Tuberculose em Idade Pediátrica: Experiência de 12 Anos num Centro Terciário de Referência em Portugal

Introduction: The diagnosis of tuberculosis in children is a challenge namely because extrapulmonary tuberculosis and severe disease are more frequent in this age group. The aim of this study was to evaluate and reflect about severe tuberculosis in pediatric age, in a metropolitan area of Lisbon.Material and Methods: Descriptive study about patients under 18 years of age admitted with tuberculosis disease in a tertiary pediatric hospital, from 2008 to 2019 (12 years).Results: We report 145 patients, average of 12 cases/year, with an increase in the last three years. Median age of 12.9 years, 42.8% born in Portuguese-speaking African countries and 20% had a chronic disease. The diagnosis was pulmonary tuberculosis in 52.4% (n = 76) and extrapulmonary tuberculosis in 47.6%: lymphatic (n = 26), skeletal (n = 15), miliary (n = 8), meningeal (n = 7), peritoneal/ intestinal (n = 6), pleural (n = 4), renal (n = 1), cutaneous (n = 1), thoracic wall (n = 1) and salivary glands (n = 1). The tuberculin test was positive in 78/99 (78.8%) and Interferon Gamma Release Assay in 61/90 (67.8%). In 20.7% (n = 30) acid-fast bacilli were identified in gastric aspirate/sputum and the agent was identified in 59.3% (n = 86). Tuberculosis was resistant in 11% (n = 16). Patients with extrapulmonary tuberculosis were younger (p = 0.006) and had more prolonged therapy (p < 0.001). Therapy-related complications occurred in 11% (n = 16). One patient died (with terminal cancer).Conclusion: This study highlights the need for screening of tuberculosis in children from endemic countries, patients with immunosuppression and chronic disease.

Early-Onset Neonatal Sepsis: Role of C-Reactive Protein, Micro-ESR, and Gastric Aspirate for Polymorphs as Screening Markers

Introduction. Early-onset neonatal sepsis is a major cause of morbidness and death in newborn children. Its timely diagnosis is usually a challenge in developing countries like India. Aim. To study the efficacy of C-reactive protein (CRP), micro-ESR, and gastric aspirate for polymorphs in the diagnosis of early-onset neonatal sepsis. Materials and Methods. This study included sixty term and preterm children, inborn and referred cases. The children who presented before day seven of life with clinical suspicion of sepsis or who were at high risk of developing sepsis were included. These were further investigated. Significant values for screening tests were taken as C − reactive protein > 0.6 mg / dl , micro-ESR—after 1 hour, fall in the column of blood in capillary tube was measured, and result was taken as mm fall in 1 hr, and gastric aspirate for polymorphs > 5 polymorphs / HPF . Sepsis screen positive result was 2 or more positive tests. The statistical evaluation was done using Fisher, and ANOVA tests using SPSS 20.0 version. Results. Sixty children were included in the study with forty as the referred ones. Most of them had tachypnea (45%). CRP showed high sensitivity, whereas micro-ESR and gastric aspirate for polymorphs showed high specificity. Conclusions. Neonatal sepsis screening is required for the detection of infection as the blood culture report may not be positive in all the cases, and even if positive, the result takes few hours. CRP showed high sensitivity, whereas micro-ESR and gastric aspirate for polymorphs showed high specificity independently as well as when combined.

Sternal swelling presenting as tuberculosis: a case report

Background Tuberculosis continues to be a worldwide public health problem. Despite the noted gradual decline in tuberculosis case rates in the UK, clinicians should still be aware of these unusual presentations. Sternal tuberculosis is an uncommon form of extrapulmonary tuberculosis and it can initially be a diagnostic challenge for paediatricians. These lesions can present with nonspecific signs and symptoms that may mimic malignancy. Case presentation We present a case of a 3-year-old African descent girl with a sternal swelling that was confirmed to be Mycobacterium tuberculosis complex DNA on gastric aspirate. The child had additional radiological investigations that corresponded accordingly. She was started on quadruple antituberculosis therapy with good outcome. Conclusion Tuberculosis sternal abscess is as rare finding, especially in developed countries where tuberculosis is not endemic. Tuberculosis may not always present with pulmonary symptoms in children. There should be a high suspicion of tuberculosis, especially in immigrant population presenting with unusual presentations. Our aim is to increase awareness around atypical presentations of tuberculosis in children. Although, tuberculosis is endemic to underdeveloped countries, clinicians should still be aware of presentations in view of current global migration.

