POLYMERASE CHAIN REACTION IN CHILDHOOD LEPROSY
Submitted by Rajeshwar Dayal
Rajeshwar Dayala, S. P. Singha, P. P. Mathura, V. M.
Katochb, K. Katochb, M. Natrajanb
aDepartment of Pediatrics, S. N. Medical College, Agra, India;bNational Jalma Institute for Leprosy and other Mycobacterial Diseases, Agra, India
OBJECTIVE:Our aim was to assess the diagnostic value of in situ polymerase chain reaction (PCR) in leprosy, particularly for enhancing histopathological diagnosis.
METHODS:We prospectively studied 20 children (aged ⬍16 years) with leprosy. Clinical examination of each case was performed, and skin smear for acid-fast bacillus was prepared. A biopsy of the lesion site was performed
for histopathological examination and in situ PCR test- ing.
RESULTS: Histopathological examination confirmed the clinical diagnosis in only 45% of the cases; nonspe- cific histopathology was reported for the remaining 55% of the cases. In situ PCR showed a positivity of 57.1% in the early/localized form of leprosy (indeterminate/bor- derline tuberculoid) and 61.5% in the borderline bor- derline/borderline lepromatous group. When compared with the histopathological examination, a significant en- hancement of 15% in diagnosis was seen. With in situ PCR, the diagnosis could be confirmed in 4 (36.3%) of 11 cases with nonspecific histopathological features (which is common in early disease) in addition to con- firmation of 8 (88.8%) of 9 histopathologically con- firmed tissue sections. Histopathology and in situ PCR combined together confirmed the diagnosis in 13 (65%) of the 20 cases.
CONCLUSIONS:In situ PCR is an important diagnostic tool, especially in early and doubtful cases of leprosy.
DETECTION AND MOLECULAR SEROTYPING
OF GROUP BSTREPTOCOCCUSIN FATAL
NEONATAL PNEUMONIA IN CHINA Submitted by Jianghong Deng
Jianghong Deng, Yonghong Yang
Beijing Children’s Hospital, Capital Medical University, Beijing, China
INTRODUCTION: Group B Streptococcus (GBS) has been recognized as an important pathogen in neonatal infectious disease. However, there are few data on the prevalence of neonatal GBS infection in China.
OBJECTIVE:Our aim was to estimate the infection rate of GBS in neonatal pneumonia in China and identify distribution of the GBS serotype.
METHODS: We retrospectively studied 200 children with fatal neonatal pneumonia who died between 1953 and 2004; 34 fatal neonatal cases without any infectious disease were used as a control group. Paraffin-embedded lung tissues were collected for total genomic DNA ex- traction. Polymerase chain reaction (PCR) and Southern blotting were used for GBS detection and molecular serotyping.
RESULTS:(1) The positive rate of GBS in the pneumo- nia group was significantly higher than that in the con- trol group (PCR: 26% vs 3% [P⬍.01]; Southern blot: 65% vs 18% [P⬍.01]). (2) The positive rate in neonates younger than 7 days was significantly higher than that in neonates older than 7 days (PCR: 37% vs 13% [P⬍ .01]; Southern blot: 72% vs 52% [P ⬍ .05]). (3) Risk factors were identifiable for most GBS-positive cases. (4) In the pneumonia group, 22 GBS-positive cases were serotypeable: 7 cases were identified as serotype Ia, 6
cases were serotype III, 5 cases were serotype II, and 1 case was serotype Ib.
CONCLUSIONS:In China, GBS is an important patho- gen in fatal neonatal pneumonia, especially in early- onset cases. Serotypes Ia, III, and II were the most com- mon serotypes identified.
