To assess the gross motor development of children with presumed congenital Zika virus (ZIKV) infection over the first 2 years of their lives.
Seventy-seven children were assessed at the median ages ...of 11, 18, and 24 months, using the evaluative instrument Gross Motor Function Measure (GMFM-66). At the third assessment, the children with diagnoses of cerebral palsy (CP) were classified by severity through the Gross Motor Function Classification System (GMFCS) and stratified by topography indicating the predominantly affected limbs. With these instruments in combination and using the motor development curves as reference, the rate of development and functional ability were estimated.
At 2 years of age, all children had the diagnosis of CP. Seventy-four (96.1%) presented gross motor skills similar to those of children aged 4 months or younger, according to the World Health Organization's standard. The GMFM-66 median score among the 73 (94.8%) children with quadriplegia and GMFCS level V showed significant change between 11 and 18 months (p < 0.001) and between 11 and 24 months (p < 0.001). No significant difference (p = 0.076) was found between 18 and 24 months.
Despite showing some gross motor progress during the initial 18 months of life, these children with presumed congenital ZIKV infection and CP experienced severe motor impairment by 2 years of age. According to the motor development curves, these children with quadriplegia have probably already reached about 90% of their motor development potential.
Zika virus (ZIKV) infection appeared in Brazil in 2015, causing an epidemic outbreak with increased rates of microcephaly and other serious birth disorders. We reviewed 102 cases of children who were ...diagnosed with microcephaly at birth and who had gestational exposure to ZIKV during the outbreak. We describe the clinical, neuroimaging, and neurophysiological findings. Most mothers (81%) reported symptoms of ZIKV infection, especially cutaneous rash, during the first trimester of pregnancy. The microcephaly was severe in 54.9% of the cases. All infants presented with brain malformations. The most frequent neuroimaging findings were cerebral atrophy (92.1%), ventriculomegaly (92.1%), malformation of cortical development (85.1%), and cortical⁻subcortical calcifications (80.2%). Abnormalities in neurological exams were found in 97.0% of the cases, epileptogenic activity in 56.3%, and arthrogryposis in 10.8% of the infants. The sensorineural screening suggested hearing loss in 17.3% and visual impairment in 14.1% of the infants. This group of infants who presented with microcephaly and whose mothers were exposed to ZIKV early during pregnancy showed clinical and radiological criteria for congenital ZIKV infection. A high frequency of brain abnormalities and signs of early neurological disorders were found, and epileptogenic activity and signs of sensorineural alterations were common. This suggests that microcephaly can be associated with a worst spectrum of neurological manifestations.
Community-acquired pneumonia (CAP) is the main cause of death in children under-5 years worldwide and Streptococcus pneumoniae is the most common bacterial agent. However, it is difficult to identify ...pneumococcal infection among children with CAP. We aimed to assess association between any cytokine/chemokine and pneumococcal infection in childhood CAP. Furthermore, we evaluated the diagnostic value of cytokine/chemokine for pneumococcal infection. This prospective study was conducted at an Emergency Room, in Salvador, Brazil. Children <5-years-old hospitalized with CAP in a 21-month period were evaluated. On admission, clinical and radiological data were collected along with biological samples to investigate 20 etiological agents and determine serum cytokines (interleukin (IL)-8, IL-6, IL-10, IL-1β, IL-12, TNF-α, IL-2, IL-4, IL-5, γ-interferon), and chemokines (CCL2, CCL5, CXCL9, CXCL10) concentration. From 166 patients with etiology detected, pneumococcal infection was detected in 38 (22.9%) cases among which the median IL-6(pg/ml) was 31.2 (IQR: 12.4–54.1). The other 128 cases had other causative agents detected (Haemophilus influenzae, Moraxella catarrhalis, atypical bacteria and viruses) with the median IL-6 concentration being 9.0 (IQR: 4.1–22.0; p < 0.001). The area under the ROC curve for IL-6 to predict pneumococcal CAP was 0.74 (95%CI: 0.65–0.83; p < 0.001). By multivariate analysis, with pneumococcal CAP as dependent variable, IL-6 was an independent predictor for pneumococcal infection (OR = 5.56; 95%CI: 2.42–12.75, cut-off point = 12.5 pg/ml; p = 0.0001). The negative predictive value of IL-6 under 12.5 pg/ml for pneumococcal infection was 90% (95%CI: 82–95%). Independently significant difference was not found for any other cytokines/chemokines. Serum IL-6 concentration on admission is independently associated with pneumococcal infection among children under-5 years hospitalized with CAP.
Childhood community-acquired pneumonia is a common and potentially life-threatening illness in developing countries. We assessed the prognostic value of serum procalcitonin level upon admission on ...clinical response to antibiotic treatment.