Study of extrapulmonary tuberculosis in tertiary care hospital children with reference to cartridge based nucleic acid amplification test

Background: Tuberculosis is an infectious disease cause by the mycobacterium tuberculosis which typically involve lung but can affect other site called extrapulmonary tuberculosis (EPTB). In EPTB lymph node tuberculosis is most common and most severe is tuberculous meningitis. Cartridge based nucleic acid amplification test (CBNAAT) have high sensitivity and perform both respiratory and non-respiratory specimen. The aim of this retrospective study is to find out the proportion of extra pulmonary tuberculosis in hospitalized patient and determine the association of CBNAAT in diagnosis EPTB and Rifampicin resistance.Methods: This is the retrospective observational study done at Civil Hospital Ahmedabad in between October 2017 to October 2019 among the admitted patient age 1 month to 12 year diagnosed cases of EPTB according to RNTCP guidelines. Data collection done by medical records as indoor case sheets and investigation data from laboratory department.Results: Incidence of EPTB among the hospitalized children is 1.95% and among total tuberculosis patient is 42.48%. Among 191 suspected EPTB cases 59 confirmed indicate sensitivity of 37.3% and no false positive cases indicate 100% positive predictive value. Sensitivity of CBNAAT was highest in gastric aspirate followed by CSF in present study.Conclusions: Tuberculosis is more common in male child less than 5-year-old with frequent risk factor is rural residential area, lower socioeconomic class and contact with active cases. In my study is CNS tuberculosis is most common. In my study mortality is higher among 1-to-5-year age group with co morbid condition are SAM and septicemia.

COMPARATIVE STUDY OF METOCLOPRAMIDE AND ONDANSETRON WITH PANTOPRAZOLE IN ELECTIVE CAESEREAN SECTION UNDER SPINAL ANAESTHESIA FOR ASPIRATION PNEUMONITIS PROPHYLAXIS.

BACKGROUND- Caesarean delivery, one of the most commonly performed surgical procedure. The choice of anaesthesia is spinal blockade for elective caeserean-section,unless general anaesthesia is specically indicated. Aspiration pneumonitis remains an important cause of morbidity and mortality in anaesthesia practise,particularly in obstetric patients,prophylaxis against it is paramount importance in pre-anaesthetic management. AIMS AND OBJECTIVES- The aim of this study was to compare pH and volume of gastric contents after administration of combination of metoclopramide and pantoprazole versus ondansetron and pantoprazole during elective caesarean section under spinal anaesthesia for prophylaxis against aspiration pneumonitis. METHODS: It is a prospective study where 100 parturient women, ASA 1 and 2 scheduled for elective caesarean section. They were divided into 2 groups: ondansetron(4mg) and pantoprazole(40mg),and metoclopramide(10mg), pantoprazole(40mg) administered intravenously 2hours before surgery. Gastric aspirate was taken in various positions before giving spinal anaesthesia and at the end of operation. Patients at risk were according to criteria of gastric volume more than 0.4ml/kg with pH <2.5. RESULTS:Patients at risk were 7(14%) in metoclopramide group and 1(2%) in ondansetron group before giving spinal anaesthesia(p=0.027) and 6(12%) in metoclopramide group and 0(0%) in ondansetron group at end of operation(p=0.012) . Since p-value was less than 0.05 there was signicant difference between two groups. CONCLUSION: As there was signicant difference between ondansetron and metoclopramide , it is recommended to use ondansetron and pantoprazole for prophylaxis against aspiration pneumonitis.

ROLE OF GENE XPERT AND LIQUID CULTURE IN DIAGNOSIS OF EXTRA PULMONAR TUBERCULOSIS

INTRODUCTION: Extrapulmonary Tuberculosis (EPTB) accounts for 15- 25% of all TB cases. It is more difficult to diagnose than Pulmonary tuberculosis and often requires invasive procedures to obtain tissue and or fluid samples. Histology is time-consuming and establishing a diagnosis of TB with high specificity remains difficult. Tissue smear microscopy after special staining is often negative. Tissue culture often leads to considerable delays compromising patient care and outcomes. AIMS AND OBJECTIVES:1. To diagnose Extra Pulmonary Tuberculosis by Gene Xpert(Xpert MTB/Rif assay or CBNAAT) and Liquid Cultures. 2. To evaluate the Sensitivity and Specificity of Gene Xpert in Extra Pulmonary Tuberculosis in comparison with Liquid Culture MGIT960 system. MATERIALS AND METHODS: This retrospective cross-sectional study was carried out by reviewing all suspected extra pulmonary tuberculosis samples of 430 patients attending OPD at Institute of Respiratory Diseases, Jaipur from April 2020 to March 2021.The extrapulmonary samples (pleural fluid,CSF,pus,BAL,Ascitic fluid,Synovial fluid,Gastric aspirate,Liver aspirate) were subjected to GeneXpert and Liquid culture MGIT960 system. RESULTS: Of the 430 Extra Pulmonary Samples, The Sensitivity and Specificity of CBNAAT was 79.77% and 95.30% respectively in comparison with Liquid Culture. Out of the 430 Samples CBNAAT was Positive in 87 samples of which 71(81.60%) were Rifampicin sensitive and 16(18.39%) were Rifampicin Resistant.Out of the 430 Samples,Liquid cultures was Positive in 89 samples. CONCLUSION: Gene Xpert has a notable advantage of detecting tuberculosis within two hours which is acceptable to all clinicians to institute early treatment.CBNAAT is one of the rapid diagnostic tests available in the country and it should be routinely used under the public and private health sector effectively to detect early tuberculosis in Extra Pulmonary Samples.

