Inborn Errors of Immunity in Children With Invasive Pneumococcal Disease: A Multicenter Prospective Study

BACKGROUND

In settings with universal conjugate pneumococcal vaccination, invasive pneumococcal disease (IPD) can be a marker of an underlying inborn error of immunity. The aim of this study was to determine the prevalence and characterize the types of immunodeficiencies in children presenting with IPD.

METHODS

Multicenter prospective audit following the introduction of routinely recommended immunological screening in children presenting with IPD. The minimum immunological evaluation comprised a full blood examination and film, serum immunoglobulins (IgG, IgA and IgM), complement levels and function. Included participants were children in whom Streptococcus pneumoniae was isolated from a normally sterile site (cerebrospinal fluid, pleura, peritoneum and synovium). If isolated from blood, features of sepsis needed to be present. Children with predisposing factors for IPD (nephrotic syndrome, anatomical defect or malignancy) were excluded.

RESULTS

Overall, there were 379 episodes of IPD of which 313 (83%) were eligible for inclusion and 143/313 (46%) had an immunologic evaluation. Of these, 17/143 (12%) were diagnosed with a clinically significant abnormality: hypogammaglobulinemia (n = 4), IgA deficiency (n = 3), common variable immunodeficiency (n = 2), asplenia (n = 2), specific antibody deficiency (n = 2), incontinentia pigmenti with immunologic dysfunction (n = 1), alternative complement deficiency (n = 1), complement factor H deficiency (n = 1) and congenital disorder of glycosylation (n = 1). The number needed to investigate to identify 1 child presenting with IPD with an immunologic abnormality was 7 for children under 2 years and 9 for those 2 years old and over.

CONCLUSIONS

This study supports the routine immune evaluation of children presenting with IPD of any age, with consideration of referral to a pediatric immunologist.

Not just a chalazion-focal eyelid and orbital infection with Saksaenea vasiformis in an immunocompetent child

We present the case of a 2-year-old immunocompetent boy who presented with subacute right-sided orbital cellulitis due to Saksaenea vasiformis infection. Initial differential diagnoses included chalazion and localized soft tissue malignancy. There was no history of trauma. Immunological review and investigations were unremarkable. He was treated with a total of 3 months of antifungal therapy. Following resolution, he had two episodes of spontaneously resolving localized eyelid erythema at 2 and 8 months.

Examining the interseasonal resurgence of respiratory syncytial virus in Western Australia

BACKGROUND

Following a relative absence in winter 2020, a large resurgence of respiratory syncytial virus (RSV) detections occurred during the 2020/2021 summer in Western Australia. This seasonal shift was linked to SARS-CoV-2 public health measures. We examine the epidemiology and RSV testing of respiratory-coded admissions, and compare clinical phenotype of RSV-positive admissions between 2019 and 2020.

METHOD

At a single tertiary paediatric centre, International Classification of Diseases, 10th edition Australian Modification-coded respiratory admissions longer than 12 hours were combined with laboratory data from 1 January 2019 to 31 December 2020. Data were grouped into bronchiolitis, other acute lower respiratory infection (OALRI) and wheeze, to assess RSV testing practices. For RSV-positive admissions, demographics and clinical features were compared between 2019 and 2020.

RESULTS

RSV-positive admissions peaked in early summer 2020, following an absent winter season. Testing was higher in 2020: bronchiolitis, 94.8% vs 89.2% (p=0.01); OALRI, 88.6% vs 82.6% (p=0.02); and wheeze, 62.8% vs 25.5% (p<0.001). The 2020 peak month, December, contributed almost 75% of RSV-positive admissions, 2.5 times the 2019 peak. The median age in 2020 was twice that observed in 2019 (16.4 vs 8.1 months, p<0.001). The proportion of RSV-positive OALRI admissions was greater in 2020 (32.6% vs 24.9%, p=0.01). There were no clinically meaningful differences in length of stay or disease severity.

