Enterovirus D68 in Critically Ill Children: A Comparison With Pandemic H1N1 Influenza

OBJECTIVE

In 2014, the Unites States experienced an outbreak of enterovirus D68 associated with severe respiratory illness. The clinical characteristics associated with severe illness from enterovirus D68 during this outbreak compared with those associated with the 2009 H1N1 influenza virus outbreak are unknown.

DESIGN AND SETTING

In this retrospective cohort study, we characterized the clinical features of children with enterovirus D68 admitted to the PICU between August 1, 2014, and November 1, 2014, and compared them with critically ill children infected with H1N1 influenza during the pandemic admitted between May 1, 2009, and January 31, 2010.

PATIENTS

PICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ninety-seven severely ill children with enterovirus D68 infections were compared with 68 children infected with H1N1 influenza during the 2009 pandemic. Children with enterovirus D68 were more likely to have asthma (62% vs 23%; p < 0.001) and present with reactive airway disease exacerbations, with greater receipt of albuterol (94% vs 49%) and steroids (89% vs 40%; p < 0.0001 for both). Although more children with enterovirus D68 were admitted to the ICU compared with those with H1N1 influenza, they had a shorter hospital length of stay (4 vs 7 d; p < 0.0001), with lower intubation rates (7% vs 44%), vasopressor use (3% vs 32%), acute respiratory distress syndrome (3% vs 24%), shock (0% vs 16%), and death (0% vs 12%; p < 0.05 for all). Compared with children with other enteroviruses and rhinoviruses, children with enterovirus D68 were more likely to have a history of asthma (64% vs 45%) or multiple prior wheezing episodes (54% vs 34%; p < 0.01 for both).

CONCLUSIONS

Critically ill children with enterovirus D68 were more likely to present with reactive airway disease exacerbations, whereas children with H1N1 influenza were more likely to present with pneumonia. Compared with the pandemic H1N1 influenza outbreak, the enterovirus D68 outbreak resulted in more children requiring admission to the ICU, but was associated with less severe outcomes.

[A philosophical outlook on pain in relation to the patient]

Pain is perceived by the patient as a reduction of his speaking and acting capacity. When the pain gets worse, the patient will anticipate the end of his capacity to enjoy life and relate to other people; he will also see the spectre of death. The patient and his family expect a medical answer to the problem. Today's technological mentality takes into consideration only medical treatments. Medical and human aid is irreplaceable and invaluable to patients, and it is their due. However, it is not the only answer; solidarity also has great value, and so do words and looks.

Etiology of children's diarrhea in Montevideo, Uruguay: associated pathogens and unusual isolates

We studied microorganisms associated with infant diarrhea in a group of 256 children admitted to a public pediatric hospital in Montevideo, Uruguay. Diagnostic procedures were updated to optimize detection of potential pathogens, which were found in 63.8% of cases, and to be able to define their characteristics down to molecular or antigenic type. Coinfection with two or more agents was detected in more than one-third of positive studies. Escherichia coli enteric virotypes, especially enteropathogenic E. coli (EPEC), were shown to be prevalent. Rotavirus, Cryptosporidium, Campylobacter (mainly Campylobacter jejuni), and Shigella flexneri were also often identified. Enterotoxigenic E. coli, Salmonella, and Giardia lamblia were sporadically recognized. Unusual findings included two enteroinvasive E. coli strains, one Shigella dysenteriae 2 isolate, and a non-O:1 Vibrio cholerae culture. EPEC bacteria and S. flexneri (but not Salmonella) showed unusually frequent antimicrobial resistance, especially towards beta-lactam antibiotics, which is the subject of ongoing work.

Standard case management of pneumonia in hospitalized children in Uruguay, 1997 to 1998

OBJECTIVE

To report the results of the use of antimicrobial guidelines for the management of children with community-acquired bacterial pneumonia.

METHODS

Admittance and discharge criteria and algorithms for diagnosis and treatment were established. The decision to treat with antibiotics was based on radiologic findings in pneumonia with pulmonary consolidation and left to the attending physician's criteria in the remaining cases. The use of antibiotics was limited to penicillin and derivatives (ampicillin, amoxicillin) and macrolides.

RESULTS

Of the 1163 children treated as bacterial pneumonia, hospitalized in public and private health facilities in Montevideo from September, 1997, through September, 1998, standard case management was applied in 1082 (93%). Age distribution was: <1 month, 1%; between 1 and 11 months, 29%; between 1 and 5 years, 50%; >5 years, 20%. Chest radiography showed evidence of pulmonary consolidation in 843 children (73%). Bacteria were detected in blood culture and/or pleural fluid of 57 children (5%). In 51 the identified microorganism was Streptococcus pneumoniae, susceptible to penicillin in 30, intermediate in 6 and resistant in 5 (maximum MIC, 4 microg/ml); in 10 cases etiologic diagnosis was made by antigen detection. Empyema was present in 62 children (5.3%); 38 (3.27%) required treatment in an intensive care unit; and 5 (0.4%) died.

CONCLUSIONS

Compliance with standard case management was highly satisfactory. Outcome of children treated with penicillin and derivatives was good, including children with empyema and pneumatocele and two patients with penicillin-resistant S. pneumoniae. At the present time S. pneumoniae resistant to penicillin is not an important problem in children with pneumonia in Uruguay. Surveillance of identified microorganisms and their antimicrobial susceptibility must continue.

