Dosage de la procalcitonine et bronchiolites vues dans un service d’accueil des urgences pédiatriques

Hepatic involvement in children with acute bronchiolitis

BACKGROUND

Respiratory syncytial virus (RSV) is a prevalent cause of lower respiratory tract infections. It may be associated with hepatocellular involvement, as indicated by increased liver enzymes aspartate aminotransferase and alanine transaminase (ALT).

AIM

To evaluate the rate of increased liver enzyme levels in children with acute bronchiolitis and correlate them with clinical, laboratory, and radiological variables.

METHODS

The study was a retrospective review of the medical records of children who presented with acute bronchiolitis when admitted to the Pediatric Department, Salmaniya Medical Complex, the Kingdom of Bahrain, between 2019 and 2020. We collected the demographic data, the clinical presentation, the laboratory and radiological findings, and the clinical outcomes. We compared the patients with elevated liver enzymes to those with normal levels at the time of presentation and at follow-up.

RESULTS

We included 166 (57.8%) of 287 patients with acute bronchiolitis who fulfilled the inclusion criteria. Ninety-three (56%) patients were males. The median age at presentation was 3.4 (interquartile range 1.1 to 12.4) mo. Fifty-four (28%) patients tested positive for RSV, which was confirmed in 15 of them (28%) by PCR. Laboratory findings of 161 patients tested at presentation showed high ALT levels in 14 (8.7%) patients and normal ALT in 147 (91.3%). Coagulation profiles were measured in 46 (27.7%) of 166 patients. High prothrombin time was present in 15 (32.6%), a high international normalized ratio was present in 13 (28.3%), and high activated partial thromboplastin time was present in three (6.5%). Thrombin time was elevated in nine (27.3%) of 33 patients. Five (21.7%) of 23 patients with available radiological data had hepatomegaly; one of them had findings suggestive of fatty infiltration. High ALT had a significant association with lengthy hospital stays (P < 0.05) and positive urine culture (P < 0.05). Seventy (42.2%) patients had documented follow-up with liver function tests over a median follow-up period of 10.2 (IQR, 2.4-23.3) mo. Total serum protein and serum globulin levels were normalized at the follow-up time, with a significant P value of < 0.05.

CONCLUSION

This study showed a low prevalence of liver function involvement in patients with acute bronchiolitis with a benign course. However, there was a rising trend in ALT during follow-up. Prolonged hospital stay and positive urine cultures were associated with elevated liver enzymes.

C-Reactive Protein Levels in Children with Acute Bronchiolitis

Background and Objectives. Acute bronchiolitis is a common respiratory disease in children. C-reactive protein (CRP) is an indicator of bacterial coinfection. This study is aimed at assessing the frequency of elevated CRP in children with acute bronchiolitis and at comparing the clinical characteristics, laboratory and radiological findings, antibiotics use, and outcome according to CRP levels. Material and Methods. We retrospectively reviewed medical records of children with acute bronchiolitis admitted to Pediatric Department, Salmaniya Medical Complex, Bahrain, in 2019-2020. Demographic, clinical, laboratory and radiological data, and outcomes were collected. Patients with high CRP were compared with those with normal levels. Results. Of 287 patients, 229 (79.2%) were included. 132 (57.6%) were males. Median presentation age was 3.7 (interquartile range (IQR), 1.27-12.33) months. Median CRP level was 10.4 (IQR, 2.8-35.1) mg/L. CRP was high in 167 (72.9%) patients. 17.6% (33/187 patients) had confirmed bacterial coinfection. Respiratory syncytial virus (RSV) was detected in 84 (36.7%) patients. Mean CRP level was higher in RSV-negative compared to RSV-positive patients, $31.3\pm 44.3$ versus $21.5\pm 27.7\text{mg}/\text{L}$ , respectively ( $P=0.042$ ). Respiratory viral serology profile was positive in 34.7% (17/49 patients). 66.9% (107/160 patients) had positive chest X-ray. Antibiotics were used in 78.1% (179/227 patients). Thirteen (5.7%) patients required intensive care, five (2.2%) had surgical intervention, four (1.8%) required endotracheal intubation, and four (1.8%) died. Patients with high CRP were older at presentation ( $P<0.0001$ ) and had more fever ( $P<0.0001$ ) and cough ( $P=0.002$ ), but lower hemoglobin level ( $P<0.0001$ ) compared to those with normal CRP. Fever ( $P=0.016$ ) and hemoglobin level ( $P=0.002$ ) were independent factors. Conclusion. Most children with acute bronchiolitis had high rate of elevated CRP values that did not correlate with the rate of bacterial coinfection. High CRP levels were found in older children, those presented with more fever and cough, and had a lower hemoglobin level despite that those factors were previously reported to be associated with disease severity and bacterial coinfection. This study also showed a high overall rate of antibiotic prescriptions in mostly viral disease.

Diagnostic accuracy of procalcitonin for bacterial pneumonia in children - a systematic review and meta-analysis

Objective: The predictive role of procalcitonin for childhood bacterial pneumonia, a leading cause of death, is unclear. We aimed to evaluate the diagnostic accuracy of procalcitonin for childhood bacterial pneumonia.Methods: Major bibliographic databases were searched from inception through September 2019 using pre-defined index terms, including 'procalcitonin,' 'pneumonia' and 'children'. The study is reported according to Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies. Meta-analyses of the diagnostic accuracy and odds ratio of procalcitonin for bacterial pneumonia were conducted along with subgroup analyses for different cut-offs of procalcitonin. The Quality Assessment of Diagnostic Accuracy Studies 2 instrument was used to assess the methodologic quality of eligible studies.Results: Twenty-five studies (with 2,864 patients) showed that procalcitonin for bacterial pneumonia had an overall sensitivity of 0.64 (95% confidence interval: 0.53-0.74), specificity of 0.72 (95% confidence interval: 0.64-0.79), positive likelihood ratio of 2.3 (95% confidence interval: 1.8-3.0) and negative likelihood ratio of 0.50 (95% confidence interval: 0.38-0.66), and Area Under the Receiver Operating Characteristics of 0.74 (95% confidence interval: 0.70-0.78). Using a cut-off of 0.5 ng/ml, Procalcitonin had a sensitivity of 0.68 (95% confidence interval: 0.50-0.82), specificity of 0.60 (95% confidence interval: 0.47-0.72), and Area Under the Receiver Operating Characteristics of 0.68 (95% confidence interval: 0.64-0.72). Using a cut-off of 2 ng/ml, procalcitonin had a sensitivity of 0.59 (95% confidence interval: 0.40-0.76), specificity of 0.71 (95% confidence interval: 0.58-0.81), and AUROC curve of 0.71 (95% confidence interval: 0.67-0.75). Elevated procalcitonin was not associated with increased odds of bacterial pneumonia (odds ratio: 1.36, 95% confidence interval: 0.81-1.92, p = .18). Quality assessment found minimal concerns for bias or applicability.Conclusions: Given the moderate diagnostic accuracy of procalcitonin for bacterial pneumonia, we recommend that procalcitonin be used in conjunction with other findings for management and disposition of children with pneumonia.