Epidemiological features of nosocomial candidaemia in neonates, infants and children: A multicentre study in Iran

Nosocomial bloodstream candidaemia is a life-threatening fungal infection with high morbidity and mortality, especially among paediatric patients undergoing intensive immunosuppressive therapy. Limited data on the epidemiology of candidaemia and susceptibility profiles are available for Iran. To characterise candidaemia epidemiology, comorbidity risk factors, species distribution, and antifungal susceptibility profiles among paediatric patients in Iran. This observational cross-sectional study enrolled 26 189 patients <18 years old at three reference paediatric hospitals in Mazandaran and Tehran over 2 years. Blood samples from patients with suspected fungal bloodstream infection were analysed using the BACTEC culture system. Fungal isolates were identified using matrix-assisted laser desorption ionisation time-of-flight mass spectrometry (MALDI-TOF) and DNA sequencing. Antifungal susceptibility testing was performed using the Clinical and Laboratory Standards Institute broth microdilution guideline. We observed 109 episodes of nosocomial candidaemia in paediatric patients with or without immunosuppressive therapy. The most common healthcare-associated factor was central vascular catheter use (97%). The all-cause mortality rate was 40%, of which 48% was attributable to candidaemia. While Candida albicans was the most frequent causative agent (49%), emerging and uncommon Candida species were also isolated. Candidaemia mortality by non-albicans Candida species was significantly higher than that by C. albicans (P < .05). All fluconazole-resistant species were non-albicans Candida species. Uncommon Candida species with reduced susceptibility to antifungals are emerging as major agents of nosocomial candidaemia in high-risk paediatric patients in Iran. Appropriate source control, antifungal regimens and improved antifungal stewardship are warranted for managing and decreasing the burden of nosocomial candidaemia.

Candidemia due to Candida guilliermondii in an immuno-compromised infant: a case report and review of literature

Background and Purpose:

Candidemia is a life-threatening fungal infection with significant mortality and morbidity in neutropenic individuals, immunosuppressive chemotherapy recipients, and broad-spectrum antibiotics consumers. The epidemiology and antifungal susceptibility testing of non-albicans Candida species have been poorly studied. These species are characterized by low susceptibility to azoles and echinocandins. Herein, we report the first pediatric case of candidemia due to C. guilliermondii in Iran and review the literature on fungemia caused by C. guilliermondii.

Case report:

We presented the first candidemia case due to C. guilliermondii in a 4-month-old male infant with neuroblastoma in Iran. This study also involves a comprehensive literature review on fungemia caused by C.guilliermondii during a period of 18 years (i.e., 2000-2018) to discuss the epidemiology, clinical features, and treatment of this disease. The literature review resulted in the identification of 501 cases of candidemia caused by C. guilliermondii. Most of the patients were adults and had multiple risk factors. However, the main risk factors were significantly related to cancer chemotherapy, followed by central venous catheter use and Intensive Care Unit admission. Mortality rate due to this disease had a range of 3.4-66.6%, in this regard, the patients with cancer had the highest mortality rate.

Conclusion:

Given the high mortality of candidemia, the early diagnosis of this infection and timely initiation of antifungal therapy significantly improve the patients’ survival rate and result in better outcomes. Consequently, it is highly recommended to monitor the local epidemiology of this life-threatening infection and raise awareness in this regard.

Pericardial Graft vs. Host Disease in a Patient with β-Thalassemia Major

Bone marrow transplantation (BMT) in young children improves results in β-thalassemia major. Graft versus host disease (GVHD) is an important complication of peripheral blood stem cell transplantation. GVHD affects heart with a behavior resembling an autoimmune disease, including pericardial effusion. We describe a 22-year-old β-thalassemia major patient who underwent bone marrow transplantation with an HLA-identical sibling donor. The patient didn't have any serious problem until 15 months after transplantation. He presented with chest discomfort and progressive dyspnea. Early echocardiogram showed mild pericardial effusion. Four days later, the effusion had increased, impending to cardiac temponade requiring pericardectomy. Immunospressive drugs and pericardectomy resulted in significant improvement in ventricular filling.  Cardiac cGVHD, an un-common complication of HSCT may be presented as pericardial effusion. Although early initiation of steroids is very important, heart monitoring is necessary to diagnose cardiac temponade.

Effects of nonpharmacological interventions on reducing fatigue after hematopoietic stem cell transplantation

Fatigue is one of the main complaints of patients undergoing allogeneic and autologous hematopoietic stem cell transplantation (HSCT). Since nonpharmacological interventions are cost-effective and causes fewer complications, this study aimed to review the studies performed on the effects of nonpharmacological interventions on fatigue in patients undergoing HSCT during September 2016. MEDLINE, CINAHL, Scientific Information Database, IranMedex, PubMed, ScienceDirect, Scopus, Magiran, and IRANDOC databases were searched using Persian and English keywords. A total of 1217 articles were retrieved, 21 of which were used in this study. Exercise is known as an effective intervention in alleviating physical and mental problems of patients undergoing stem cell transplant. This review-based study showed that nonpharmacological methods such as exercise might be effective in decreasing fatigue in patients undergoing stem cell transplant. There is a multitude of studies on some of the complementary and alternative therapy methods, such as music therapy, yoga, relaxation, and therapeutic massage. These studies demonstrated the positive effects of the aforementioned therapies on reduction of fatigue in patients undergoing stem cell transplantation. All the investigated methods in this study were nonaggressive, safe, and cost-effective and could be used along with common treatments or even as an alternative for pharmacological treatments for the reduction, or elimination of fatigue in patients undergoing stem cell transplantation. Given the advantages of complementary and alternative medicine, conducting further studies on this issue is recommended to reduce fatigue in patients after stem cell transplantation.

