinfections cause more severe disease than Bordetella pertussis (B. pertussis) alone remains unclear. We compared clinical disease severity and sought clinical and demographic differences between infants with B. pertussis infection alone and those with respiratory viral coinfections. We also analyzed how respiratory infections were distributed during the 2 years study. Methods: We enrolled 53 infants with pertussis younger than 180 days (median age 58 days, range 17–109 days, 64. 1% boys), hospitalized in the Pediatric Departments at “Sapienza” University Rome and Bambino Gesù Children’s Hospital from August 2012 to November 2014. We tested in naso-pharyngeal washings B. pertussis and 14 respiratory viruses with real-time reverse-transcriptase-polymerase chain reaction. Clinical data were obtained from hospital records and demographic characteristics collected using a structured questionnaire. Results: 28/53 infants had B. pertussis alone and 25 viral coinfection: 10 human rhinovirus (9 alone and 1 in coinfection with parainfluenza virus), 3 human coronavirus, 2 respiratory syncytial virus. No differences were observed in clinical disease severity between infants with B. pertussis infection alone and those with coinfections. Infants with B. pertussis alone were younger than infants with coinfections, and less often breastfeed at admission. Conclusions: In this descriptive study, no associations between clinical severity and pertussis with or without co-infections were found

Leydig Cell Tumor in a 53-Year-Old Patient with Gynecomastia and Gynecodynia: A Case Report and Literature Review

Introduction: Testicular cancer is a rare neoplasm that afflicts men particularly in specific age-range. 5% to 6% of these tumors are non-germ cell tumors, in which Leydig cell tumors (LCTs) are included. Case Presentation: This case report describes an uncommon presentation of a Leydig tumor cell in a 53 year old man with gynecomastia and gynecodynia Conclusions: LCT is a rare neoplasm of the testis; its origin is still unknown and it could also present out of the normal range-age with the highest incidence. The radical surgery is still preferred, even if an organ sparing approach is reported. There are a lot of reports and case series in literature about LCT's but our work focus the attention of uncommon signs of presentation of this disease, expecially gynecodynia

Why pertussis is still a concern? Reasons for resurgence and improving strategies

Pertussis is a highly contagious, vaccine-preventable, bacterial infectious disease, caused by B. pertussis. It affects children less than 6 months of age with severe clinical symptoms especially in newborns. Pertussis continues as a public health concern threat given its re-emergence despite high vaccination coverage; re-emergence could be caused by the waning of vaccine immunity consequent to introduction of the acellular (aP) vaccine, by the adaptation of circulation of variants B. pertussis strains and by the improvement of diagnostic methods and active surveillance. We conducted a longitudinal case-controls double center study on 141 infants younger than 6 months, hospitalized with typical symptoms of pertussis and 235 healthy controls. Inclusion criteria: age lower than 180 days, with cough lasting more than 5 days, paroxysmal cough, apnea or cyanosis and post-cough vomit. Exclusion criteria: chronic diseases and genetic syndromes. A total of 157 breastfeeding mothers from cases and controls infants were included in the immunological study and requested to undergo a blood and breast milk sample collection. A total of 167 parents from 145 infants were enrolled in the study about the serum-epidemiology of pertussis. Our project leads to identify a prevalence of more than 50% of pertussis cases among the population studied. We demonstrated that breastfeeding does not exert a protective role against pertussis infection in infants, showing a low immunologic activity of breast milk against B. pertussis, compared with other pathogens, and that the presence of at least one sibling doubled the risk to contract pertussis. In addition, comparing the specific immune response of mother of cases and mothers of controls, we showed that both mothers groups have pre-existing pertussis-specific antibodies and memory B cells and react against the infection with a recall response increasing the levels of specific serum IgG and the frequency of all isotypes of memory B cells. Finally, we found that 40% of parents of infants hospitalized with pertussis had a serological evidence of recent infection, and only 30% showed respiratory symptoms in the previous 3 weeks; interestingly, 30% of parents who not reported symptoms had a serological evidence of recent infection. The combination of these results allows to suppose a source of contagion in almost 90% of them. In conclusion, the prevalence and severity of the disease among infants should increase the attention on the disease, leading to better strategies for its prevention and care. It is mandatory to advise parents about pertussis transmission to the newborns and to be aware of respiratory symptoms in the household. Breastfeeding remains a milestone of prevention for several infectious diseases, but in our study, we showed no protective role in the prevention of B. pertussis infection. Vaccination remains the major strategy for the prevention of pertussis but, this project supports an improving in pertussis surveillance, the detection of escape mutants, and the development of more effective vaccines

