Cytokine storm in Chikungunya: Can we call it multisystem inflammatory syndrome associated with Chikungunya?

Paraguay is currently facing a new outbreak of Chikungunya virus. This report summarizes two severe cases of Chikungunya (CHIKV) infection, confirmed by real-time reverse transcription polymerase chain reaction. We present the cases of patients with acute CHIKV infection and multisystem involvement, with fever, rash, abdominal pain, vomiting, myocarditis, and coronary artery anomalies, very similar to the cases described in MIS-C related to SARS-CoV-2 during the COVID-19 Pandemic. Both patients received IVIG and methylprednisolone, with good clinical response. In this setting of cytokine storm in Chikungunya, can we call it "Multisystem inflammatory syndrome associated with Chikungunya"?.

Impacto socio – económico de casos de dengue con signos de alarma y severo, neumonía y meningitis bacteriana aguda, en pacientes pediátricos hospitalizados en un centro de referencia

Introducción: El dengue, la neumonía y la Meningitis Bacteriana Aguda (MBA), producen un elevado impacto socioeconómico, una elevada carga económica y social en los sistemas de salud y la sociedad. Objetivo: comparar el costo económico y la carga por dengue, neumonía y MBA en ≤15 años hospitalizados, entre enero/07 y mayo/19. Materiales y Métodos: Estudio observacional, descriptivo. Los datos fueron obtenidos de expedientes de pacientes hospitalizados con diagnósticos de Dengue, neumonía y MBA. Los costos médicos directos se obtuvieron de la base de datos del IMT. Para los costos directos no médicos y los indirectos se utilizó literatura internacional estimados para Paraguay. Los DALYs fueron calculados a partir de la suma de los AVPP y los DVSP. Resultados: Se identificaron 784, 1419 y 125 pacientes con Dengue, neumonía y MBA, respectivamente. La edad media fue de 118,1±53,6; 34,0±38,9 y 52,1±64,3 meses, respectivamente (p<0.05). La media de días de hospitalización: 4,8±2,8; 9,4±8,7 y 13,8±14,0 días, respectivamente. El 8,9%(70/784) de los casos con dengue, el 29,6%(420/1419) de las neumonías y el 70,4%(88/125) de las MBA requirieron UCI. El 0,6%(5/784), el 5,3%(78/1419) y el 31,2%(39/125) pacientes fallecieron. El costo por hospitalización por dengue, neumonía y meningitis fue de 465496, 3094721 y 127063 US$, respectivamente; los AVPP fueron de 328.1, 5373.4 y 1846.7 años, respectivamente; los DVSP fueron 1459.8, 8595.2 y 996.1, respectivamente y los DALYs de 1641.66; 13968.6 y 2842.8, respectivamente. Conclusiones: Los costos de atención de estas patologías, inmunoprevenibles, son considerables, producen un impacto social importante, en el sector salud y la economía en general del país.

[Dengue economic impact in Paraguay]

BACKGROUND

Since the end of the 20th century, dengue has periodically devastated Paraguay. Its high morbidity and mortality translate into a high global socio-economic impact and a high burden on health care systems.

AIM

To determine the economic cost and burden of dengue in Paraguay.

METHODS

The direct and indirect costs of dengue were estimated in both outpatient and hospitalized cases. Likewise, the years of life adjusted for disability (DALY) were calculated from the sum of the years of life lost (YPLL) due to premature mortality in the population and years lost due to disability (DVSP).

RESULTS

The unit cost per ambulatory case was US dollars 52.5 and for hospitalized patients US dollars 300 with a total cost for the 4 years of US dollars 276,804.864 and US dollars 23,236.45, respectively. The AVPP were 18,469.7 per million inhabitants; the DVSP of 185,835 and the DALYs 32,676 years per million inhabitants.

CONCLUSIONS

Dengue imposes considerable costs for both the health sector and the economy in general in Paraguay.

Clinical manifestations of primary and secondary dengue in Paraguay and its relation to virus serotype

INTRODUCTION

Dengue virus (DENV) infection is currently a major cause of morbidity in the world, and its incidence has mainly increased during the last years in Latin America, including Paraguay. The objective of this study was to compare the clinical and laboratory findings of dengue and assess whether the serotype is a risk factor for severity.

METHODOLOGY

We included patients ≤ 15 years old hospitalized with dengue at the Institute of Tropical Medicine, from Paraguay, from 2007 to 2018. Patients were classified according to the 2009 WHO dengue classification guidelines and were stratified by serotype into three groups according to the hospitalization period: the 2007 epidemic (DENV-3), the 2012-2013 epidemic (DENV-2) and the 2016-2018 epidemic (DENV-1).

