Discrepancy between total white blood cell counts and serum C-reactive protein levels in febrile children

Glucose indices as inflammatory markers in children with acute surgical abdomen: a cross-sectional study

BACKGROUND

Glycaemic dysregulation potentiates the pro-inflammatory response and increases oxidative injury; therefore, preoperative hyperglycaemia is linked to increased mortalities. In addition, inflammation is accompanied by higher glycated haemoglobin (HbA1c) levels, and the relationship between this and random blood sugar (RBS) could be non-linear.

METHODS

This is a cross-sectional study. Non-diabetic paediatric patients with acute surgical abdomen, presenting to the emergency surgical services were enrolled, over a period of 6 months. They were all screened for their random blood sugar and HbA1c levels.

RESULTS

Fifty-three cases were studied. The prevalence of glycaemic dysregulation in the enrolled children was high. Abnormal HbA1c was observed in 66% of the study group. Stress hyperglycaemia was observed in 60% of the enrolled children. There was a significant correlation (r = 0.770, p-value: < 0.001) between RBS and the total leucocytic count (TLC). The TLC cutoff value for predicting stress hyperglycaemia was 13,595 cells/mm3. The cutoff value of RBS for predicting leukocytosis was 111.5 mg/dl. Median RBS level was significantly higher in complicated appendicitis (169.5 mg/dl), compared to uncomplicated appendicitis (118.0 mg/dl).

CONCLUSION

HbA1c and RBS could be used as inflammatory markers for surgical acute abdomen and its degree of severity, respectively. HbA1c rises in a considerable number of cases with surgical acute abdomen, irrespective of the disease stage. However, as the disease progresses, the random blood sugar rises due to stress hyperglycaemia, thus becoming a surrogate inflammatory marker.

Characteristics and outcomes of frail patients with suspected infection in intensive care units: a descriptive analysis from a multicenter cohort study

Background

Frailty is associated with morbidity and mortality in patients admitted to intensive care units (ICUs). However, the characteristics of frail patients with suspected infection remain unclear. We aimed to investigate the characteristics and outcomes of frail patients with suspected infection in ICUs.

Methods

This is a secondary analysis of a multicenter cohort study, including 22 ICUs in Japan. Adult patients (aged ≥16 years) with newly suspected infection from December 2017 to May 2018 were included. We compared baseline patient characteristics and outcomes among three frailty groups based on the Clinical Frailty Scale (CFS) score: fit (score, 1–3), vulnerable (score, 4), and frail (score, 5–9). We conducted subgroup analysis of patients with sepsis defined as per Sepsis-3 criteria. We also produced Kaplan–Meier survival curves for 90-day survival.

Results

We enrolled 650 patients with suspected infection, including 599 (92.2%) patients with sepsis. Patients with a median CFS score of 3 (interquartile range [IQR] 3–5) were included: 337 (51.8%) were fit, 109 (16.8%) were vulnerable, and 204 (31.4%) were frail. The median patient age was 72 years (IQR 60–81). The Sequential Organ Failure Assessment scores for fit, vulnerable, and frail patients were 7 (IQR 4–10), 8 (IQR 5–11), and 7 (IQR 5–10), respectively (p = 0.59). The median body temperatures of fit, vulnerable, and frail patients were 37.5 °C (IQR 36.5 °C–38.5 °C), 37.5 °C (IQR 36.4 °C–38.6 °C), and 37.0 °C (IQR 36.3 °C–38.1 °C), respectively (p < 0.01). The median C-reactive protein levels of fit, vulnerable, and frail patients were 13.6 (IQR 4.6–24.5), 12.1 (IQR 3.9–24.9), 10.5 (IQR 3.0–21.0) mg/dL, respectively (p < 0.01). In-hospital mortality did not statistically differ among the patients according to frailty (p = 0.19). Kaplan–Meier survival curves showed little difference in the mortality rate during short-term follow-up. However, more vulnerable and frail patients died after 30-day than fit patients; this difference was not statistically significant (p = 0.25). Compared with the fit and vulnerable groups, the rate of home discharge was lower in the frail group.

Conclusion

Frail and vulnerable patients with suspected infection tend to have poor disease outcomes. However, they did not show a statistically significant increase in the 90-day mortality risk.

The Osteoarticular Infection in a Pediatric Emergency Setting: A Challenging Diagnosis

OBJECTIVES

The study aimed to evaluate the emergency department (ED) presentation of children with a diagnosis of osteomyelitis, septic arthritis, or both.

