Severe atypical Lemierre syndrome caused by methicillin-sensitive Staphylococcus aureus: Two pediatric case reports

BACKGROUND

Lemierre syndrome is typically associated with ear, nose, and throat (ENT) infections caused by Fusobacterium necrophorum. Since 2002, cases of atypical Lemierre-like syndrome secondary to Staphylococcus aureus have been reported.

CASES

We report two pediatric cases of atypical Lemierre syndrome with a similar presentation: exophthalmia, absence of pharyngitis, metastatic lung infection, and intracranial venous sinus thrombosis. Both patients had a favorable outcome following treatment with antibiotics, anticoagulation, and corticosteroids.

CONCLUSION

Regular therapeutic monitoring of antibiotic levels helped to optimize antimicrobial treatment in both cases.

Two pediatric cases of multisystem inflammatory-like syndrome following COVID-19 vaccination

Multisystem inflammatory syndrome in children (MIS-C) is a novel post-infectious disease occurring in the context of SARS-CoV2 infection. COVID-19 vaccines have been authorized since December 2020, and adverse events including myocarditis have been reported following vaccination. We describe the cases of two pediatric patients presenting with clinical and laboratory features suggestive of MIS-C a few days after receiving their first dose of the Pfizer BNT162b2 vaccine. The outcome was favorable for both patients (after corticosteroid and immunoglobulin administration for one patient). These cases suggest an association between the COVID-19 vaccine and the occurrence of MIS-C.

Symptoms of emotional difficulties and hyperactivity/inattention among children during the COVID-19 epidemic and associated lockdown: data from the SAPRIS project

Background

COVID-19 limitation strategies led to widespread school closures around the world. The present study aims to provide a description of children's mental health and associated factors during the COVID-19 school closure in France.

Methods

We conducted a cross-sectional analysis in the SAPRIS study during the COVID-19 pandemic in France, relying on 2 ongoing national birth cohorts, ELFE and EPIPAGE 2. Using weighted multinomial logistic regression models, we estimated associations between children's mental health (i.e., hyperactivity/inattention and emotional symptoms; assessed by the Strengths and Difficulties Questionnaire), children's health behaviors, schooling, as well as sociodemographic and socioeconomic characteristics of children family.

Results

The sample consisted of 5702 children aged 8 - 9 years and 49.3% girls. Sleep disturbance and parents' dominant socio-professional category were associated with both hyperactivity-inattention (adjusted Odds Ratio (aOR)=2.10 95%Confidence Interval [1.85-2.38]; aOR=0.45 [0.33-0.61] respectively) and emotional symptoms and (aOR=6.33 [5.26-7.63]; aOR=0.62 [0.39-0.98] respectively). Specifically associated with hyperactivity/inattention were: male sex (aOR=2.51 [2.24-2.82]), presence of regular care and its pursuit during school closure (aOR=1.69 [1.33-2.15]), emotional symptoms (aOR=2.74 [2.23-3.37]), school situation (aOR=2.19 [1.69-2.82]), presence of tutoring and difficulties with it (aOR=2.56 [2.13-3.08]), type of housing (aOR=0.79 [0.70-0.89]). Factors associated with emotional symptoms were: presence of covid cases in the household (aOR=2.33 [1.92-2.82]), hyperactivity/inattention (aOR=2.94 [2.45-3.52]) and financial difficulties (aOR=1.71 [1.39-2.11]).

Conclusions

Policy makers need to balance pros and cons of closing schools, taking into consideration educational and psychological consequences for children and the various factors associated with mental health.

The challenging management of a series of 43 infants with Netherton syndrome: unexpected complications and novel mutations

BACKGROUND

Netherton syndrome (NS) is a rare disease caused by SPINK5 mutations, featuring variable skin and hair involvement and, in many cases, allergic manifestations with a risk of lethality, particularly in infants. The clinical management of NS is challenging.