Out of 89 patients, the median (IQR) age was 19(12–29) months and 60% were boys. Viral (49.5%), typical bacterial (38%) and atypical bacterial (12.5%) infections as well as probable pneumococcal infections (26%) were diagnosed.
Seventy-five (84%) children became afebrile ≤48h after treatment. In 14 children who remained febrile after 48h of treatment, medianIQR serum procalcitonin (ng/ml) level on admission was higher than in those with rapid recovery (2.10.8–3.7 vs 0.60.1–2.2; P=0.025). In the slow-responding children, pneumococcal infections were more common (71% vs 17%; P<0.001). Procalcitonin concentrations on admission were higher in children with pneumococcal pneumonia compared to children with non-pneumococcal pneumonia (20.7–4.2 vs 0.50.08–2.1; P=0.002). The ROC curve found that <0.25ng/ml of serum procalcitonin had a high negative predictive value (93%95%CI:80%–99%) for pneumococcal infection. All children that remained febrile after 48h of treatment had procalcitonin >0.25ng/ml on admission. The majority of children with pneumonia in a developing country become afebrile within 48h after onset of antibiotic treatment.
Serum procalcitonin <0.25ng/ml predicted rapid clinical response and non-pneumococcal etiology.
•Serum PCT level on admission <0.25ng/ml predicts rapid response to treatment.•Serum PCT level on admission <0.25ng/ml also predicts nonpneumococcal infection.•This cutoff has a high negative predictive value for pneumococcal infection.•This cutoff could contribute to identify who would not benefit from antibiotic use.
•IL-6 was significantly higher among children with pneumococcal pneumonia.•IL-6 was significantly higher among children with pleural effusion.•IL-6 was independently associated with pleural effusion ...and pneumococcal infection.•High IL-6 is associated to pneumococcal infection if pleural effusion is absent.•IL-6 may be a pneumococcal infection biomarker if pleural effusion is absent.
Community-acquired pneumonia (CAP) diagnosis remains a challenge in paediatrics. Chest radiography is considered gold standard for definition of pneumonia, however no previous study assessed the relationship between immune response and radiographic-confirmed-pneumonia. We assessed association between cytokines/chemokines levels and radiographic abnormalities in children with CAP.
Children < 5-years-old hospitalized with CAP were investigated in a prospective study at the Federal University of Bahia Hospital, Brazil. On admission, clinical data and biological samples were collected to investigate 20 aetiological agents and determine serum cytokines/chemokines levels; chest radiographs were performed.
Among 158 patients, radiographic diagnosis of pneumonia was confirmed in 126(79.7%) and 17(10.8%) had pleural effusion. Viral, bacterial and pneumococcal infection were detected in 80(50.6%), 78(49.4%) and 37(23.4%) cases. By comparing the median concentrations of serum cytokines/chemokines between children with or without pleural effusion, interleukin(IL)-6 was higher (26.618.6–103.7 vs 3.00.0–19.8; p < 0.001) among those with pleural effusion; and between children with or without radiographic-confirmed-pneumonia, IL-6 was higher in the first subgroup (4.50.0–23.4 vs 0.00.0–3.6; p = 0.02) after having excluded cases with pleural effusion. Stratified analyses according to aetiology showed IL-6 increase in the radiographic-confirmed-pneumonia subgroup inside the pneumococcal infection (28.25.9–64.1 vs 0.00.0–0.0; p = 0.03) subgroup. By multivariable analysis, with IL-6 as dependent variable, pneumococcal infection and pleural effusion showed independent association with IL-6 elevation respective OR: 5.071 (95%CI = 2.226–11.548; p < 0.001) and 13.604 (95%CI = 3.463–53.449; p = 0.0001). Considering the cases without pleural effusion, the area under the curve of IL-6 to predict pneumococcal infection was 0.76 (95%CI = 0.66–0.86; p < 0.001).
IL-6 increase is a potential biomarker of pneumococcal infection among children with CAP without pleural effusion upon admission.
The role of chest radiograph (CXR) among children with community-acquired pneumonia is controversial. We aimed to assess if there is association between a specific etiology and radiologically ...confirmed pneumonia.
This was a prospective cross-sectional study. Based on report of respiratory complaints and fever/difficulty breathing plus the detection of pulmonary infiltrate/pleural effusion on the CXR taken upon admission read by the pediatrician on duty, children <5-year-old hospitalized with community-acquired pneumonia were enrolled. On admission, clinical data and biological samples were collected to investigate 19 etiological agents (11 viruses and 8 bacteria). CXR taken upon admission was independently read by a pediatric radiologist blinded to clinical data.