METHODS

A retrospective single-center study was conducted on all children aged between 1 month and 18 years evaluated in the ED over a 7-year period and having a final diagnosis of osteoarticular infection. One hundred seventeen patients were enrolled.

RESULTS

Only 39.3% of patients were admitted after the first evaluation, and only 45.3% had a proper diagnosis of admission. Pain was the only symptom reported by all. White cell count, C-reactive protein level, and erythrocytes sedimentation rate were normal in 49.5%, 21.4%, and 17.1% of children, respectively. X-ray findings were unremarkable in 48% of cases. Clinical and bone structural sequelae were described in 19.23% and 56.86% of all cases. No statistically significant differences were found among osteomyelitis, arthritis, and the combination of both regarding all considered variables, except for structural outcomes resulting more significant in the third group. Significant differences were evident in clinical manifestations, blood examinations, and findings of osteolysis between patients diagnosed within and after 1 week since the disease onset. Finally, questionable differences between white blood cells and C-reactive protein level were found among patients younger than 5 years and older ones, whereas a history of trauma was more often reported in the second group.

CONCLUSIONS

The difficulty in recognizing osteoarticular infection in a pediatric ED can be due to the possible lack of the classic signs and symptoms, and the absence of specific laboratory and radiologic findings.

Profile of C-reactive protein, white cells and neutrophil populations in febrile children from rural north-eastern Tanzania

Introduction

C-reactive protein (CRP), white blood cell (WBC) and absolute neutrophil counts (ANC) are important inflammatory biomarkers in the early diagnosis of infections. However, little is known on their profile and usefulness in fever case management in children attending outpatient clinic in rural north-eastern Tanzania.

Methods

Patients aged between 2 and 59 months presenting with fever at Korogwe District Hospital were enrolled. Venous blood was collected for evaluation of serum CRP, WBC and ANC. Individual patient diagnosis was based on integrated management of childhood illness (IMCI) guidelines and laboratory investigations (blood and urine cultures).

Results

A total of 867 patients were enrolled, out of which 691 (79.7%) had complete clinical and laboratory data available for analysis. Acute upper respiratory tract infection 284 (41.1%), acute gastroenteritis 127 (18.4%) and pneumonia 100 (14.5%) were the most frequent diagnoses. The geometric mean levels of serum CRP, WBC and ANC were 10.4 (95% CI: 9.2 - 11.8), 11.5 (95% CI: 11.1 - 11.9) and 5.5 (95% CI: 5.2 - 5.8), respectively. CRP≤20, WBC≤15 (10³cells/µL) and ANC≤10 10³cells/µL) were observed in the majority of the patients with upper respiratory tract infection, pneumonia, acute gastroenteritis and non-specific febrile illness. Only serum CRP levels were positively correlated with positive blood cultures at a calculated cut-off value of 37.3 mg/L, giving a specificity of 77.8% and sensitivity of 74.2%.

Conclusion

CRP assessment together with IMCI guidelines may be useful in assisting the diagnosis and management of paediatric febrile infections in Tanzania.

Alteration of thiol-disulphide homeostasis in acute tonsillopharyngitis

OBJECTIVE

Thiol-disulphide homeostasis (TDH) has a critical role in various clinical disorders. We aimed to assess the association of TDH with acute tonsillopharyngitis (AT) in children.

METHODS

This study included 94 (73 viral and 21 bacterial) tonsillopharyngitis patients and 88 control children. Their native thiol, total thiol, and disulphide levels were measured.

RESULTS

Viral and bacterial tonsillopharyngitis patients had lower native thiol levels compared with healthy children (P < 0.001 and P = 0.008, respectively). Both groups had lower total thiol levels compared with control children (P = 0.002 for viral, P = 0.011 for bacterial). The disulphide levels were lower in bacterial than in viral tonsillopharyngitis patients (P = 0.04), and there was a significant difference between viral tonsillopharyngitis patients and the control group (P < 0.001). The native/total thiol ratio in each patient group was lower than in the control group (P < 0.001 for viral, P = 0.017 for bacterial). The disulphide/native thiol and disulphide/total thiol ratios were significantly higher in viral (P < 0.001 for both) and bacterial tonsillopharyngitis patients (P = 0.017 for both) than in healthy children. In all patients, a correlation was found between the levels of C-reactive protein (CRP) and native thiol (r = -0.211, P = 0.04), CRP and total thiol (r = -0.217, P = 0.036), white blood cell (WBC) and native thiol (r = -0.228, P = 0.002), WBC and total thiol (r = -0.191, P = 0.01), and WBC and disulphide (r = 0.160, P = 0.03).