OBJECTIVES

To analyse the clinical manifestations of a cohort of infants with NS managed in a reference centre and to draw up recommendations for management.

METHODS

We conducted a monocentric analysis of patients with NS. The inclusion criteria were management in our reference centre, a histologically or molecularly confirmed diagnosis of NS and available epidemiological, clinical and laboratory data.

RESULTS

A total of 43 patients with NS were included. Hypernatraemia was reported in 23 cases (54%) and associated with a greater likelihood of enteral and/or parenteral nutritional support (P < 0.001). Moreover, hypernatraemia was more frequent in patients with skin manifestations at birth (P = 0.026) and in patients bearing the c.153delT mutation in SPINK5 exon 3 (P = 0.014). The need for enteral and/or parenteral nutritional support was associated with a history of hypernatraemic dehydration (P < 0.001). Several unexpected extracutaneous complications were recorded, and new mutations were reported. The death rate (9% overall) was higher among the subset of patients bearing the c.153delT deletion.

CONCLUSIONS

Our data emphasize that neonatal NS is a severe and sometimes lethal multisystem disorder. Patients have a high risk of variable metabolic anomalies (i.e. lethal hypernatraemia) and therefore have major nutritional needs. Cases of NS associated with c.153delT are particularly severe. Unexpected clinical manifestations broadened the phenotypic spectrum of NS. We provide recommendations on the management of the life-threatening manifestations of NS in neonates based on our multidisciplinary experience.

Severe and fatal forms of COVID-19 in children

Objectives

The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes.

Methods

This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included.

Results

We analyzed the data of 27 children. Comorbidities (n = 19, 70%) were mainly neurological (n = 7), respiratory, (n = 4), or sickle cell disease (n = 4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n = 9), catecholamine (n = 4), erythropheresis (n = 4), renal replacement therapy (n = 1), and extracorporeal membrane oxygenation (n = 1). Five children died, of whom three were without past medical history.

Conclusion

This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children.

Population pharmacokinetics of cefazolin in critically ill children infected with methicillin-sensitive Staphylococcus aureus

OBJECTIVES

Cefazolin is one of curative treatments for infections due to methicillin-sensitive Staphylococcus aureus (MSSA). Both growth and critical illness may impact the pharmacokinetic (PK) parameters. We aimed to build a population PK model for cefazolin in critically ill children in order to optimize individual dosing regimens.

METHODS

We included all children (age < 18 years, body weight (BW) > 2.5 kg) receiving cefazolin for MSSA infection. Cefazolin total plasma concentrations were quantified by high-performance liquid chromatography. A data modelling process was performed with the software MONOLIX. Monte Carlo simulations were used in order to attain the PK target of 100% fT _> 4 ×MIC.

RESULTS

Thirty-nine patients with a median (range) age of 7 (0.1-17) years and a BW of 21 (2.8-79) kg were included. The PK was ascribed to a one-compartment model, where typical clearance and volume of distribution estimations were 1.4 L/h and 3.3 L respectively. BW, according to the allometric rules, and estimated glomerular filtration rate (eGFR) on clearance were the two influential covariates. Continuous infusion with a dosing of 100 mg/kg/day to increase to 150 mg/kg/day for children with a BW < 10 kg or eGFR >200 mL/min/1.73m² were the best schemes to reach the PK target of 100% fT_> 4 ×MIC.

CONCLUSIONS

In critically ill children infected with MSSA, continuous infusion seems to be the most appropriate scheme to reach the PK target of 100 % fT _> 4 ×MIC in children with normal and augmented renal function.