INTERPRETATION

The 2020 RSV season was in summer, with a larger than expected peak. There was an increase in RSV-positive non-bronchiolitis admissions, consistent with infection in older RSV-naïve children. This resurgence raises concern for regions experiencing longer and more stringent SARS-CoV-2 public health measures.

Prevalence of Immunodeficiency in Children With Invasive Pneumococcal Disease in the Pneumococcal Vaccine Era: A Systematic Review

IMPORTANCE

Despite increasing access to vaccination, invasive pneumococcal disease (IPD) is responsible for approximately 826 000 deaths worldwide in children younger than 5 years each year. To allow early identification and prevention, an improved understanding of risk factors for IPD is needed.

OBJECTIVES

To review the literature on the prevalence of primary immunodeficiency (PID) in children younger than 18 years presenting with IPD without another predisposing condition and to inform guidelines for immunologic evaluation after the first episode of IPD based on published evidence.

EVIDENCE REVIEW

A literature search of PubMed, Embase (inception [1974] to February 28, 2019), and MEDLINE (inception [1946] to February 28, 2019) was conducted using the terms Streptococcus pneumonia, Streptococcus pneumoniae, pneumococcal infection, Streptococcus infection, pneumococcal meningitis, immunodeficiency, immune response, immunocompromised, susceptib*, precursor, predispose*, recurren*, newborn, neonat*, infan*, toddler, child, preschooler, adolescen*, and pediatric. Publications reporting original data on immunodeficiency in children with microbiologically confirmed primary or recurrent IPD were included. Strength of clinical data was graded according to the 5-point scale of the Oxford Centre for Evidence-Based Medicine.

FINDINGS

In 6022 unique children with primary IPD, 5 of 393 (1.3%) to 17 of 162 (10.5%) of all children and 14 of 53 (26.4%) of those older than 2 years had a PID identified. Higher rates of PID, up to 10 of 15 (66.7%), were found in children with recurrent IPD. Antibody deficiency was the most common immunodeficiency, followed by complement deficiency, asplenia, and rarer defects in T-cell signaling. The site of infection was a key indicator for the risk of underlying PID, with the greatest risk of PID in children with meningitis or complicated pneumonia.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that invasive pneumococcal disease, and particularly recurrent IPD, is an important marker of underlying PID in children without other risk factors. The findings also suggest that children older than 2 years with pneumococcal meningitis or complicated pneumonia and all children with recurrent IPD should be referred for an immune evaluation.

TRIAL REGISTRATION

PROSPERO identifier: CRD42017075978.

Does increased nerve length within the treatment volume improve trigeminal neuralgia radiosurgery? A prospective double-blind, randomized study

PURPOSE

To test the hypothesis that increasing the nerve length within the treatment volume for trigeminal neuralgia radiosurgery would improve pain relief.

METHODS AND MATERIALS

Eighty-seven patients with typical trigeminal neuralgia were randomized to undergo retrogasserian gamma knife radiosurgery (75 Gy maximal dose with 4-mm diameter collimators) using either one (n = 44) or two (n = 43) isocenters. The median follow-up was 26 months (range 1-36).

RESULTS

Pain relief was complete in 57 patients (45 without medication and 12 with low-dose medication), partial in 15, and minimal in another 15 patients. The actuarial rate of obtaining complete pain relief (with or without medication) was 67.7% +/- 5.1%. The pain relief was identical for one- and two-isocenter radiosurgery. Pain relapsed in 30 of 72 responding patients. Facial numbness and mild and severe paresthesias developed in 8, 5, and 1 two-isocenter patients vs. 3, 4, and 0 one-isocenter patients, respectively (p = 0.23). Improved pain relief correlated with younger age (p = 0.025) and fewer prior procedures (p = 0.039) and complications (numbness or paresthesias) correlated with the nerve length irradiated (p = 0.018).

CONCLUSIONS

Increasing the treatment volume to include a longer nerve length for trigeminal neuralgia radiosurgery does not significantly improve pain relief but may increase complications.