PERIPHERAL BLOOD COUNT FOR DENGUE SEVERITY PREDICTION: A PROSPECTIVE STUDY IN THAI CHILDREN
Submitted by Nanthakorn Eu- Ahsunthornwattana
Nanthakorn Eu-Ahsunthornwattanaa, Jakris Eu-
ahsunthornwattanab, Usa Thisyakorna
aKing Chulalongkorn Memorial Hospital, Bangkok, Thailand;bFaculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
INTRODUCTION: Dengue viral infection has a wide range of severity levels and requires different levels of medical attention. Early severity prediction using clinical features is difficult. Certain lymphocytic subtypes can be used to predict severity; we postulate that peripheral blood counts can also predict severity, which would be more useful in smaller rural hospitals.
OBJECTIVE: We aimed to compare the peripheral blood counts between patients with mild dengue infec- tion and those with severe dengue infection and identify simple yet sensitive early severity predictors.
METHODS:We enrolled 91 patients with serologically confirmed dengue infection who were admitted to King Chulalongkorn Memorial Hospital. Their leukocytic counts on admission were compared. Potential predic- tors were identified by using receiver-operating-charac- teristic analysis.
RESULTS:Compared with patients with mild infection, those with severe infection (dengue hemorrhagic fever grade II or worse) had a higher leukocyte count (3580 vs 3050 cells perL;P⫽.04), and fewer had leukopenia on admission (70% vs 89%;P⫽.03). They also had a lower percentage of “typical” lymphocytes (24% vs 40%;P⫽ .02). Two predictors were identified; either one classified ⬃19% of all admitted patients as being at low risk. Typical lymphocyte counts of ⬍40% excluded patients with mild disease with 89% sensitivity and 24% speci- ficity (negative predictive value: 77%; positive predictive value: 45%). A combination of parameters [(white blood cells perL) ⫹470 ⫻(% typical lymphocytes)⫹5⫻ (atypical lymphocytes perL)ⱖ⫺14 950] improved the sensitivity and specificity to 92% and 26% (negative predictive value: 82%; positive predictive value: 46%).
CONCLUSIONS:The absence of leukopenia and a low percentage of typical lymphocytes predict severe dengue illness. Simple hematologic parameters may be used to reduce unnecessary admissions of patients with sus-
pected dengue infection in the absence of more sophis- ticated predictors.
SPECTRUM AND MANAGEMENT OF OTITIS MEDIA IN AUSTRALIAN INDIGENOUS AND NON-INDIGENOUS CHILDREN: A NATIONAL STUDY
Submitted by Hasantha Gunasekera Hasantha Gunasekeraa,b, Stephanie Knoxc, Peter
Morrisd, Helena Brittc, Peter McIntyreb,e, Jonathan
Craigb
aChildren’s Hospital at Westmead, Westmead, Australia; cAustralian General Practice Statistics and Classification Center, Parramatta, Australia;dMenzies School of Health Research, Darwin, Australia;eNational Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, Sydney, Australia;bSchool of Public Health, University of Sydney, Sydney, Australia
INTRODUCTION:The reported prevalence and sever- ity of otitis media are highest among the world’s Indig- enous children, but whether their clinical management varies accordingly is unknown.
OBJECTIVE:Our aim was to study the spectrum and management of otitis media in Indigenous and non- Indigenous children in Australia.
METHODS: From a representative Australian cluster survey of consecutive primary health care consultations, we analyzed all consultations with children (aged 0 –18 years). We compared the practitioners’ investigation, treatment, and referral practices for Indigenous and non-Indigenous children with otitis media after adjust- ing for clustering.