[Pregnancy in patients with a history of ischaemic heart disease - Case series and literature review]

Heart diseases complicate 1 to 3% of pregnancies and are the leading cause of indirect maternal deaths. Prior ischaemic heart event in pregnant patients is increasing. Most knowledge is based on few reports and there are no French nor international recommendations about the specific management of these patients. The specificity of the management of these patients during pregnancy, delivery and post-partum depends on the severity of the prior cardiac event and its consequences. This will be illustrated by the report of four recent cases managed in our hospital. First patient had myocardial infarction with normal left ventricular ejection fraction (LVEF). Second patient had a Tako-Tsubo syndrome with LVEF 45%. Third patient had ischemic cardiopathy with LVEF 30%. Fourth patient had myocardial infarction with LVEF 20%. A multidisciplinary follow-up should be required, especially in patients with severe ventricular dysfunction. The risk of fetal growth restriction appears to be increased, suggesting that closer ultrasound monitoring is necessary.

[Should yellow fever vaccination be recommended during pregnancy or breastfeeding?]

Yellow fever vaccine is produced from a live attenuated virus that is contraindicated in case of immunodeficiency and subject to restrictions for pregnant or breastfeeding women. The purpose of this review of available information on yellow fever vaccination during pregnancy and breastfeeding is to assist physicians in making recommendations prior to departure to yellow-fever endemic zones. Regarding pregnancy, there is no evidence to support a major risk of yellow-fever-vaccine-related complications in mothers or children. Although this finding is reassuring, it should be underlined that most reported series have been small. Regarding breastfeeding, the risk was recently confirmed by a report describing vaccine-induced encephalitis occurring in an infant 8 days after primary vaccination of the mother. The final decision to vaccinate depends on whether or not the trip can be postponed. If travel is mandatory, vaccination may be recommended in pregnant women preferably during the first trimester since the immunological response appears to be better at that time. Antibody titer should be checked following delivery. During breastfeeding, vaccination may be performed but breastfeeding must be stopped during the postvaccinal viremia phase. Breastfeeding can be resumed after a 10-day period of formula feeding.

[Imported malaria: diagnostic traps and rapid tests]

Imported malaria is a disease prevalent in France: 6,000 to 8,000 cases a year, of which 15% are pediatric cases. Despite this high incidence, the diagnosis is often delayed. The patient may then evolve to a severe form. This diagnostic delay is due to non-specific clinical symptoms in children. The most common symptoms are fever and digestive disorders (diarrhea, vomiting). In the absence of thrombocytopenia, the laboratory tests are not very useful for diagnosis. Parasitological examinations are dependent on the experience of the biologist, particularly in cases of low parasitemia as those observed in children who have received partial chemoprophylaxis. The recent introduction of rapid tests based on the detection of Plasmodium proteins, allows emergency remedy to this problem. The blood smears remains the gold standard and has to be used to confirm the results of rapid tests. If rapid tests improve the detection of Plasmodium in 2009, it remains mandatory to evoke the diagnosis of malaria in any febrile child coming from an endemic area.

[Long-term clinical benefits of using active stents in diabetic patients: two year follow-up of a consecutive series of 122 patients]

The objective of our study is to evaluate the long-term results of coronary angioplasty using active stents in a population of diabetic patients. This is a single-centre study on a consecutive series of 122 diabetic patients (40% of them insulin dependent) who between January 2003 and June 2004 underwent angioplasty with implantation of an active stent (sirolimus Cypher(R) or paclitaxel Taxus(R)) for one or more de novo coronary lesions. The mean age was 66 +/- 10 years and a total of 171 coronary segments were treated. The lesions treated were complex (type B2 + C) in 69% of the cases, with a mean stent length of 21 +/- 15 mm and a mean stent diameter of 2.7 +/- 0.3 mm. Follow-up at two years for 119 patients (3 lost to follow-up) revealed a mortality rate of 4.2%, and a myocardial infarction rate of 7.5%. The rates for revascularisation of the target lesion and the target vessel were 11.4% and 17.8% respectively, with a rate of major cardiac events of 22.5%. During this period, 25.2% of the patients underwent revascularisation of at least one vessel. This study confirms the benefits of using active stents for revascularisation of the target lesion in diabetic patients. However, it serves as a reminder that the progression of coronary atheroma is global, and that the prognosis for these patients depends essentially upon managing risk factors, and particularly on controlling their diabetes.