RESULTS

Of 784 children hospitalized for dengue, 50 cases (6.3%) were caused by DENV-3, 471 (60%) by DENV-2, and 263 (33.5%) by DENV-1. Myalgias and headache were associated with DENV-3 cases and abdominal pain was associated with DENV-2 cases. Bleeding was observed mainly in DENV-1 and 2 cases. Patients with DENV-2 infections experienced more severe disease, required fluid expansion more frequently, and exhibited more often shock and admission in the ICU. Secondary cases of dengue were more severe that primary cases. Patients with infection by DENV-2 had longer hospital stays (5.1 ± 2.8 days) when compared to DENV-3 o DENV-1 infection cases (2.9 ± 1.6 days and 4.36 ± 2.7 days, respectively) (p < 0.05).

CONCLUSIONS

The DENV serotype has a profound impact on the clinical manifestations and severity of dengue. DENV-2 infections were associated more frequently to requirement of fluid expansion, shock, and longer hospital stay.

Prognostic factors of severity of invasive community acquired Staphylococcus aureus infections in children

OBJECTIVE

To describe the clinical characteristics of invasive Staphylococcus aureus infections in children and identify the prognostic factors of severity and mortality.

MATERIALS AND METHODS

Observational study in patients < 16 years old hospitalized between 2010 and 2015 due to invasive S. aureus infections at the Instituto de Medicina Tropical, in Asunción, Paraguay. Patients were distributed based on whether or not they required admission to the intensive care unit, and clinical, laboratory, and evolutionary outcome measures were compared.

RESULTS

Out of the 107 included patients, 50 (47 %) developed bacteremia; 50 (47 %), pneumonia; and 21 (19 %), multifocal disease. Among the patients who were admitted to the intensive care unit (41 %), prior antibiotic use (p < 0.05), the presence of bacteremia (p = 0.01), the presence of comorbidities (p < 0.05), and multifocal disease (p < 0.01) were more frequent. The overall mortality rate was 15 %. The mortality-associated risk factors were the presence, at the time of admission, of hypotension (p < 0.01), multifocal disease (p < 0.01), bacteremia (p < 0.01), leukopenia (p < 0.01), severe anemia (p < 0.01), and metabolic acidosis (p < 0.01), among others.

CONCLUSIONS

The prognostic factors of severity included prior antibiotic use, bacteremia, the presence of comorbidities, and presentation with multifocal disease. Mortality was significant; associated risk factors included the presence, at the time of admission, of hypotension, multifocal disease, leukopenia, severe anemia, and metabolic acidosis.

Tuberculosis: Factores de riesgo asociados a mortalidad en pacientes ≤19 años hospitalizados en el Instituto de Medicina Tropical

Introducción: La Organización Mundial de la Salud estima que anualmente ocurren 10 millones de casos incidentes de Tuberculosis (TB) en el mundo, de los cuales 10% ocurren en niños <15 años.  Las dificultades en el acceso a los establecimientos de salud y el retraso en el diagnóstico y tratamiento apropiados incrementan la mortalidad en el niño. Objetivos: analizar las características clínicas, laboratoriales y los factores asociados a mortalidad en <19 años en pacientes hospitalizados por TB en Instituto de Medicina Tropical. Metodología: estudio observacional descriptivo, retrospectivo. Se incluyeron pacientes con diagnóstico de tuberculosis, hospitalizados, durante los años 2010 a 2018. Los datos fueron obtenidos de base de datos del Departamento de Epidemiología. Las variables incluidas fueron datos demográficos, formas de presentación, diagnóstico, tratamiento y factores asociados a la mortalidad. Se realizó análisis descriptivo y analítico. Se considero error alfa < 5%. Resultados: Se identificaron 98 pacientes (pts) ≤19 años, con edad media de 9,3±6,3 años, 65,3% de sexo masculino. El 34,6% con infección por Virus de la inmunodeficiencia humana, y el 23,4% (23/98) con desnutrición. El 42,4% procedían de poblaciones con <100.000 hab y el 23,4% pertenecían a pueblos originarios. El 19,4% (19/98) fallecieron. La mortalidad se asoció a vivienda en poblaciones con <100.000 habitantes (33,3% vs 8,9%, p=0,02. RR=2,3. IC 1,1 – 5,0) y a la forma de TB meníngea (46,2% vs 15,3%, p<0,01. RR= 3,0; IC 1,4 – 6,5).  Conclusiones: La TB predominó en el sexo masculino, más del 80% presento comorbilidades. La mortalidad fue elevada y se asoció a viviendas en aéreas con<100.000 habitantes y a la TB meníngea. Correspondencia: Antonio Arbo; Correo: antonioarbo@hotmail.com Conflicto de interés: Los autores declaran no poseer conflicto de interés Recibido: 10/07/2019 Aceptado: 23/07/2019   

Mortality Predictive Scores for Community-Acquired Pneumonia in Children

PURPOSE OF REVIEW

The use of severity score for the staging of pneumonias has emerged as a necessity for the physician caring for this disease. Although there are several established prognostic scoring systems for community-acquired pneumonia in adults, the availability for children are scarce.