RESULTS: Over 8 years (1998 –2006), 7991 practitio- ners managed 141 693 problems in 119 503 consulta- tions with children, including 2856 (2.4%) with Indig- enous children. Ear problems were the fourth most common problems managed. Otitis media was managed slightly more commonly in Indigenous than non-Indig- enous children (9.8% vs 7.3% consultations;P⬍.05). When otitis media was diagnosed, Indigenous children were significantly more likely to have severe otitis media (chronic and/or suppurative and/or perforation: 7.9% vs 1.7%;P⬍.001), discharging ears (3.9% vs 0.1%;P⬍ .001), ear swabs (3.9% [95% confidence interval (CI): 1.6 – 6.2] vs 0.8% [95% CI: 0.6 – 0.9]), and topical ear- drops administered (10.7% [95% CI: 6.8 –14.6] vs 4.5% [95% CI: 4.1–5.0]) but not more likely to receive oral antibiotics (71.8% vs 75.9%), have ear syringing (1.1% vs 0.2%), or be referred to an otolaryngologist (6.1% vs 3.4%) or audiologist (1.8% vs 1.1%) (allP⬎.05).
CONCLUSIONS:In the Australian primary health care setting, Indigenous children are 5 times more likely to be diagnosed with severe otitis media than non-Indigenous children, but reported management is not substantially
different, which is inconsistent with established national guidelines. This spectrum-management discordance may contribute to continued worse outcomes for Indig- enous children with otitis media.
SEROLOGICAL STUDY ON IMMUNITY TO MEASLES AND MUMPS IN NORTHERN GREEK CHILDREN
Submitted by Katerina Haidopoulou
Katerina Haidopouloua, Asimina Fylaktoub, Myrofora
Goutakia, Aikaterini Papadimitrioub, Serafeia
Kalamitsoua, George Varlamisa
aFourth Pediatric Department, School of Medicine, and bMicrobiology-Virology-Biochemistry Department,
Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
INTRODUCTION:Routine immunization against mea- sles and mumps has substantially reduced the number of these infections annually. However, outbreaks have been reported recently, even in highly vaccinated pop- ulations.
OBJECTIVE: Our goal was to determine the levels of serum antibodies against measles and mumps in a pop- ulation of children who were vaccinated against mea- sles-mumps-rubella (MMR).
METHODS: The study population consisted of 260 healthy children (aged 15 months to 14.5 years) who were separated into 2 groups according to the number of MMR vaccine doses previously administered: groups A (1 dose) and B (2 doses). Immunoglobulin G (IgG) and IgM antibody levels for measles and mumps were deter- mined in blood serum by the enzyme-linked immu- nosorbent assay (Genzyme Virotech, Ru¨sselsheim, Ger- many) semiquantitive method.
RESULTS: Groups A and B consisted of 53 children aged 15 months to 8 years and 207 children aged 5 to 14.5 years old, respectively. A majority (93.08%) of the children were protected against measles. Group A and B protection rates were similar (92.27% and 96.23%, re- spectively). Although most of the children were pro- tected against mumps, the total protection rate was sig- nificantly less (81.92%) (P ⬍.01). The protection rate against mumps in group A was significantly lower than that in group B (67.92% vs 85.51%;P⬍.03).
CONCLUSIONS: Our results indicate high protection rates against measles conferred even by a single dose of the MMR vaccine. A respected percentage of the chil- dren were found to be susceptible to mumps even after completion of a 2-dose immunization schedule. Primary vaccine failure may be implicated as a cause of recent mumps outbreaks, but additional studies are needed.
COMPARISON OF PEDIATRIC LOGISTIC ORGAN DYSFUNCTION (PELOD) SCORE AND PEDIATRIC RISK OF MORTALITY (PRISM) III AS A MORTALITY PREDICTOR IN PATIENTS WITH DENGUE SHOCK SYNDROME
Submitted by Henny R. Iskandar
Henny R. Iskandar, Dharma Mulyo, Praptiwi Agnes, Yuliatmoko Suryatin
Pediatric Intensive Care Unit, Children’s and Maternity Harapan Kita Hospital, Jakarta, Indonesia
INTRODUCTION:The mortality rate for dengue shock syndrome (DSS) in the PICU at Children’s and Maternity Harapan Kita Hospital is still high (13.2%).
OBJECTIVE:We evaluated performance of the Pediat- ric Logistic Organ Dysfunction (PELOD) score compared with the Pediatric Risk of Mortality III (PRISM III) for predicting mortality in our PICU.