[Mycotic coronary aneurysm with Escherichia coli sepsis: a case report]

We report the case of a patient who was admitted for acute coronary syndrom associated with fever originating from urinary tract. Coronary arteriography revealed a huge coronary aneurysm which ruptured a short time after diagnosis. After surgery, it was proven to be mycotic aneurysm related to Escherichia Coli sepsis.

[Benefit of hip ultrasound in management of the limping child]

OBJECTIVE

To evaluate the contribution of sonography of the hip in the management of nontraumatic limping in children.

PATIENTS AND METHODS

Prospective study including children consulting for nontraumatic limping (n=93). These children had a clinical examination, a biological and imaging workup (pelvis x-rays (n=88), initial sonograph of the hip (n=93), and follow-up sonograph of the hip (n=29)).

RESULTS

Ninety-three children (69 boys, 24 girls) aged from 10 months to 13 years (median, 4 years) were included and divided into two groups: The sensitivity and specificity of sonography in establishing a serious diagnosis was 57% and 59%, respectively.

CONCLUSION

The advantage of systematic hip sonography is challenged in this study because of low sensitivity and specificity. Its main advantage seems to be in its negative results, which prompt other investigations.

[Simultaneous outbreaks of rotavirus and respiratory syncytial virus in Paris: a 12-year survey]

OBJECTIVE

The authors had for aim to study the coincidence of RSV and rotavirus epidemic peaks in pediatric patients hospitalized in the Paris area.

METHODOLOGY

A retrospective hospital-based monocentric cohort study was made over a 12-year period (1993-2004). Clinical and laboratory findings were prospectively collected on admission.

RESULTS

Three thousand and four hundred ninety-six stool samples were positive for rotavirus; 3,507 nasopharyngeal aspirates were positive for RSV. The coincidence of epidemic peaks for both viruses in November, December, and January was observed during the 12 years of the study.

CONCLUSION

The exact coincidence of winter outbreaks of RSV and rotavirus is a characteristic of the Paris area. It contributes to increase overcrowding in pediatric units and nosocomial infections.

Pertussis in young infants: apnoea and intra-familial infection

This study investigated 41 infants, aged <4 months, who were hospitalised with symptoms compatible with pertussis. Of these, 16 had Bordetella pertussis infection confirmed by real-time PCR. For four of these 16 patients, the initial sample was PCR-negative, but samples collected 5-7 days after the onset of infection were PCR-positive. PCR was also positive with samples from 15/16 families and 20/41 household contacts. Nine of the 20 positive household contacts were asymptomatic. Among the 16 infants with proven pertussis, apnoea was more frequent than in a control group for whom PCR was negative with both children and household contacts (69% vs. 28%). It was concluded that real-time PCR performed with samples from household contacts facilitates the diagnosis of infants suspected clinically of having pertussis, thereby enabling earlier treatment.

[Distinction between bacterial and aseptic meningitis in children: refinement of a clinical decision rule]

OBJECTIVES

To refine and to re-validate the best current tool (the Nigrovic rule: ''outpatient management may be considered for children without seizure, blood neutrophil count>or=10,000/mm(3), positive cerebrospinal fluid -CSF- Gram-staining, CSF protein>or=80 mg/dl, or CSF neutrophil count>or=1,000/mm(3)'') proposed to distinguish between aseptic meningitis (AM) and bacterial meningitis (BM) in the emergency department.

METHODS

Children hospitalized for BM between 1995 and 2004, or AM between 2000 and 2004 were included, and randomly divided into derivation (111 children, 14 BM) and internal validation (57 children, 7 BM) sets. The Nigrovic rule was refined on the derivation set, introducing new variables (purpura, toxic appearance and high serum procalcitonin), changing variables thresholds (CSF protein) and withdrawing some variables (blood neutrophil count, CSF neutrophil count), according to previous results, with the aim to obtain 100% sensitivity user friendly tool. The refined rule was then applied on the internal validation set, stayed blinded during the derivation process.