A community-based study of acute respiratory tract infections in children in Uruguay

Acute respiratory tract infection (ARI) was investigated in children less than 5 years old in a longitudinal community-based study of 166 families living in a socioeconomically depressed area in Montevideo, Uruguay. Pediatricians made home visits every 10 days from May 1985 to December 1987, and symptoms and signs of ARI were recorded. The incidence of ARI was 5.8 episodes per child-year during the first 12 months of life and decreased with increasing age of the index children; the rate was highest in children 1-5 months old. Children observed from birth were ill during 21% of the visits. According to the definitions of the study, the incidence of lower respiratory tract infection was 11.6% higher than the incidence of upper respiratory tract infections. The rates of ARI were higher during the colder months. Most risk factors for ARI were only marginally statistically significant.

[Complete atrioventricular block and acute abdominal pain: initial symptoms in a case of rheumatic fever]

Delayed atrioventricular conduction, as reflected in prolongation of the P-R interval, is commonly found and is a non specific finding in acute rheumatic fever (minor manifestation). Prolongation of atrioventricular conduction may lead to second-degree A-V block, while a complete heart block is a rare event with or without Stokes-Adams attacks. In these cases temporary pace-maker may be usefully employed. Another uncommon symptom of acute rheumatic fever is abdominal pain, which occurs in fewer than 5% of patients, and is usually vague and not acute. An unusual case of onset of rheumatic fever characterized by acute complete heart block and acute abdominal pain simulating appendicitis is reported.

[Electrocardiographic findings in a school-age population using a computerized system: calculation of standard norms for heart rate and PR, QRS, and QT intervals]

We evaluated some ECG parameters (HR, P-R, Q-R-S, Q-T) in a healthy school-age population. One-thousand-eight-hundred and ninety children ranging in age from 5 to 12 coming from different zones of the city of Naples were studied. On physical examination all subjects were free from cardiac disease. A computerized ECG (Muse 12SL System Marquette) was performed on every subject. One-hundred and seventy-four of the 1890 children were excluded from statistical analysis because of ectopic rhythm (junctional rhythm or wandering pacemaker) or poor quality of the recording. Of the 1716 children included in the study, 837 were male and 879 were female. The computerized ECG 12SL System Marquette registers an ECG record consisting of all 12 classical ECG leads acquired simultaneously over a 10 second period. Each individual complex can be analyzed in all leads by the computer. An interpretation using this extended record, along with an ECG record of conventional length, is presented to the physician for review. The first step in computerized ECG analysis is Q-R-S identification, then P wave identification, beat classification, rhythm analysis, morphology analysis, complex alignment and computation of median complex. All parameters were divided for sex and age and gathered into tables. The variability of P-R, Q-R-S, Q-T versus HR were also evaluated. The following conclusions were drawn: 1) Sex is a very important variable in the parameters examined. Males have a much slower HR, greater Q-R-S duration, and longer Q-T interval when compared to females. 2) As age increases, HR slowly decreases, while P-R, Q-R-S and Q-T intervals increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-invasive electrophysiological evaluation of calcium antagonist long-term therapy

The evaluated effects of oral administration of verapamil, diltiazem, and nifedipine in patients with first degree A-V block by using a new noninvasive technique: signal averaged ECG. The study group consists of 5 females and 3 males ranging from 52 to 70 years old. All patients showed a first degree A-V block at surface ECG and an abnormal A-V time (suprahisian lengthening) during signal averaged ECG (SAECG). Verapamil 240 mg/daily, diltiazem 180 mg/day and nifedipine 30 mg/day were given separately for a week followed by a wash out period of 5 days before giving next drugs. An ECG and SAECG were performed before and after every administration. PR, A-H and H-V interval were evaluated in every recording. Verapamil and diltiazem induced a significant lengthening of A-V conduction (PR increase was 15.4% and 15.1%, respectively). No significant modification appeared after nifedipine. Our data, using a noninvasive technique, agreed with values of previous invasive evaluations. We suggest precaution in using verapamil and diltiazem in patients with BAV 1 degree and advise a selective use of calcium antagonist therapy.

Amiodarone treatment in cardiac preexcitation syndrome: use of signal averaged electrocardiogram

Amiodarone effectiveness to prevent reentrant arrhythmia in Wolff-Parkinson-White (WPW) syndrome is well known. Authors tried to evaluate the results of long-term therapy in a group of 11 patients (mean age 39 +/- years) suffering from WPW syndrome. Before amiodarone treatment, a conventional ECG and a high resolution ECG (a new noninvasive technique) were performed in order to define Hisian activity. After 50 days of therapy (600 mg daily for the first week, 400 mg daily for the second week, 200 mg daily for 5 days in the following period), a second recording revealed the evidence a a lengthening of PR segment (p less than 0.05) and a disappearance of delta wave (1 patient) and arrhythmia. Before treatment, His deflection was defined only in 2 patients. After amiodarone therapy the H-V time was clearly evaluated in 9 patients. Probably the drug has induced a lengthening of AV node refractoriness and primarily an increase of accessory pathway refractoriness.