[Analysis of the clinical features and the risk factors of severe adenovirus pneumonia in children]

Objective: To analyze the clinical characteristics, risk factors for critical illness and death of severe adenovirus pneumonia in children, so as to provide clinical evidences for early diagnosis and reliable treatment. Methods: A total of 75 pediatric cases with severe adenovirus pneumonia admitted to Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January to October 2019 were studied. The clinical features, laboratory and imaging data, therapeutic approaches, efficacy of the treatments and prognosis were investigated retrospectively. Patients were divided into severe group and critical group. Chi square test and Mann-Whitney U rank sum test were used to analyze the data of the two groups. The risk factors for critical illness and death were analyzed by univariate and multivariate Logistic regression. Results: Among the 75 children, there were 52 males and 23 females, aged from 3 months to 8 years, including 30 of severe cases and 45 of critical case. The positive rate of adenovirus antigen in nasopharyngeal swab was 21% (15/72), and the positive rate of serum adenovirus IgM antibody was only 13% (10/75). However, the positive rate of adenovirus nucleic acid in nasopharyngeal swab was 75% (21/28). What is more, the positive rates of metagenomics next generation sequencing (mNGS) in plasma and bronchoalveolar lavage fluid were 92% (33/36) and 96% (54/56), respectively, of which 95% (63/66) were confirmed as adenovirus type 7. Relatively high dose of ribavirin and integrated therapeutic approaches (respiratory support, glucocorticoids, immunoglobulin and organ supportive therapies) were used. The recovery rate was 77% (58/75), the improvement rate was 8% (6/75) and the mortality rate was 15% (11/75). The proportion of children with the duration of fever longer than 3 days after ribavirin treatment in the critical group was significantly higher than that in the severe group(51% (18/35) vs. 8% (2/26), χ²=12.949, P<0.05). The risk factors for critical illness were younger than 4 years, longer duration of fever before and after admission to PICU, oxygenation index<300 mmHg (1 mm Hg=0.133 kPa), ferritin>1 000 μg/L, lactate dehydrogenase (LDH)>1 500 U/L, 5 lung lobes involvement, pleural effusion and (or) air leakage (all P<0.05). Among them, 5 lung lobes involvement was the independent risk factor for critical illness (adjusted OR=49.641, 95%CI 4.186-588.618, P=0.002). Risk factors for death included longer duration of fever after being admitted to PICU, oxygenation index<100 mmHg, ferritin>2 000 μg/L, interleukin (IL)-6>100 ng/L, LDH>1 500 U/L, pleural effusion and (or) air leakage (all P<0.05). Among them, IL-6>100 ng/L was the independent risk factor for the mortalities of critically ill children (adjusted OR=16.094, 95%CI 2.059-25.787, P=0.008). Conclusions: The mortality rate of severe pediatric adenovirus pneumonia caused by adenovirus type 7 is high. High positive rates of adenovirus nucleic acid in nasopharyngeal swabs and mNGS in plasma or bronchoalveolar lavage fluid contribute to early diagnosis, and mNGS can also be used for serotyping. Younger children under 4 years of age, persistent fever, extensive pulmonary lesions and significantly increased inflammatory cytokines such as IL-6 are warning indicators for critical illness and poor prognosis. Relatively high dose of ribavirin combined with integrated therapeutic approaches are beneficial for prognosis.

[Analysis of pathogenic composition and clinical characteristics of viral acute gastroenteritis in children under five years old in Beijing]

Objective: To understand the epidemiological characteristics and clinical features of rotavirus-, norovirus-, adenovirus-and astrovirus-associ ated acute gastroenteritis in children under 5 years old in Beijing from Octorber, 2015 to March, 2017. Methods: In the intestinal clinic of 6 hospitals in 6 districts of Beijing, information and stool samples of the first 30 patients with acute gastroenteritis who are under the age of 5 years are collected monthly.Rotavirus, norovirus, adenovirus and astrovirus are identified by PCR.Descriptive epidemiological method was used to describe the epidemiological characteristics of diarrhea caused by rotavirus, norovirus, adenovirus and astrovirus in Beijing. One-way analysis of variance was used to analyze the Vesikari clinical severity score of of acute gastroenteritis caused by each virus. Unconditional logistic regression analysis was used to analysis the associated factors of clinical features. Results: Of the 2 052 samples, 709 (34.6%) were non-mixed infections: the positive rate of rotavirus, norovirus, adenovirus and astrovirus were 20.0%, 7.5%, 4.2% and 2.9%, respectively. A total of 135 cases (6.6%) were mixed infection. The mean and standard deviation of Vesikari clinical severity score was 8.0±3.1 for rotavirus associated acute gastroenteritis, which was significantly higher than norovirus (6.4±2.4, P<0.001), adenovirus (6.2±2.1, P<0.001) and astrovirus (6.1±2.0, P<0.001). The comparison of clinical features showed that compared with astrovirus, the children under 5 years old infected with rotavirus were more likely to have a diarrhea ≥5 days (OR=3.334), have vomiting ≥3 times within one day (OR=8.788), have vomiting≥1 day (OR=3.963), have a Vesikari clinical severity score ≥11 severe cases (OR=13.194). Norovirus infected cases were prone to have vomiting≥3 times in 1 day (OR=5.710).Adenovirus infected cases were prone to have a diarrhea≥5 days (OR=2.616). When using rotavirus as a reference, children under 5 years of age were less likely to develop fever≥38.4 ℃ after infection with norovirus (OR=0.397) or adenovirus (OR=0.280). Conclusions: The results of this study showed that the characteristics of acute gastroenteritis caused by different viruses are different. The clinical symptoms caused by rotavirus are more serious. Children under 24 months of age are at high risk of rotavirus infection. Effective preventive measures such as vaccination should be taken as soon as possible.