Broncomalacia e tracheomalacia

La broncomalacia e la tracheomalacia sono anomalie delle grandi vie respiratorie e possono essere associate ad un’ampia varietà di condizioni congenite e acquisite. I sintomi clinici includono lo stridore ad esordio precoce, la presenza di un sibilo fisso alla auscultazione del torace, le infezioni ricorrenti, la tosse metallica e la dispnea improvvisa con asfissia, a seconda del sito e della gravità della lesione. Il gold standard per la diagnosi rimane la broncoscopia flessibile in un bambino che respira autonomamente, ma può anche essere identificata con tecniche di imaging dinamiche come la broncografia volumetrica, la tomografia computerizzata o la risonanza magnetica. I test di funzionalità polmonare possono fornire prove di supporto, ma non sono considerati diagnostici. La gestione può essere medica o chirurgica, a seconda della natura e della gravità. Il trattamento farmacologico con broncodilatatori, agenti anti-muscarinici, mucolitici e antibiotici è supportato da scarse evidenze sul loro beneficio; anche la fisioterapia respiratoria è comunemente prescritta, soprattutto finalizzata alla clearance delle secrezioni. In caso di sintomatologia grave le migliori opzioni terapeutiche risultano essere quelle chirurgiche: l’aortopessia, la tracheopessia o il posizionamento di stent interni. Nei casi in cui si manifesti la necessità di un supporto respiratorio, la modalità più comunemente usata è la CPAP con maschera facciale o tramite tracheostomia nei pazienti che necessitano di ventilazione per molte ore al giorno.Bronchomalacia and tracheomalacia are abnormalities of the large respiratory tract and can be associated with many congenital and acquired conditions. Clinical signs include early-onset stridor, fixed wheezing, recurrent infections, metal cough and respiratory distress with asphyxia in more severe cases. The gold standard for the diagnosis is the flexible bronchoscopy in children who breathe autonomously, but can also be identified with dynamic imaging techniques such as volumetric bronchography, computed tomography or magnetic resonance imaging. Lung function tests may provide supportive evidence but are not considered diagnostic. Management can be medical or surgical, depending on the nature and clinical severity. Pharmacological treatment with bronchodilators, anti-muscarinic agents, mucolytic and antibiotics is supported by scarce evidence on their benefit; respiratory physiotherapy is also generally prescribed, especially aimed to the clearance of secretions. In case of severe symptoms, the best therapeutic options are surgical: aortopexy, tracheopexy or positioning of internal stents. In cases of need of respiratory support, the most used modality is CPAP with face mask or via tracheostomy in patients who need ventilation for many hours per day

Studi del sonno

I disturbi del sonno pediatrici hanno una prevalenza del 25%. I più frequenti sono i disturbi respiratori (DRS), di cui il maggiore rappresentante sono le apnee ostruttive del sonno (OSA), con una prevalenza dell’1-3%, che aumenta considerevolmente in caso di patologie genetiche (Sindrome di Down e di Prader-Willi). La fascia d’età maggiormente colpita è tra i 3 e i 6 anni; cause principali sono l’obesità, l’ipertrofia adeno-tonsillare e le malformazioni cranio-facciali. La sintomatologia notturna comprende il russamento, la presenza di pause respiratorie (apnee) e di frammentazione e agitazione del sonno. Segni diurni sono invece la sonnolenza, l’irritabilità e lo scarso rendimento scolastico. L’esame diagnostico gold standard è la polisonnografia eseguita in ambiente ospedaliero. Il trattamento prevede la perdita di peso, l’adeno-tonsillectomia e nei casi molto gravi la ventilazione meccanica a pressione continua. Il caso clinico presentato in questo articolo evidenzia l’importanza dello studio del sonno nell’ambito della valutazione multidisciplinare del paziente affetto da sindrome di Prader-Willi.Pediatric sleep disorders have a prevalence of 25% and sleep respiratory disorders (SRD) are the most frequent. The most representative is the Obstructive Sleep Apnea Syndrome (OSAS), with a prevalence of 1-3%, that increases considerably in case of genetic diseases (Sindrome di Down e di Prader-Willi). The most frequent age is between 3 and 6 years, and the main causes are represented by obesity, adeno-tonsillar hypertrophy and cranio-facial malformations. Nocturnal symptoms include snoring, respiratory pauses (apneas), and sleep fragmentation and agitation. Daytime symptoms are drowsiness, irritability, and poor academic performance. The gold standard diagnostic test is polysomnography performed in a hospital setting. The treatment involves weight loss, adeno-tonsillectomy and in very severe cases mechanical ventilation with continuous pressure. The case report herein described highlights the importance of sleep studies in the multidisciplinary evaluation of the patient affected by Prader-Willi syndrome

