Pneumonias in Children

Pneumonije i sada imaju velik udio u pobolu i smrtnosti djece osobito u zemljama u razvoju. Spektar kliničkih slika je od blage do za život opasne infekcije. Rizik od nastanka teških infekcija osobito je velik u dojenačkoj i predškolskoj dobi. Na osnovi kliničkih znakova, laboratorijske i radiološke obrade vrlo je teško razlučiti bakterijsku od virusne pneumonije. Posljednjih godina diljem svijeta sve češće se opisuju rezistentni uzročnici na antibiotike. U ovom preglednom radu, na osnovi recentne literature iznose se današnje spoznaje o uzročnicima pneumonije u djece, kao i o mogućnostima liječenja.Childhood pneumonia remains one of the most important causes of morbidity and mortality, particularly in developing countries. Its clinical spectrum ranges from a mild illness to life threatening conditions. Infants and preschool children are at particular risk for the development of severe infections. There are no reliable ways to differentiate viral from bacterial aetiologies using clinical clues, radiological alterations or laboratory data. A dramatic increase in the prevalence of antibiotic-resistant pathogens has been reported worldwide. Based on the recent literature, this article provides the current knowledge of childhood pneumonia pathogens and available therapies

MICROBIOLOGY OF RESPIRATORY SAMPLES FROM CHILDREN WITH CYSTIC FIBROSIS

SAŽETAK Analizirani su retrogradno dvogodišnji (2005. – 2006.) rezultati mikrobiološke obrade respiratornih uzoraka dobivenih od bolesnika s cističnom fibrozom, liječenih u Klinici za dječje bolesti KBC-a Rijeka. Od 114 obrađenih kliničkih uzoraka, u 95,6% slučajeva kultura je bila pozitivna, a najčešći izolat bio je Pseudomonas aeruginosa (77,8%). Staphylococcus aureus izoliran u 9,6% uzoraka, dominantan je izolat u mlađe djece. Burkholderia cepacia izolirana je u samo jednome slučaju (0,6%). Dok je među testiranim sojevima vrste Pseudomonas aeruginosa najveći postotak otpornosti uočen prema gentamicinu (49,4%), netilmicinu (47,2%) i ceftazidimu (44,9%), u dvama je izolatima (2,2%) zabilježena otpornost na kolistin.SUMMARY The aim of the study was to analyze the microorganisms cultured from respiratory samples of children with cystic fibrosis treated in the Clinic for children diseases, University Hospital Rijeka, during 2005 – 2006. In 95.6% of 114 clinical samples, microbiological examination yielded positive culture. The most frequently isolated microorganisms was Pseudomonas aeruginosa (77.8%). Staphylococcus aureus was isolated in 9.6% of samples and was dominant in younger CF children. Burkholderia cepacia was isolated just in one case (0.6%). A high resistance to gentamicin (49.4%), netilmicin (47.2%) and ceftazidime (44.9%) was observed in Pseudomonas aeruginosa strains, and two of them were colistin resistant (2.2%)

Tibial Stress Fracture Simulate Osteomyelitic Foci in the Course of Chronic Recurrent Multifocal Osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an extremely rare and most severe form of chronic nonbacterial osteomyelitis of unknown etiology. Here we present the first case of a six-year-old girl in which was observed that the stress fracture mimic osteomyelitic foci in the course of CRMO

The use of an interferon gamma release assay (IGRA) in the immunodiagnosis of tuberculosis