METHODS: A total of 42 patients (48% boys, 52% girls) admitted to the PICU from January to December 2006 were enrolled onto the study. Diagnosis of DSS was made according to 1997 World Health Organization cri- teria and confirmed with serologic-positive dengue blot taken on the fifth day of fever (93% secondary infection and 7% primary infection). PELOD and PRISM scores were evaluated on the first day.
RESULTS: From 42 admissions, 1 was excluded for insufficient data. Median age of the children was 7 years. Death occurred in 11.9% of the patients with DSS. Anal- ysis showed that the mean PELOD score was 7.2 (Mann- WhitneyUtest between survivors and nonsurvivors was significant at P ⫽ .001) compared with the PRISM III (mean score was significant also atP ⫽ .008). The re- ceiver operating characteristic curves for the PELOD and PRISM III were 0.954 and 0.868, respectively.
CONCLUSIONS:PELOD and PRISM III scores showed a good discrimination for predicting mortality in patients with DSS in our PICU.
MIDDLE-EAR FLUIDSTREPTOCOCCUS
PNEUMONIAESUSCEPTIBILITY AND SEROTYPE AND DISTRIBUTION IN MEXICAN CHILDREN WITH ACUTE OTITIS MEDIA
Submitted by Claudia Lopez-Enriquez Claudia Lopez-Enriqueza, A. Blanco-Monteroa, L. E.
Espinosa-Monterosb, R. Rodriguezc, C. De La Torred,
D. Gomez-Barretob
aHospital Espanol de Mexico, Mexico City, Mexico;bHospital General Manuel Gea Gonzalez, Mexico City, Mexico; cSecretaria de Salud, Cuauhte´moc, Mexico;dHospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
INTRODUCTION: Acute otitis media (AOM) is the most common microbial respiratory tract infection in early childhood: Streptococcus pneumoniae is a common pathogen isolated from patients with AOM. The Amer- ican Academy of Pediatrics advises immunization with a 7-valent pneumococcal conjugate vaccine for children with recurrent AOM.
OBJECTIVE:We aimed to establish the most common S pneumoniaeserotypes present in the middle-ear fluid of Mexican children with AOM and to analyze antimicro- bial susceptibility patterns and assess the potential pro- tection provided by the new conjugated S pneumoniae vaccines.
METHODS: During 2002 and 2003, 72 S Pneumoniae isolates were obtained from 138 Mexican children with AOM. Serotyping distribution was performed by the quellung reaction with antisera from Statens Serum In- stitute (Copenhagen, Denmark). Tests for susceptibility were performed by using the agar-dilution method ac- cording to Clinical and Laboratory Standards Institute protocol for 18 antibiotics.
RESULTS: The most common S pneumoniaeserotypes isolated were 6B and 19F (16.67% each) and 6A, 14, and 23F (15.27% each). The overall rate of resistance (defined as the rate of intermediate resistance plus the rate of resistance) for penicillin was 65.38% (intermedi- ate and resistant categories were 29.17% and 36.11%, respectively), for cefotaxime was 19.45%, for azithro- mycin and erythromycin was 23.61%, for trimethoprim/ sulfamethoxazole was 61.11%, for amoxicillin was 5.5%, and for clindamycin was 12.5%. With amoxicil- lin/clavulanate, ceftriaxone, imipenem, meropenem, teicoplanin, telithromycin, and vancomycin, we found susceptibility for 100% of the isolates. The most com- mon resistant serotypes were 19F and 23F.
CONCLUSIONS: The serotype distribution of S pneu- moniaethat causes pediatric AOM in Mexico is similar to that reported from developed countries. The current heptavalent pneumococcal conjugate vaccine covers 63.89% of AOM episodes in Mexican children.