High-dose trigeminal neuralgia radiosurgery associated with increased risk of trigeminal nerve dysfunction

OBJECTIVE

Stereotactic radiosurgery is being used with more frequency in the management of patients with trigeminal neuralgia. To improve facial pain outcomes, many centers have increased the prescribed radiation dose to the trigeminal nerve.

METHODS

Between April 1997 and December 1999, 68 patients underwent radiosurgery for trigeminal neuralgia with use of the Leksell gamma knife (Elekta Instruments, Norcross, GA) and a single 4-mm isocenter of radiation. Twenty-seven patients (40%) received 70 Gy (low dose) of irradiation and 41 patients (60%) received 90 Gy (high dose). The groups were similar with regard to age, sex, duration of pain, number of prior surgeries, and preexisting trigeminal deficits. The primary facial pain outcomes for analysis were excellent (pain-free, no medications) and good (pain-free, reduced medications). The mean length of follow-up after radiosurgery was 14.4 months (range, 2-36 mo).

RESULTS

At last follow-up examination, 11 (41%) of the 27 patients with low-dose radiosurgery remained pain-free compared with 25 (61%) of the 41 patients with high-dose radiosurgery (P = 0.17). Additional surgery was performed in 12 low-dose patients (44%) and 8 high-dose patients (20%) (P = 0.05). High-dose radiosurgery was associated with an increased rate of permanent trigeminal nerve dysfunction (54% versus 15%, P = 0.003). Bothersome dysesthesias occurred in 13 high-dose patients (32%), whereas only 1 low-dose patient had this complication (P = 0.01). Three high-dose patients (8%) developed corneal numbness after radiosurgery. Pain recurred with more frequency in patients not developing trigeminal nerve dysfunction after radiosurgery (9 of 22 patients, 41 %) compared with those who sustained facial numbness, paresthesias, or dysesthesias (4 of 27 patients, 15%); however, the difference was not statistically significant (P = 0.08).

CONCLUSION

Higher doses of radiation may correlate with better facial pain outcomes after radiosurgery for trigeminal neuralgia. However, the incidence of significant trigeminal nerve dysfunction is markedly increased after radiosurgery for patients receiving high-dose radiosurgery. Because of the nonselective nature of this ablative technique, dose prescription should be limited to less than 90 Gy.

Development of a model to predict permanent symptomatic postradiosurgery injury for arteriovenous malformation patients. Arteriovenous Malformation Radiosurgery Study Group

PURPOSE

To better predict permanent complications from arteriovenous malformation (AVM) radiosurgery.

METHODS AND MATERIALS

Data from 85 AVM patients who developed symptomatic complications following gamma knife radiosurgery and 337 control patients with no complications were evaluated as part of a multi-institutional study. Of the 85 patients with complications, 38 patients were classified as having permanent symptomatic sequelae (necrosis). AVM marginal doses varied from 10-35 Gy and treatment volumes from 0.26-47.9 cc. Median follow-up for patients without complications was 45 months (range: 24-92).

RESULTS

Multivariate analysis of the effects of AVM location and the volume of tissue receiving 12 Gy or more (12-Gy-Volume) allowed construction of a significant postradiosurgery injury expression (SPIE) score. AVM locations in order of increasing risk and SPIE score (from 0-10) were: frontal, temporal, intraventricular, parietal, cerebellar, corpus callosum, occipital, medulla, thalamus, basal ganglia, and pons/midbrain. The final statistical model predicts risks of permanent symptomatic sequelae from SPIE scores and 12-Gy-Volumes. Prior hemorrhage, marginal dose, and Marginal-12-Gy-Volume (target volume excluded) did not significantly improve the risk-prediction model for permanent sequelae (p >/= 0.39).

CONCLUSION

The risks of developing permanent symptomatic sequelae from AVM radiosurgery vary dramatically with location and, to a lesser extent, volume. These risks can be predicted according to the SPIE location-risk score and the 12-Gy-Volume.

Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis

OBJECTIVE

To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization.

MATERIAL AND METHODS

The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case.

RESULTS

Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve.

CONCLUSION

Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.