Cilj: Otkrivanje latentne tuberkuloze sukladno nacionalnim smjernicama uključuje procjenu rizika, radiografsku pretragu, izvođenje tuberkulinskog kožnog / PPD testa (PPD – purificirani proteinski derivat) i/ili novijeg ex vivo testa otpuštanja interferona gama (engl. Interferon Gamma Release Assay – IGRA). U radu je analizirana dinamika izvođenja i rezultati dobiveni dijagnostičkom primjenom imunoenzimske IGRA pretrage na M. tuberculosis. Metode: Izvršena je retrospektivna analiza rezultata Quantiferon-TB Gold In-Tube (QFT-GIT) testiranja provedenih u Laboratoriju za dijagnostiku tuberkuloze Nastavnog zavoda za javno zdravstvo Primorsko-goranske županije (Hrvatska). Rezultati: U sedmogodišnjem razdoblju (2007. – 2013.) u Laboratoriju za dijagnostiku tuberkuloze primjenom QFT-GIT testa analizirano je 2.110 uzoraka krvi pacijenata koji su pripadali različitim dobnim skupinama (od dobi od mjesec dana do 95 godina; x̄ = 41,9 godina; SD = 29,1; mod 56 godina). Rezultati analize su bili pozitivni u 585 (27,7 %), negativni u 1.498 (71 %) uzoraka, a u 27 (1,3 %) izvršenih pretraga su bili neodredivi. Pozitivni nalazi podjednako su zastupljeni u pretragama izvršenim za muškarce (29 % od 1.058 pretraga) i žene (26 % od 1.052 pretrage). Veća zastupljenost pozitivnih nalaza zabilježena je u osoba starijih od 56 godina, napose u dobnoj skupini od 81 do 85 godina (61 % od 44 pretrage). Prema uputnoj dijagnozi pozitivni nalazi su zastupljeniji kod hiperreaktora (40,5 % od 84 analize), TB kontakata (35,1 % od 464 analize) i zdravstvenih radnika (34,9 % od 43 analize). Rasprava i zaključci: Primjena in vitro IGRA QFT-GIT testa u kombinaciji s konvencionalnim metodama danas je prepoznata kao dijagnostički postupak koji ima značajnu ulogu u otkrivanju LTB-a, što predstavlja važan korak u prevenciji tuberkuloze, posebice kod rizičnih skupina.Aim: Tuberculosis (TB) remains a major global public health problem. Screening for latent tuberculosis infection (LTB) usually involves risk assessment, chest X-ray, the tuberculin skin/PPD (Purified Protein Derivate) test, and/or interferon-gamma release assay (IGRA), according to country-specific guidelines. This paper describes the frequency of application and the results obtained by enzyme-linked immunosorbent IGRA assay for M. tuberculosis. Methods: We conducted a retrospective analysis of the results obtained using Quantiferon-TB Gold In-Tube (QFT-GIT) analysis at the Laboratory for the diagnosis of tuberculosis – Teaching Institute of Public Health County Primorsko-goranska (Croatia). Results: In the seven-year period (2007–2013) QFT-GIT analysis were processed in 2110 blood samples of patients from different age groups (aged 1 month-95 years; x̄ = 41.9 years; SD = 29.1; mode 56 years). Results were positive in 585 (27.7 %) samples, whereas negative results were found in 1498 (71 %) cases, and in 27 (1.3 %) samples the results were indeterminate. Positive results were distributed equally among males (29 % of 1058 samples) and females (26 % of 1052 samples). Higher incidence of positive results was observed in people over the age of 56, especially in the age group between 81-85 years (61 % of 44 tests). Positive results were most common in the group of hyperreactors (40.5 % of 84 tests) then in TB contacts (35.1 % of 464 tests), as well as health workers (34.9 % of 43 tests). Discussion and Conclusions: Applying in vitro IGRA QFT-GIT test in combination with conventional methods is recognized as a diagnostic method that plays an important role in uncovering LTB and as such represents an important step in prevention of tuberculosis, especially in high-risk groups