ROLE OF THROMBOMODULIN IN DETECTION OF ENDOTHELIAL CELL DESTRUCTION AFTER INFECTION WITH FALCIPARUM AND TERTIAN MALARIA Submitted by Max Mantik
Max Mantik, Tonny Rampengan, Mariane Kilis, Josef Tuda
Department of Pediatrics, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
INTRODUCTION:Thrombomodulin is an endothelial cell receptor for thrombin. In tropical and tertian ma- laria, thrombomodulin is secreted after endothelial cell
destruction after infections with Plasmodium falciparum orPlasmodium vivax.
OBJECTIVE: Our goal was to investigate whether thrombomodulin levels can be used to detect the endo- thelial cell destruction after tropical or tertian malaria and whether thrombomodulin is related to the severity of tropical malaria.
METHODS: This was a cross-sectional observational analytical study conducted in 5 hospitals in north Su- lawesi, Indonesia, from June to September 2006, in patients aged 2 to 13 years with tropical or tertian ma- laria. Thrombomodulin levels were determined with an enzyme-linked immunosorbent assay using a thrombo- modulin kit (Fujirebio Diagnostics, Inc, Malvern, PA). Data were analyzed by independentttest and Spearman rank correlation coefficient.
RESULTS: For 30 patients with tropical malaria (thrombomodulin level: 0.060 – 0.180 FU/mL) and 2 pa- tients with tertian malaria (thrombomodulin level: 0.068 – 0.075 FU/mL), there was a significant difference int-test results between tropical and tertian malaria (P⫽ .044). For 11 patients with severe malaria (thrombo- modulin level: 0.086 – 0.162 FU/mL), there was also a very significant difference in t-test results for compli- cated and uncomplicated tropical malaria (P ⫽ .009). The Spearman rank test showed significant positive cor- relation between thrombomodulin and parasitemia lev- els (rs⫽0.686;P⫽.001).
CONCLUSIONS:Thrombomodulin levels can be used to detect endothelial cell destruction in malaria; the thrombomodulin level in tropical malaria was found to be higher than that of tertian malaria. Thrombomodulin levels were very significantly different in complicated and uncomplicated tropical malaria and also correlated significantly with the degree of parasitemia.
ROTASCORE STUDY: EPIDEMIOLOGICAL OBSERVATIONAL STUDY OF ACUTE GASTROENTERITIS WITH OR WITHOUT ROTAVIRUS IN GREEK CHILDREN YOUNGER THAN 5 YEARS
Submitted by Vassiliki Papaevangelou Vassiliki Papaevangeloua, Ioannis Kavaliotisb, Heleni
Kokoric, Lito Mantagoud, Georgios Trimise, Vithleem
Papadopouloub, Georgios Niotakisc, Nikoleta
Nikolakopouloud, Andreas Konstantopoulosa
aSecond Pediatric Department, Children’s Hospital Aglaia Kiriakou, Athens University, Athens, Greece;bPediatric Department, Thessaloniki Hospital of Infectious Diseases, Thessaloniki, Greece;cSecond Pediatric Department, Venizelio Hospital, Heraklion, Crete, Greece;dPediatric Department, Patras University, University Hospital of Rio, Patras, Greece; eFirst Pediatric Department, Agia Sophia Children’s Hospital, Athens University, Athens, Greece
INTRODUCTION: Pediatric rotavirus gastroenteritis (PRG) is the most frequent cause of severe acute gastro- enteritis (AGE) in children up to 5 years of age world- wide.
OBJECTIVE:We sought to determine the proportion of PRG and compare its clinical burden to that of AGE caused by other pathogens.
METHODS: The study was conducted in 4 hospital emergency units (HEUs) and 50 private pediatric clinics between January and May 2006. Children up to 5 years of age were included. A rapid stool immunochromato- graphic test for rotavirus antigen detection was per- formed. Symptom-severity scores were calculated by us- ing the Clark scale.