GASTRIC ASPIRATE: A SCREENING TOOL FOR DETECTION OF EARLY NEONATAL SEPSIS-A PROSPECTIVE STUDY IN TERTIARY CARE CENTRE, INDORE

Background: Infections in early neonatal period are one of the important factors responsible for high mortality and morbidity in neonates in developing countries. Although it is being frequently observed by pediatricians in neonates, still insufficient relevant studies are documented. The objective of the present study was to evaluate the utility of gastric aspirate cytology as a screening tool for neonatal sepsis, and to determine the polymorphonuclear leukocyte count present in smear of gastric aspirate and correlating it with blood culture proven sepsis. Methods: The study was conducted on 100 neonates suspected with septicemia in inborn patients in Index medical college hospital and research centre. Gastric aspirate sample was collected within 6 hours of birth for septic screening of neonates. All the collected data was statistically analysed by applying Chi-square test using SPSS 2.0 software. Results: Gastric aspirate cytology has sensitivity 0f 53.19% and specificity of 62.28% with positive predictive accuracy of 51.33% and negative predictive accuracy of 63.4%.The relationship between gastric aspirate cytology and maternal risk factors like PROM are found to be highly significant. Conclusions: We conclude that gastric aspirate cytology in neonates is an excellent screening technique for neonatal sepsis added to a detailed perinatal history and clinical examination. The chances of positivity of gastric aspirate increase as the duration of rupture of membranes increased. Keywords: Gastric aspirate cytology, Neonatal sepsis, Blood culture, Polymorphonuclear leukocytes.

Helicobacter pylori infection and hypochlorhydria in Zambian adults and children: A secondary data analysis

Background Hypochlorhydria (gastric pH >4) increases susceptibility to diarrhoea, iron deficiency, and gastric cancer. We sought to clarify the prevalence of this condition and its predisposing factors in Zambia by pooling data from previous studies conducted in hospital and community settings. Methods Gastric pH was measured in participants from five separate studies by collecting gastric aspirate from fasted adults and children under 3 years of age undergoing gastroscopy. Gastric pH was correlated with serological testing for Human Immunodeficiency Virus (HIV) and Helicobacter pylori (H. pylori) infections. Results We studied 597 individuals (487 adults and 110 children). Hypochlorhydria was present in 53% of adults and 31% of children. HIV infection was detected in 41% of adults and 11% of children. H. pylori serology was available for 366 individuals: 93% of adults and 6% of children were seropositive. In univariate analysis, hypochlorhydria was significantly associated with HIV seropositivity (OR 1.7; 95% CI 1.2–2.4; p = 0.004) and H. pylori antibody seropositivity (OR 4.9; 95% CI 2.8–8.6; p<0.0001), and with advancing age in HIV negative individuals (p = 0.0001). In multivariable analysis, only H. pylori was associated with hypochlorhydria (OR 4.0; 95% CI 2.2–7.2; p<0.0001) while excluding possible exposure to proton pump inhibitors. Conclusions Hypochlorhydria is common in our population, with H. pylori being the dominant factor. Only young HIV seronegative individuals had a low prevalence of hypochlorhydria. This may have implications for the risk of other health conditions including gastric cancer.

Isolated hepatosplenic tuberculosis: a rare presentation with persistent fever in a 2-year-old female child

A 2-year-old female child from South India presented with persistent fever for 3 weeks, pallor and hepatosplenomegaly. There was no history of contact with tuberculosis (TB) and BCG scar was absent. Tests for TB (Mantoux and gastric aspirate) were negative. Blood and bone marrow tests for other infections, inflammation and infiltration were inconclusive. Chest X-ray was normal. Ultrasound study (USS) of abdomen showed multiple microabscesses in the liver and spleen. USS-guided fine needle aspiration cytology from splenic lesion demonstrated epithelioid granuloma while bacteriology was negative. Commencement of anti-tubercular therapy (ATT) resulted in remarkable clinical improvement in a week with resolution of lesions on follow-up USS in 2 months. Isolated hepatosplenic TB in children, though rare, has a wide, non-specific clinical spectrum and potential of delaying diagnosis. Probability diagnosis and therapeutic trials of ATT are accepted approaches, using treatment response as indirect confirmation of the likely cause.