OUR EXPERIENCES WITH CEFEPIME IN THE TREATMENT OF HOSPITALISED CHILDREN WITH COMMUNITY-ACQUIRED PNEUMONIA

Uvod. Publicirana zapažanja i iskustva o kliničkoj primjeni cefepima, cefalosporina četvrte generacije, u djece s pneumonijom su oskudna. Cilj rada. Iznijeti iskustva primjene cefepima u bolnički liječene djece s ozbiljnom kliniËčom slikom tipične domicilne pneumonije. Metode. Cefepim je korišten u liječenju osam dječaka i tri djevojčice srednje dobi od 6,5 godina, uz raspon dobi od 4 do 14 godina zbog domicilne pneumonije. Svi su bolesnici prethodno neuspje no ambulantno liječeni peroralnim antibioticima. Cefepim je primjenjivan u obliku kratkotrajne intravenske infuzije, dvaput na dan, u pojedinačnoj dozi od 50 mg/kg (maksimalno 1 g) tijekom sedam dana. Rezultati. Desetero bolesnika (91%) imalo je dobar klinički odgovor na liječenje, popraćen značajnim padom vrijednosti reaktanata akutne faze upale i normalizacijom nalaza bijele krvne slike. U jednog djeteta došlo je do razvoja manjega pleuralnog izljeva pa je u liječenje uveden vankomicin. Djeca nisu imala simptome niti su pokazivala znakove koje bi mogli pripisati kakvoj ozbiljnoj nuspojavi lijeka. Zabilježen je statistički značajan (p<0,05), blaæi porast funkcionalnih jetrenih proba. Zaključak. Naša iskustva upućuju na dobru učinkovitost cefepima u empirijskom liječenju hospitalizirane djece s ozbiljnom domicilnom pneumonijom. Iako se lijek pokazao dobro podnošljivim i sigurnim. Nakon provedenog liječenja potrebno je kontrolirati serumske razine jetrenih enzima.Introduction. Publicised data about clinical use of cefepime, a fourth generation cephalosporin, in children with pneumonia are modest. Aim. To show our experiences with cefepime in the treatment of hospitalised children with serious community acquired pneumonia. Methods. Eight boys and 3 girls (mean age 6.5 years; span 4-14) were hospitalised and were treated with cefepime because of serious domicile pneumonia. All children were unsuccessfully treated with oral antibiotics prior to hospitalisation. Cefepim was administered as a rapid intravenous infusion, twice daily, during 7 days. Single dose was 50 mg/kg (max. 1 g). Results. Ten patients (91%) showed good clinical response characterised by significant decrease of acute-phase reactants and by normalisation of white blood cell count. The development of a smaller pleural effusion was detected in one child whom vancomycin was introduced into treatment. Children had nor symptoms nor signs which could be defined as serious adverse reactions to drug. However, statistically significant (p<0,05), mild increase of liver enzymes levels was noticed. Conclusion. Our experiences showed very good effectiveness of cefepime in the treatment of hospitalised children with serious community acquired pneumonia. Although cefepime appeared to be well tolerated and safe, we suggest that liver enzymes levels should be controled after the treatment is completed

OUR EXPERIENCES WITH CEFEPIME IN THE TREATMENT OF HOSPITALISED CHILDREN WITH COMMUNITY-ACQUIRED PNEUMONIA

Uvod. Publicirana zapažanja i iskustva o kliničkoj primjeni cefepima, cefalosporina četvrte generacije, u djece s pneumonijom su oskudna. Cilj rada. Iznijeti iskustva primjene cefepima u bolnički liječene djece s ozbiljnom kliniËčom slikom tipične domicilne pneumonije. Metode. Cefepim je korišten u liječenju osam dječaka i tri djevojčice srednje dobi od 6,5 godina, uz raspon dobi od 4 do 14 godina zbog domicilne pneumonije. Svi su bolesnici prethodno neuspje no ambulantno liječeni peroralnim antibioticima. Cefepim je primjenjivan u obliku kratkotrajne intravenske infuzije, dvaput na dan, u pojedinačnoj dozi od 50 mg/kg (maksimalno 1 g) tijekom sedam dana. Rezultati. Desetero bolesnika (91%) imalo je dobar klinički odgovor na liječenje, popraćen značajnim padom vrijednosti reaktanata akutne faze upale i normalizacijom nalaza bijele krvne slike. U jednog djeteta došlo je do razvoja manjega pleuralnog izljeva pa je u liječenje uveden vankomicin. Djeca nisu imala simptome niti su pokazivala znakove koje bi mogli pripisati kakvoj ozbiljnoj nuspojavi lijeka. Zabilježen je statistički značajan (p<0,05), blaæi porast funkcionalnih jetrenih proba. Zaključak. Naša iskustva upućuju na dobru učinkovitost cefepima u empirijskom liječenju hospitalizirane djece s ozbiljnom domicilnom pneumonijom. Iako se lijek pokazao dobro podnošljivim i sigurnim. Nakon provedenog liječenja potrebno je kontrolirati serumske razine jetrenih enzima.Introduction. Publicised data about clinical use of cefepime, a fourth generation cephalosporin, in children with pneumonia are modest. Aim. To show our experiences with cefepime in the treatment of hospitalised children with serious community acquired pneumonia. Methods. Eight boys and 3 girls (mean age 6.5 years; span 4-14) were hospitalised and were treated with cefepime because of serious domicile pneumonia. All children were unsuccessfully treated with oral antibiotics prior to hospitalisation. Cefepim was administered as a rapid intravenous infusion, twice daily, during 7 days. Single dose was 50 mg/kg (max. 1 g). Results. Ten patients (91%) showed good clinical response characterised by significant decrease of acute-phase reactants and by normalisation of white blood cell count. The development of a smaller pleural effusion was detected in one child whom vancomycin was introduced into treatment. Children had nor symptoms nor signs which could be defined as serious adverse reactions to drug. However, statistically significant (p<0,05), mild increase of liver enzymes levels was noticed. Conclusion. Our experiences showed very good effectiveness of cefepime in the treatment of hospitalised children with serious community acquired pneumonia. Although cefepime appeared to be well tolerated and safe, we suggest that liver enzymes levels should be controled after the treatment is completed