RESULTS

The refined rule was: start antibiotics in case of seizure, purpura, toxic appearance, procalcitonin>or=0.5 ng/ml, positive CSF Gram-staining, or CSF protein>or=50 mg/dl. The refined rule had 100% sensitivity on the derivation and the internal validation sets (95% confidence interval 78-100, and 65-100, respectively) with 62 and 51% specificity, respectively.

CONCLUSION

The refined rule (called Meningitest) was a highly sensitive, specific and user friendly tool that could allow to safely avoid>50% a posteriori unuseful antibiotic treatments for patients with AM.

Tuberculose de l'enfant après contage familial : une expérience en pédiatrie générale

The heterogeneity of clinical presentations of children in contact with a tuberculous adult do not allow simple guidelines for treatment and exams. Indications of thoracic computed tomography (CT) in young children and the risk of a follow-up without antituberculous treatment are always discussed.

PATIENTS

Sixty-nine children, belonging to 50 families, living in close contact with an adult treated for tuberculosis were explored during 7 years in a General Pediatric Unit. A CT was performed in 51 patients.

RESULTS

Mantoux test was negative in 3/17 children with typical tuberculous disease on X-ray. When results of CT were compared with those of standard thoracic X-ray, a difference for the diagnosis of mediastinal adenopathies was found only in children younger than 5 years. Fifty-eight patients were given usual treatment of latent or patent tuberculosis if indicated, or a chemoprophylaxis. All of them had normal clinical and X-ray exam 2 to 4 years later. Eleven children, initially checked in an other unit, were given no treatment, but a follow-up was set up. However, after 6 to 24 months, 4/11 had a patent tuberculosis and 5/11 a latent tuberculosis, 6/9 being aged more than 3 years.

CONCLUSION

This study shows that risk of tuberculosis after familial contamination is high, and that the choice of absence of treatment with following re-evaluation, is sometimes questionable because families or doctors do not perform the prescribed follow-up. To perform systematically a thoracic CT, searching for mediastinal adenopathies, is useful only before the age of 5 years.

Clinical decision rules to distinguish between bacterial and aseptic meningitis

BACKGROUND

Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations.

AIMS

To evaluate the reproducibility and to compare the diagnostic performance of five clinical decision rules.

METHODS

All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to the patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity, and the greatest simplicity for a bedside application.

RESULTS

Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although three rules achieved 100% sensitivity (95% CI 84-100), one had a significantly lower specificity (13%, 95% CI 8-19) than those of the other two rules (57%, 95% CI 48-65; and 66%, 95% CI 57-73), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al (a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid (CSF) Gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper.

CONCLUSION

On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid two thirds of unnecessary antibiotic treatments and hospitalisations.

Delay in diagnosis of imported Plasmodium falciparum malaria in children

The study reported here prospectively evaluated the time-to-diagnosis of imported Plasmodium falciparum malaria in children in seven French pediatric emergency departments during a 1-week period. For the 29 patients included, the mean patient, doctor and total delays were 3.1, 1.5 and 4.7 days, respectively. The late medical diagnosis for 11 patients was mainly due to the treating physician's failure to consider malaria, despite having been informed that the child had been in an endemic area, and erroneously making a diagnosis of viral infection. The five patients who were diagnosed correctly without delay had higher mean platelet counts than the others (206,000 vs 118,541/mm(3); p=0.008). The results indicate that greater awareness of the risk of malaria in returning travelers may help reduce delays in diagnosis and its consequences.