The study group comprised 209 cases with evaluated CXR and establishment of a probable etiology. Radiologically confirmed pneumonia, normal CXR and other radiographic diagnoses were described for 165 (79.0%), 36 (17.2%) and 8 (3.8%) patients, respectively. Viral infection was significantly more common among patients without radiologically confirmed pneumonia (68.2% vs. 47.9%; P = 0.02), particularly among those with normal CXR (66.7% vs. 47.9%; P = 0.04) when compared with patients with radiologically confirmed pneumonia. Bacterial infection was more frequent among cases with radiologically confirmed pneumonia (52.1% vs. 31.8%; P = 0.02). Likewise, pneumococcal infection was more frequently detected among children with radiologically confirmed pneumonia in regard to children with normal CXR (24.2% vs. 8.3%; P = 0.04). Sensitivity (95% confidence interval) of radiologically confirmed pneumonia for pneumococcal infection was 93% (80-98%), and negative predictive value (95% confidence interval) of normal CXR for pneumococcal infection was 92% (77-98%).
Bacterial infection, especially pneumococcal one, is associated with radiologically confirmed pneumonia.
To provide cutting‐edge information for the management of community‐acquired pneumonia in children under 5 years, based on the latest evidence published in the literature.
A comprehensive search was ...conducted in PubMed, by using the expressions: “community‐acquired pneumonia” AND “child” AND “etiology” OR “diagnosis” OR “severity” OR “antibiotic”. All articles retrieved had the title and the abstract read, when the papers reporting the latest evidence on each subject were identified and downloaded for complete reading.
In the era of largely implemented bacterial conjugate vaccines and widespread use of amplification nucleic acid techniques, respiratory viruses have been identified as the most frequent causative agents of community‐acquired pneumonia in patients under 5 years. Hypoxemia (oxygen saturation ≤ 96%) and increased work of breathing are signs most associated with community‐acquired pneumonia. Wheezing detected on physical examination independently predicts viral infection and the negative predictive value (95% confidence interval) of normal chest X‐ray and serum procalcitonin < 0.25 ng/dL was 92% (77‐98%) and 93% (90‐99%), respectively. Inability to drink/feed, vomiting everything, convulsions, lower chest indrawing, central cyanosis, lethargy, nasal flaring, grunting, head nodding, and oxygen saturation < 90% are predictors of death and can be used as indicators for hospitalization. Moderate/large pleural effusions and multilobar infiltrates are predictors of severe disease. Orally administered amoxicillin is the first line outpatient treatment, while ampicillin, aqueous penicillin G, or amoxicillin (initiated initially by intravenous route) are the first line options to treat inpatients.
Distinct aspects of childhood community‐acquired pneumonia have changed during the last three decades.
Fornecer informações de ponta para o manejo de crianças menores de cinco anos com pneumonia adquirida na comunidade, com base nas evidências mais recentes publicadas na literatura.
Uma pesquisa abrangente foi feita no PubMed, com as expressões: “community‐acquired pneumonia” + “child” + “etiology” ou “diagnosis” ou “severity” ou “antibiotic”. Todos os artigos encontrados tiveram o título e o resumo lidos e os artigos que relatavam as evidências mais recentes sobre cada assunto foram identificados e recuperados para leitura completa.
Na era das vacinas bacterianas conjugadas amplamente usadas e do uso difundido de técnicas de amplificação de ácidos nucléicos, os vírus respiratórios foram identificados como os agentes causadores mais frequentes de pneumonia adquirida na comunidade em pacientes com menos de cinco anos. A hipoxemia (saturação de oxigênio ≤ 96%) e o aumento do esforço respiratório são os sinais mais associados à pneumonia adquirida na comunidade. A sibilância detectada ao exame físico prediz de forma independente a infecção viral e o valor preditivo negativo (intervalo de confiança de 95%) da radiografia de tórax normal e a procalcitonina sérica < 0,25 ng/dL foi de 92% (77‐98%) e 93% (90‐99%), respectivamente. Incapacidade de beber e se alimentar, vomitar todo o alimento, convulsões, retração torácica subcostal, cianose central, letargia, aleteo nasal, estridor e saturação de oxigênio < 90% são preditores de óbito e podem ser usados como indicadores de hospitalização. Derrames pleurais moderados/grandes e infiltrados multilobulares são preditores de doença grave. A amoxicilina administrada por via oral é a opção de primeira linha para tratar pacientes ambulatoriais e a ampicilina ou penicilina cristalina G ou amoxicilina (administrada inicialmente por via intravenosa) são as opções de primeira linha para tratar pacientes hospitalizados.
Aspectos distintos da pneumonia adquirida na comunidade durante a infância mudaram durante as últimas três décadas.
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