Childhood-onset systemic lupus erythematosus in Croatia: demographic, clinical and laboratory features, and factors influencing time to diagnosis

OBJECTIVES Childhood-onset systemic lupus erythematosus (cSLE) presents with diverse clinical features and often with non-classical symptoms that may delay diagnosis and increase risk of morbidity and mortality. This paper aims to analyse incidence, and clinical and laboratory features of cSLE in Croatia between 1991 and 2010, and to identify factors influencing time to diagnosis. ----- RESULTS Medical records at three university-based tertiary care centres were analysed retrospectively for 81 children with cSLE (68 girls). Mean age at onset was 13.4±2.8 yr (interquartile range 3), and annual incidence varied from 1-15 per million at risk. The most frequent clinical and laboratory features were musculoskeletal symptoms (80%) and increased erythrocyte sedimentation rate (96%). The most frequent immunological laboratory findings were the presence of antibodies against histones (86%), double-stranded DNA (73%), and Sm protein (64%), as well as low levels of C3 complement (69%). Haematuria was present in 58% of children, proteinuria in 56%, and biopsy-confirmed lupus nephritis in 43%. Median time from symptom onset to diagnosis was 2 months (range 0-96). Time to diagnosis was inversely associated with ECLAM score (p<0.001), but it showed no association with age, gender, clinical features or distance from the nearest paediatric centre. ----- CONCLUSIONS This is the first large-scale, in-depth study of clinical and laboratory features of cSLE in Croatia. Among all demographic, laboratory and clinical features examined, ECLAM score alone was inversely associated with time to diagnosis. This highlights the need to improve detection of children with fewer symptoms early in the course of the disease, therefore serious consequences for prognosis could be avoided