RECENT FINDINGS

Recently, scoring system for risk stratification of children with pneumonia were developed in low- and middle-income countries. They use clinical variables that represent known risk factors for severe outcomes of respiratory illness in children, such as hypoxemia, chest indrawing, refusal to feed, malnutrition, age, and stage of HIV disease among others factors. Although they showed good discriminating power and are very useful in low-resource settings, the characteristics of the patients, the local epidemiology of concurrent diseases, the social conditions, and the facilities of the hospitals make them not applicable to developed countries. A new prognostic scale for estimating mortality based on the modified PIRO scale used in adults with pneumonia can be useful for developed countries. Although several scoring systems for the estimation of mortality in childhood CAP were developed in the last years, most of them come from developing countries and the results are not applicable to patients with pneumonia in developed countries. Prospective studies applying scores adapted to the reality of the developed countries are needed.

Characterization of type I interferon responses in dengue and severe dengue in children in Paraguay

BACKGROUND

Infection with dengue virus (DENV) produces a wide spectrum of clinical illness ranging from asymptomatic infection to mild febrile illness, and to severe forms of the disease. Type I interferons (IFNs) represent an initial and essential host defense response against viruses. DENV has been reported to trigger a robust type I IFN response; however, IFN-α/β profile in the progression of disease is not well characterized.

OBJECTIVES AND STUDY DESIGN

In this context, we conducted a retrospective study assessing the circulating serum levels of type I IFNs and related cytokines at different phases of illness in children during the 2011 outbreak of DENV in Paraguay. Demographic, clinical, laboratory and virological data were analyzed.

RESULTS

During defervescence, significantly higher levels of IFN-β, IL-6 and MIP-1β, were detected in severe vs. non-severe dengue patients. Additionally, a significant positive correlation between INF-α and viremia was detected in children with severe dengue. A significant positive correlation was also observed between IFN-β serum levels and hematocrit during the febrile phase, whereas IFN-α levels negatively correlated with white blood cells during defervescence in severe dengue patients. Furthermore, previous serologic status of patients to DENV did not influence type I IFN production.

CONCLUSIONS

The distinct type I IFN profile in children with dengue and severe dengue, as well as its association with viral load, cytokine production and laboratory manifestations indicate differences in innate and adaptive immune responses that should be investigated further in order to unveil the association of immunological and physiological pathways that underlie in DENV infection.

Treatment of Childhood Complicated Community-Acquired Pneumonia with Amoxicillin/Sulbactam

The clinical and microbiological efficacy, as well as the tolerability of the amoxicillin/sulbactam combination as empiric treatment for complicated community-acquired pneumonia (CCAP) were evaluated in children from 3 months to 15 years with CCAP who were randomized 1:1 to receive either amoxicillin/sulbactam or cefuroxime. Of 234 patients hospitalized with CCAP in the study period (June, 1999-April, 2002), 62 patients qualified for the study: 32 received amoxicillin/sulbactam and 30 cefuroxime. Two were excluded. Demographic and clinical data showed that both groups were comparable at entry. One etiologic agent was identified in 55% of the patients, with Streptococcus pneumoniae being the most frequent. After treatment, the days of fever, duration of intravenous treatment, and hospitalization stay were similar in both groups. Overall favorable clinical responses were comparable: 97% for amoxicillin/sulbactam vs 100% for the comparative therapy. There was good tolerance to both drugs. Amoxicillin/sulbactam produced a satisfactory therapeutic outcome similar to that of cefuroxime for treatment of CCAP, and may be an appropriate choice for the treatment of this serious pediatric infection.

Risk factors for mortality in Paraguayan children with pneumococcal bacterial meningitis

BACKGROUND

Over the last decade Streptococcus pneumoniae has emerged as the most common bacterial pathogen for meningitis in all age groups, beyond the neonatal period.

OBJECTIVE

To determine the epidemiological and clinical characteristics; and risk factors for mortality of pneumoccocal meningitis in children in a developing transitional country.

MATERIALS AND METHODS

A retrospective study that included patients<15 years of age admitted at the Instituto de Medicina Tropical of Paraguay, from January 1990 until December 2003 with the diagnosis of bacterial meningitis caused by S. pneumoniae. Clinical and laboratory data were collected and analysed in order to identify risk factors associated with morbidity and mortality outcomes of this infection.

RESULTS

Seventy-two patients (between the ages of 35 days and 14 years) were identified. Forty-two per cent of patients had seizures prior to or at the time of admission, 36% were admitted in a comatose state, and 19% with shock. Mortality was 33% (24/72), and 18% of the survivors (11/60) developed severe sequelae. Upon admission, the following variables were strongly correlated with mortality: age<12 months (P=0.007), the presence of seizures (P=0.0001) or development of seizures 48 h after admission (P=0.01), a cerebrospinal fluid (CSF) glucose level of <10 mg/dl (P=0.01), CSF albumin>200 mg/dl (P=0.0003), an absolute blood neutrophil count<2000/mm3 (P=0.006) and a haemoglobin value of <9 g/dl (P=0.0001).

CONCLUSIONS

This study confirms the high morbidity and mortality associated with S. pneumoniae meningitis in Paraguay. Certain clinical parameters and laboratory findings in blood and CSF at the time of admission could be used as predictors for mortality or severe sequelae among survivors.