RESULTS:Seven hundred and six children participated in the study (median age: 20 months; 385 boys [54.5%]); 273 patients (38.6%) visited HEUs, and 433 (61.4%) visited private clinics. The proportion of PRG was 29% (95% confidence interval [CI]: 25.9%–32.6%) in the total study group, 18.3% (95% CI: 14.9%–22.3%) in private clinics, 45.7% (95% CI: 40.0%–51.7%) in HEUs, and 49.1% in hospitalized patients (95% CI: 42.3%–55.7%). Most children with PRG (71.7%) were between 6 months and 3 years old. Behavioral changes and signs of dehydration, weight loss, fever atⱖ38°C, diarrhea, and vomiting were more prevalent with PRG (P ⬍.01). In children with PRG, a higher incidence of moderate or severe gastroenteritis (P ⫽.013 and .021, respectively), hospitalization (P⫽.011), and need for a clinical reevaluation (P ⫽ .012) was observed, as was longer hospitalization (5.14⫾3.18 vs 3.69⫾2.25 days; P⫽.039).
CONCLUSIONS: PRG was responsible for nearly half the patients with AGE who visited HEUs or required hospitalization. Vaccination against rotavirus would help prevent this frequent and often severe disease.
DIAGNOSIS OF TUBERCULOSIS LYMPHADENITIS IN CHILDREN Submitted by Ileana Puiu
Ileana Puiu, Polixenia Stancu, Dumitru Bulucea, Carmen Niculescu, Veronica Elena Nicolescu, Felicia Stoian
Pediatrics Clinic, Tuberculosis Center, Emergency Clinical Hospital, University of Medicine and Pharmacy, Craiova, Romania
INTRODUCTION: Tuberculosis represents a major health problem, and the most frequent cause of ex- trapulmonary tuberculosis is tuberculous lymphadenitis.
OBJECTIVE: The aim of this study was to determine the relative contribution of tuberculous lymphadenitis as a cause of persistent cervical lymphadenopathy.
METHODS: Our study included 87 children (aged 6 months to 18 years) suffering from tuberculous lymph-
adenitis who were admitted to our tuberculosis center during a period of 10 years.
RESULTS: Our 10-year study of 1112 children with lymphadenopathy showed that tuberculous adenitis was encountered in 87 children (7.8%). The disease was present at all ages but was found more frequently be- tween the ages of 10 and 18 years (39.1%). The most common location was the anterior cervical space in 43 children (49.4%), followed by the axillary and supracla- vicular areas. Systemic clinical signs (fever, weight loss, tiredness, night sweats) were encountered by 69 chil- dren (79.3%). Granulomatous infection was confirmed in 19 children (21.8%) who had abnormal chest radio- graph findings. The diagnosis of tuberculous lymphade- nitis was based on histological demonstration of caseat- ing epithelioid cell granulomas in the specimen obtained by excision biopsy in 56 cases (64.3%). Tuberculin skin- test results were positive in 76 cases (87.3%). Positive family history of tuberculosis was discovered in 72 cases (82.7%).
CONCLUSIONS:In most cases, the diagnosis was es- tablished on the basis of the specific histopathological aspect, tuberculin skin-test result, positive family history of tuberculosis, and the abnormal chest radiograph find- ings.
SURVEILLANCE OF INFLUENZA IN CHILDREN YOUNGER THAN 5 YEARS IN A TERTIARY CARE HOSPITAL IN BANGKOK, THAILAND
Submitted by Piyarat Suntarattiwong Piyarat Suntarattiwonga, Parada Thongtipa, Chortip
Sian-norka, Pranee Thawatsuphab, Rungruang
Kitphatib, Tawee Chotpitayasunondha
aQueen Sirikit National Institute of Child Health, Ministry of Public Health, Bangkok, Thailand;
bDepartment of Medical Science, Ministry of Public Health, National Institute of Health, Bangkok, Thailand
INTRODUCTION: Influenza is a common febrile illness with a significant impact on the pediatric population. Few data regarding influenza in young children have come from tropical resource-limited