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF HEREDITARY ANGIOEDEMA

Hereditarni angioedem (HAE) rijetka je, ali potencijalno za život opasna bolest zbog nepredvidivih napadaja bezbolnih, ograničenih, recidivirajućih otoka supkutanog ili submukoznog, intersticijskog tkiva u trajanju od nekoliko sati do nekoliko dana. Oboljelih od HAE u RH ima oko 100 (ali vjerojatno ima više nedijagnosticiranih). Poseban kvalitativni napredak u usklađivanju dogovora o liječenju HAE jesu Smjernice Svjetske alergološke organizacije koje su donesene 2012. Oslanjajući se na taj dokument, Radna grupa hrvatskih stručnjaka pripremila je prijedlog smjernica za liječenje HAE u Hrvatskoj. Napadaji angioedema u HAE posljedica su mutacije gena za plazmatski protein inhibitor C1. Zbog manjka inhibitora ili njegove disfunkcionalnosti dolazi do okidačem (trigerom) potaknute autoaktivacije C1 i cijele kaskade s konačno povećanom propusnošću krvnih žila i edemom tkiva. Postoje tri tipa hereditarnog angioedema: tip I uzrokovan sniženom razinom C1inh proteina, tip II uzrokovan proizvodnjom nefunkcionalnog C1inh proteina te tip III karakteriziran normalnom funkcijom i razinom C1inh. U svih bolesnika sa sumnjom na HAE mora se odrediti nivo C4 i inhibitora C1, kao i funkcija inhibitora C1. Liječenje akutne atake HAE: Svi napadaji angioedema koji onesposobe dijelove tijela i/ili zahvaćaju lice, vrat, trbuh, a pogotovo gornje dišne putove zahtijevaju liječenje. Terapija mora biti odmah dostupna (On-Demand Treatment). U akutnoj ataci treba odmah primijeniti koncentrat inhibitora C1 (dobiven iz plazme ili rekombinantni), ikatibant ili ekalantid. Ako ovi lijekovi nisu dostupni, akutni napadaji edema mogu se liječiti plazmom obrađenom detergentom. Ako se ovakva plazma ne može dobiti, angioedemi se liječe svježe smrznutom plazmom. Intubacija ili traheotomija moraju se izvesti na vrijeme ako progredira edem gornjih dišnih putova. U napadaju angioedema bolesnik može dobiti i adjuvantnu terapiju (analgetike, infuzije). Preporučuje se da svi bolesnici uvijek nose sa sobom lijekove za samoprimjenu. Preporučljiva je kratkoročna profilaksa edema prije kirurških zahvata (osobito stomatoloških zahvata), zahvata u kojima je potrebna endotrahealna intubacija, zahvata na gornjim dišnim putovima ili farinksu te prije bronhoskopije i endoskopije. Dugoročna profilaksa indicirana je ako se javi jedna ili više težih ataka angioedema na mjesec. Kao dugoročna profilaksa mogu se rabiti koncentrat inhibitora C1 ili androgeni. Probir djece za HAE trebalo bi odgoditi do 12. mjeseca života. Sve potomke bolesnika treba testiratiHereditary angioedema (HAE) is a rare but potentially fatal genetic disorder with nonpitting, nonerythematous, and not pruritic swelling which can affect the hands, feet, face, genitals and visceral mucosa. The type, frequency, and severity of the attacks vary between patients, and over the lifetime of an individual patient. Efforts in Croatian counties have identified approximately 100 patients (but there must be more undiagnosed patients). The first global guideline for the management of HAE was developed by the World Allergy Organization HAE International Alliance and published in 2012. Based on that document the Working group of Croatian experts was assigned to propose guideline for HAE management in Croatia. HAE is is most often related to decreased or dysfunctional C1 inh with autoactivation of C1 and bradykinin accumulation leading to localized dilatation and increased permeability of blood vessels resulting in tissue swelling. A diagnosis of HAE can be confirmed by measuring complement and C1 inh quantitative and functional levels.Three HAE types could be differentiated: HAE type 1 (C1 inh level is low), HAE type 2 (C1 inh level is normal but dysfunctional), and HAE type 3 (normal level and function of C1 inh). All patients suspected to have HAE-1/2 should be assessed for blood levels of C4, C1 inh protein, and C1 inh function. All attacks that result in debilitation/dysfunction and/or involve the face, the neck, or the abdomen should be considered for on-demand treatment. It is recommended that attacks are treated as early as possible. HAE attacks are treated with C1 inh, ecallantide, or icatibant.If these drugs are not available, attacks should be treated with solvent detergent-treated plasma (SDP). If SDP is not available, then attacks should be treated with frozen plasma.Intubation or tracheotomy should be considered early in progressive upper airway edema. Patients with attacks could receive adjuvant therapy when indicated (pain management, intravenous fluids). All patients should have on-demand treatment for two attacks and carry their on-demand treatment at all times. The administration of short-term prophylaxis should be considered before surgeries (dental/intraoral surgery, where endotracheal intubation is required), where upper airway or pharynx is manipulated, and before bronchoscopy or endoscopy. Long-term prophylaxis should be considered in all severely symptomatic HAE-1/2 patients. C1 inh concentrate or androgens can be used. Screening children for HAE-1/2 should be deferred until the age of 12 months, and all offspring of an affected parent should be tested