[Acute or sub-acute thrombosis of steel stents]

The use of coronary endoprostheses has greatly contributed to the improvement in the results of coronary angioplasty. Nevertheless, the risk of stent thrombosis remains a major preoccupation. We studied a retrospective series of 2997 patients who had undergone coronary angioplasty between 1999 and 2003. 36 patients (1.2%) had an acute or sub-acute stent thrombosis, occurring in two thirds of cases in the first 4 days with particularly serious clinical consequences: 5 deaths (13.8%) and 27 myocardial infarctions (75%). A comparison between the 2 groups of patients with thrombosis (n = 36) and without thrombosis (n = 2961) using multivariate analysis determined predictive factors for thrombosis: systolic LV dysfunction < 40% (p < 0.0001 OR 3.8 [2-7.3]), angioplasty for lesions on the anterior interventricular artery (p < 0.0001 OR 2.7 [1.4-5]), angioplasty performed in the acute phase of MI (p < 0.05 OR 13.9 [6.7-29.2]), B2-type complex lesions (p < 0.01 OR 2.5 [1.3-5]), residual dissection at the dilated site (p < 0.02 OR 5.1 [1.4-18.2]). More than ever, acute thrombosis remains a topical subject. This study emphasises the incidence of steel stent thrombosis; the clinical consequences and the predictive factors for early occlusion.

[Mycoplasma pneumoniae, community-acquired pneumonia and asthma]

Mycoplasma pneumoniae is an intracellular pathogen, devoid of cell wall, able to invade airway epithelial cells. Infection may either remain asymptomatic or induce bronchitis and pneumonia. M. pneumoniae is the first-ranking aetiological agent of community-acquired pneumonias in children over five years of age. Clinical features are usually mild, but this should not preclude the initiation of a treatment, in order to avoid serious sequelae such as impairment of pulmonary gas exchange capacity. In children at high-risk of asthma, infection with M. pneumoniae can induce exacerbation. A survey was performed in children admitted to hospital Saint-Vincent-de-Paul (Paris) for an episode of severe asthma exacerbation with persistent hypoxemia. Mycoplasma infection was identified in 26% of children with a history of asthma and 50% of those for whom the exacerbation was the presenting manifestation of the disease. Furthermore, if the Mycoplasma infection was atypical, asthma exacerbation recurred within one month. M. pneumoniae should be considered not only as a preeminent agent of respiratory infection in children, but also as a triggering factor in exacerbation and even inception of asthma. As a consequence, it is mandatory to carefully search for and actively treat Mycoplasma infection in children.

[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]

OBJECTIVE

To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI).

METHODS

Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004.

RESULTS

The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004).

CONCLUSION

In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

Pneumonies communautaires et infection grippale

Children without chronic or serious medical conditions are at increased risk for hospitalization during influenza seasons, mainly with respiratory tract infections. But influenza virus infections frequently remain undiagnosed, even in hospitalized patients. We prospectively studied the rate of concomitant and preceding influenza infections in children hospitalized with a community acquired pneumonia (CAP).

POPULATION AND METHODS

All 1-15-year-old children with CAP requiring hospitalization between 1st April 2000 and 2002 had nasopharyngeal aspirate for viruses, immunofluorescence and serologies for respiratory pathogens. The peak of influenza IgG measured by complement fixation (CF) is transient, and a titer of 1/64 or more indicates an acute influenza infection in the preceding weeks. Children with chronic disease were excluded and a control group of patients from outpatient clinic was measured.

RESULTS

Among 33 previously healthy children (age 4.9 years, range 1.2-14 years), 8 had a pneumococcal pneumonia, 10 a pneumonia caused by Mycoplasma pneumoniae (MP), 1 by Chlamydia pneumonia, and 8 of unknown origin. In six patients immunofluorescence was positive: Respiratory Syncitial Virus, 2, Adenovirus, 1 and Influenza A, 3 (including a patient with concomitant MP infection). Thirteen of the 33 children (39.4%) had evidence of a recent influenza A infection with CF ab > or = 1/64: with pneumococcal pneumonia, 5/10 with MP pneumonia, 3/8 with unknown origin pneumonia, 9/13 of these previous influenza infections being clinically inapparent. Only 1/30 children of control group (3.3%) had CF ab > or = 1/64.