Virus respiratorio sinciziale: un virus non solo dell’età neonatale

In un periodo in cui l’attenzione alla prevenzione dei virus respiratori è altissima, dobbiamo ricordare che non esiste solo il nuovo Coronavirus. Il Virus Respiratorio Sinciziale (VRS) è un virus ubiquitario ed il 70% dei bambini ne è colpito nei primi 2 anni di vita. La manifestazione clinica del VRS nei lattanti è la bronchiolite; in età prescolare può manifestarsi con bronchite asmatica, nell’età adolescenziale e adulta con riacutizzazioni di asma/BPCO, mentre può assumere una forma di patologia respiratoria critica nel soggetto anziano. In età infantile è frequente la necessità di ricovero ospedaliero soprattutto nei lattanti con comorbilità, che hanno un rischio molto maggiore di decesso. Negli adulti, la maggioranza delle ospedalizzazioni e decessi per infezione da VRS avviene in soggetti con più di 65 anni. La prevenzione è la prima arma contro i virus respiratori: distanziamento sociale, lavaggio delle mani, evitare il contatto con soggetti ammalati e fragili, favorire l’allattamento al seno ed evitare il fumo passivo sono solo alcuni dei punti cardine. L’infezione da VRS non ha ancora un trattamento mirato, né la possibilità di attuare un vaccino efficace, ma esiste la possibilità di immunizzazione passiva con anticorpi monoclonali (palivizumab e nirsevimab) che hanno dimostrato una significativa efficacia in termini di ospedalizzazione.In a period of high attention on the prevention of respiratory viruses, it is mandatory to remember that there is not only the novel Coronavirus. The Respiratory Syncytial Virus (RSV) is a ubiquitous virus and 70% of children are affected in the first 2 years of life. Clinical manifestation of RSV in children is bronchiolitis; in preschool age, it can cause asthmatic bronchitis, in adolescence and adulthood exacerbations of asthma/COPD, while it can cause critical respiratory disease in the elder age. In childhood, the need for hospitalization is frequent, especially in infants with comorbidities, who have a much higher risk of death. In adults, the majority of RSV hospitalizations and deaths occur in people over the age of 65 years. Prevention is the first weapon against respiratory viruses: social distancing, washing hands, avoiding contact with sick and frail subjects, promoting breastfeeding and avoiding passive smoking are just some of the key points. RSV infection does not yet have a targeted treatment, nor the possibility of implementing an effective vaccine, but there is the possibility of passive immunization with monoclonal antibodies (palivizumab and nirsevimab) which have shown significant efficacy in terms of hospitalization in infants

Novità dal XXIV Congresso SIMRI: l’inverno sta arrivando

Lo scorso ottobre (il 16 e 17) si è svolto con successo e buona partecipazione di pubblico, per la prima volta in modalità digitale a causa delle restrizioni legate all’emergenza COVID-19, il XXIV Congresso della Società Italiana Malattie Respiratorie Infantili (SIMRI). Tra tutte le interessantissime sessioni che si sono succedute nella due giorni virtuale, abbiamo scelto di porre attenzione su quelle della professoressa Stefania La Grutta (Palermo) e del professor Fabio Cardinale (Bari), che rispettivamente ci hanno esposto le novità sugli aspetti pratici della nebulizzazione (aerosol) e sulla terapia del wheezing prescolare (WP). Entrambi gli argomenti assumono un carattere di grande attualità vista la stagione invernale che si appresta a iniziare