Effect of late vs early clamping of the umbilical cord (on haemoglobin level) in full-term neonates

Sixty term infants delivered vaginally were assigned randomly to one of the two management groups; early cord clamping (ECC) or delayed cord clamping (DCC). Six months after delivery, the children in both groups were called back for follow-up. Blood samples were obtained for measuring haemoglobin (Hb), haematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), serum iron (SI), transferrin saturation (TS) and serum ferritin (SF) levels. The mean Hb, HCT, SI and TS at 6 months were significantly higher in the DCC group (95% confidence interval (CI); p<0.001, p<0.001, p<0.024 and p<0.009). The mean SF at 6 months was also higher in the DCC group but it was not significant (p<0.071). Polycythaemia, jaundice and other undesirable side-effects of DCC were not seen.

L-asparaginase induced hyperlipidaemia in acute lymphoblastic leukaemia

OBJECTIVE

To evaluate hyperlipidaemia in patients with acute lymphoblastic leukaemia (ALL) receiving L-asparaginase.

METHODS

A case-control study carried out between October 2007 and October 2010 with 77 patients undergoing chemotherapy at a teaching children's hospital in Babol, Iran. Patients were treated with anti-leukaemic agents according to the protocols for standard-risk and high-risk ALL. Those patients who received asparaginase represented the cases and those who did not receive it were the controls. Biochemical markers were checked during the induction phase chemotherapy. Lipid profile of patients was recorded. Data was analysed using SPSS 16.

RESULTS

Of the 77 patients, 37 (48.05%) received asparaginase therapy and 40 (51.94%) patients did not.The mean peak triglyceride and cholesterol levels during asparaginase therapy in the first group were significantly higher than the levels in the second group.

CONCLUSION

Severe hyperlipidaemia may be the cause of some morbidity in children receiving asparaginase. Asparaginase-induced hyperlipidaemia should be monitored in ALL patients during the induction phase of treatment.

Evaluation of inhibitor antibody in hemophiliaA population

BACKGROUND

Inhibitor antibody to exogenous Factor VIII (FVIII) is a major complication of hemophilia treatment. This study was conducted to determine the prevalence of inhibitor antibody directed against FVIII.

METHODS

From May 2010 to May 2011, 52 patients with severe hemophilia A admitted in Amirkola Children's Hospital were evaluated. Those who had abnormal mixing study, antibody against FVIII were measured. Data were collected and analyzed.

RESULTS

The age range of the patients was 4-60 years. The inhibitor antibody was seen in 9 (17.3%) patients. The mean age of patients with inhibitor at the time of diagnosis was 10.22 years (ranged 4-31 years). Old patients had more hemarthrosis than young patients. The mean level of inhibitor antibody was 8.47 Bethesda unit (ranged 2.3-29). Six patients had inhibitor antibody level ≥5 Bethesda unit and three patients had inhibitor antibody level <5 Bethesda unit.

CONCLUSION

This study showed that the prevalence of inhibitor antibodies in young patients is more than the old patients.

Acute Lymphoblastic Leukemia with Eosinophilia and Strongyloides stercoralis Hyperinfection

BACKGROUND

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children. Bone pain is an important symptom that can be severe. Eosinophilia without any other abnormal laboratory findings is rare in ALL. Strongyloides stercoralis in ALL causes disseminated fatal disease.

CASE PRESENTATION

This 9-year-old girl presented with bone pain in lumbar region. Bone pain was the only symptom. The patient didn't have organomegaly. The BM samples were studied by flow cytometry, which showed pre-B cell ALL. Larva of Strongyloides stercoralis was found in fecal examination. Plain chest x ray showed bilateral para-cardiac infiltration. Strongyloidiasis was treated before starting chemotherapy. After two days treatment with Mebendazol the patient developed cough, dyspnea, respiratory distress and fever. The treatment changed to Ivermectin for 2 days. Chemotherapy started five days after diagnosis of leukemia.

CONCLUSION

The patient complained merely of bone pain in lumbar region without any other signs and symptoms. Peripheral blood smear showed eosinophilia without any other abnormality. Stool examination showed Strongyloides stercoralis larvae. We suggest that all patients diagnosed as ALL in tropical and subtropical regions should be evaluated for parasitic infection especially with Strongyloides stercoralis.

Severe generalized muscular atrophia, nerve optic atrophia, ear problem and disability with Pelger-Huet anomaly

BACKGROUND

The Pelger-Huet anomaly dominantly is a rare and benign inherited defect of terminal neutrophil differentiation. Although neutrophil migration may be minimally impaired, granulocytes function is otherwise normal association abnormalities such as ocular, musculoskeletal are reported very rare. Case Presentation : An eight year-old boy with good consciousness but severe muscular atrophia and difficulty in respiration was admitted in Amirkola Hospital at Babol University of Medical Sciences Babol, Iran. The patient was febrile at presentation. The chest x-ray was normal and other causes of respiratory problem were ruled out. The patient and his mother have 30% to 40% band and Pelger-Huet cells in peripheral blood smear. He gradually has gotten hearing loss and decreased visual acuity for three years. He has optic nerve atrophia.

CONCLUSION

The patient is an unusual type of Pelger-Huet anomaly with multiple organ dysfunctions probably due to simultaneous muscular degenerative disease.