CONCLUSION

In this study, influenza infection is the direct cause of CAP of children in 12% of cases. In other children with CAP, 39.4% of patients had an influenza infection in the preceding weeks which leads to secondary infection caused by Streptococcus pneumoniae or by MP or other pathogens.

[Ciprofloxacin after clinical failure of beta-lactam antibiotics in children with salmonellosis]

BACKGROUND

Children with enteric fever or severe salmonella infections are usually treated with beta-lactam antibiotics, particularly ceftriaxone. Due to their poor penetration into cells, beta-lactam antibiotics, even if active in vitro, are sometimes clinically ineffective because they cannot reach the intracellular sites of Salmonella multiplication.

OBJECTIVES

To evaluate in a retrospective study usefulness, efficacy and safety of oral ciprofloxacin in patients with severe salmonellosis and clinical failure of ceftriaxone or beta-lactam antibiotics.

PATIENTS AND METHODS

From July 1, 1995 to 2000, the bacteriology laboratory of a French pediatric hospital had identified 215 patients aged between 1 month and 15 years with positive blood or stools for Salmonella sp, 113 of them requiring hospitalization due to their clinical symptoms. Three were excluded for sickle-cell disease or poor nutritional status. None of the 110 strains (including 4 S. typhi, 51 S. typhimurium, 25 S. enteritidis, 6 S. hadar and 5 S. heidelberg) isolated was resistant to ceftriaxone or ciprofloxacin. Forty-one of the 110 strains (37.3%) produced a beta-lactamase. Twelve patients had a rapid recovery without antibiotic treatment, and 98 (mean age 3.9 years) were given antibiotics (ceftriaxone in 91 and amoxicillin in 7) for dysentery (43%), shock (15%) or persistent high fever and severe diarrhea (42%).

RESULTS

In 72 children (mean age = 3.6 years) ceftriaxone treatment (amoxicillin in 5) for 5 or 7 days was rapidly effective: apyrexia was obtained in 1.5 day after the start of treatment and the number of stools per day was 4 or less in 2.2 days. Two to 3 weeks after clinical recovery, asymptomatic carriage was present in 22/38 patients. In the 26 other patients ceftriaxone (amoxicillin in 2) treatment was clinically ineffective, despite good in vitro activity, and was switch for oral ciprofloxacin (20 mg kg(-1) d(-1), 5 days) after 2 to 7 days of lasted fever and/or severe diarrhea. Clinical improvement with ciprofloxacin was obtained in less than 48 h. The strains involved in these 26 patients included the 4 S. typhi and 15 S. typhimurium (P < 0.05), 13/15 (P < 0.01) producing beta-lactamase. Asymptomatic carriage was found in 5/22 patients (P < 0.05) after recovery. None of the patient treated with ciprofloxacin had side effect.

CONCLUSION

In severe salmonellosis, the clinical failure of treatment with ceftriaxone is not rare, particularly in S. typhimurium producing beta-lactamase infection and short treatment with oral ciprofloxacin is safe and allows to obtain a rapid recovery.

Thrombocytopenia and Plasmodium falciparum malaria in children with different exposures

We studied thrombocytopenia during acute Plasmodium falciparum malaria in 64 traveller children from Paris (France), 85 children from Dakar (Senegal) with an intermittent exposure (69 with severe attack or cerebral malaria), and 81 children from Libreville (Gabon) with a perennial exposure (43 with severe attack or cerebral malaria). Initial thrombocytopenia was present in 43-58% of children with P falciparum malaria but was not more frequent in severe outcome or cerebral malaria. Low parasitaemia may lead to the misdiagnosis of malaria and delayed treatment when there is associated thrombocytopenia