[Effect of high-titer plasma in pediatric patients with severe adenovirus pneumonia]

Objective: To explore the efficacy and safety of high-titer plasma in the treatment of pediatric patients with severe adenovirus pneumonia. Methods: The clinical data of 92 pediatric patients with severe adenovirus pneumonia admitted to pediatric intensive care unit (PICU) in Guangzhou Women and Children's Medical Center from January 2016 to October 2019 were retrospectively collected. According to the treatment with or without high-titer plasma, the patients were divided into plasma treatment group (n=41) and non-plasma treatment group (n=51). The 51 patients with chest radiograph showing more than half the lungs involved were divided into plasma treatment group (n=29) and non-plasma treatment group (n=22). According to fever duration before plasma treatment, patients were divided into early group (≤5 days, n=5), middle group (>5-10 days, n=14), and late group (>10 days, n=22). Baseline data, therapeutic effects, and prognosis of patients in each group were analyzed with t test, non-parametric rank sum test, one-way ANOVA and chi-square test. Results: Ninety-two patients were included. There were no significant differences in age, gender, body weight, fever duration, sequential organ failure assessment, and Murray lung injury score between plasma treatment group and non-plasma treatment group before admission (all P>0.05). The proportion of patients whose temperature drop to normal within 5 days was higher in plasma treatment group than that in non-plasma treatment group (88% (36/41) vs. 69% (35/51), χ(2)=4.745, P=0.029). However, there were no significant differences between the two groups in the proportions of invasive ventilator weaning within 14 days (63% (26/41) vs. 76% (39/51), χ(2)=1.868, P=0.172), transfer out from PICU within 14 days (49% (20/41) vs. 69% (35/51), χ(2)=3.724, P=0.054), discharge within 28 days (51% (21/41) vs. 61%(31/51), χ(2)=0.846, P=0.358) and survived patients (85% (35/41) vs. 76%(39/51), χ(2)=1.143, P=0.285). Among patients with severe chest radiograph, the proportions of patients whose temperature drop to normal within 5 days and survived patients were higher in plasma treatment group than those in non-plasma treatment group (86% (25/29) vs. 59% (13/22), χ(2)=4.843, P=0.028; 83% (24/29) vs. 55%(12/22), χ(2)=4.796, P=0.029, respectively). However, there were no significant differences between the two groups in the proportions of invasive ventilator weaning within 14 days (52% (15/29) vs. 59% (13/22), χ(2)=0.274, P=0.601), transfer out from PICU within 14 days (34% (10/29) vs. 45% (10/22), χ(2)=0.632, P=0.427), and discharge within 28 days (45% (13/29) vs. 45% (10/22), χ(2)=0.002, P=0.964). Among early, middle and late group, the proportions of invasive ventilator weaning within 14 days were 2/5, 13/14 and 50% (11/22), respectively, with statistically significant difference (χ(2)=8.119, P=0.017). There were no significant differences in the proportions of patients whose temperature drop to normal within 5 days (4/5, 14/14, 82% (18/22), χ(2)=2.965, P=0.227), transfer out from PICU within 14 days (2/5, 10/14, 36%(8/22), χ(2)=4.386, P=0.112), discharge within 28 days (2/5, 8/14, 50% (11/22), χ(2)=0.462, P=0.794) and survived patients (4/5, 13/14, 82% (18/22), χ(2)=0.966, P=0.617) in the three groups. Only one case with high-titer plasma therapy had rash in the course of infusing plasma and no other adverse reactions were observed. Conclusions: High-titer plasma can shorten the fever time and improve the proportion of survival patients in pediatric severe adenovirus pneumonia. The clinical effect of high-titer plasma is better in 5-10 days of fever course. High-titer plasma is an effective and safe treatment.