DISCUSSION

TDH is altered in AT in children. The alteration is more prominent in viral than in bacterial tonsillopharyngitis.

Emotional processes in patients undergoing coronary artery bypass graft surgeries with extracorporeal circulation in view of selected indicators of the inflammatory condition

Background

The aim of this study was to describe positive and negative emotions in patients undergoing coronary artery bypass graft (CABG) surgeries with extracorporeal circulation and the correlations between emotions and basic indicators of the inflammatory condition: C-reactive protein (CRP) concentration, body temperature, and leukocyte count.

Material/Methods

Standardized tools were used to select 52 patients (aged 47–63 years, 6 women – 11.5% and 46 men – 88.5%) without dementia or depression. The Positive and Negative Affect Schedule (PANAS) was used to examine positive affect (PA) and negative affect (NA) and the State-Trait Anxiety Inventory (STAI X1 and X2) was used to examine the anxiety level. The patients underwent CABG surgery according to a common anesthesia protocol and for 5 consecutive days they were observed in the ward, where selected indicators of the inflammatory condition were monitored.

Results

A detailed description of the results of examinations of emotions was presented. The patients with low PA-trait level, high NA-trait level, and high anxiety-trait level (STAI X2) exhibited statistically significantly higher body temperatures than the other patients in the postoperative period. The patients with high NA-trait and anxiety-state levels (STAI X1) had statistically significantly lower CRP levels in the postoperative period than the patients with low NA-trait and anxiety-state levels (STAI X1).

Conclusions

Patients undergoing CABG operations express both positive and negative affects. The changes in the inflammatory markers are expressed mostly by CRP concentration. There exist relationships between the result of tests assessing emotions and the markers of the inflammatory condition.

Leukocyte populations and C-reactive protein as predictors of bacterial infections in febrile outpatient children

Objective: Infections remain the major cause of unnecessary antibiotic use in pediatric outpatient settings. Complete blood count (CBC) is the essential test in the diagnosis of infections. C-reactive protein (CRP) is also useful for assessment of young children with serious bacterial infections. The purpose of the study was to evaluate leukocyte populations and CRP level to predict bacterial infections in febrile outpatient children.

Materials and Methods: The values of CBC by Cell-DYN 4000 autoanalyzer and serum CRP levels were evaluated in 120 febrile patients with documented infections (n:74 bacterial, n:46 viral) and 22 healthy controls.

Results: The mean CRP, neutrophil and immature granulocyte (IG) values were significantly higher in bacterial infections than in viral infections and controls (p<0.05). C-reactive protein was significantly correlated with neutrophil level in bacterial infections (r: 0.76, p<0.05). Specificity of IG was greatest at 93%, only a modest 56% for neutrophil and mild 18% for CRP, whereas 100% for combination of IG, neutrophil and CRP.

Conclusion: Acute bacterial infection seems to be very unlikely in children with normal leukocyte populations and CRP values, even if clinically signs and symptoms indicate acute bacterial infections.

Procalcitonin as an early marker of bacterial infection in neutropenic febrile children with acute lymphoblastic leukemia

OBJECTIVE AND DESIGN

The aim of this study was to assess the value of procalcitonin (PCT), C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-a), interleukin (IL)-1b, IL-8, and soluble TNF receptor II (sTNFRII) in early and rapid diagnosis of infection in neutropenic children with acute lymphoblastic leukemia (ALL) and to distinguish bacterial from viral infections.

PATIENTS

The study included five groups (A, B, C, D, and E) of children with ALL undergoing intensive chemotherapy. Groups A and B consisted of neutropenic children with bacterial and viral infection, respectively. Groups C and D consisted of nonneutropenic children with bacterial and viral infection, respectively. Group E consisted of children without neutropenia and without fever.

METHODS

In all groups, blood samples were collected upon admission and then for 7 days on a daily basis. Levels of CRP, PCT, TNF-a, IL-1b, IL-8, and sTNFRII were determined in all blood samples.

RESULTS

We found a highly significant difference in PCT levels between bacterial and nonbacterial episodes. Sensitivity and specificity of PCT were 94 and 96.5%, respectively.

CONCLUSIONS

Serial measurement of PCT levels on a daily basis seems to be helpful for early prediction of severe bacterial infections, monitoring febrile episodes regarding response to antibiotic therapy, and early detection of complications in the infectious process.