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Title of Case(s)

FEVER AND CHOLESTASIS IN A MULTIVISCERAL TRANSPLANT RECIPIENT

Background

Infections due to multidrug resistant microorganisms represent a therapeutic challenge regarding the limited antibiotic options, especially in the pediatric population.

Case Presentation Summary

A 17-year-old male was admitted for acute cholangitis. He received a second multivisceral transplant 4 years ago (in treatment with sirolimus and corticosteroids) because of short bowel syndrome. He was also a candidate for retransplantation due to hepatic disorder with bile ducts stenosis and predisposition to recurrent cholangitis (need for replacement of several biliary prosthesis). He carried a plastic biliary prosthesis and presented recurrent cholangitis due to multidrug resistant microorganisms (last episode due to VIM-producing P.aeruginosa).

In this episode, empirical treatment with meropenem, colistin and vancomycin was started, and other options were considered in case of no response or resistance to treatment, such as cefiderocol or ceftazidime-avibactam-aztreonam combination as a last option. On the second day of admission, VIM-producing P.aeruginosa was isolated in peripheral blood culture being colistin sensitive with intermediate sensitivity to meropenem (MIC 4 mcg/ml). An endoscopic retrograde cholangiopancreatography (ERCP) was performed, with dilation and replacement of biliary prosthesis, controlling the source of infection with fever resolution after 48 hours; vancomycin sensitive Enterococcus faecium and VIM-producing P. aeruginosa were isolated from bile and biliary prosthesis cultures.

He completed a three-week course of meropenem, vancomycin and colistin, with clinical improvement and blood culture negativization.

Key Learning Points

When we have few active antibiotics against the causative microorganism, we could consider the use of new antibiotics, however more studies are needed to determine their effectiveness and penetration. This case highlights the importance of controlling the source of infection as part of the treatment.

Title of Case(s)

The relevance of a multidisciplinary approach

Background

The main objective of the paediatric Antibiotic Stewardship Programs (pASP) is to enhance patients’ outcome effectively treating infections, protecting them from harms caused by unnecessary antibiotic use (including antibiotic resistances), and optimizing treatment cost-effectiveness.

We present a case that underlines the importance of a multidisciplinary approach including source control to solve recurrent infections in a severely immunocompromised patient.

Case Presentation Summary

A 6-year-old boy, born from non-consanguineous parents, diagnosed of hepatitis-associated aplastic anemia was admitted due to febrile neutropenia while in search for HSCT donor.

During the firsts weeks of admission, he presented several febrile neutropenic episodes with negative cultures, each 7-10 days, treated per protocol with piperacillin-tazobactam (PT) and amikacin, or meropenem if hemodynamic instability. One month later he presented sepsis due to Klebsiella pneumoniae (PT and ceftazidime resistant) treated with meropenem (5 days), then cefotaxime (7 days). Five days after antibiotic withdrawal, bacteriemia recurred. Physical examination revealed profound and progressive anal fissure. MR ruled out fistula and abscesses.

Further episodes of bacteraemia by multi-drug resistant microorganisms (MDR) were documented, concomitant isolation of Pseudomonas putida, Enterococcus faecium and Staphylococcus haemolyticus (treated with ceftazidime); vancomycin-resistant Enterococcus faecium (treated with tigecycline); Klebsiella pneumoniae (treated with cefotaxime) and vancomycin-and-tigecycline resistant Enterococcus faecium (treated with linezolid). The recurrence and characteristics of the isolated microorganisms (polymicrobial bacteraemia, enteric rods) were highly suggestive of a colonic or rectal reservoir, after a multidisciplinary meeting led by the pASP group, a discharge colostomy was performed 4 months after admission. Although he presented early surgical complications with VIM-producing Pseudomonas aeruginosa- septic shock, PICU admission and requirement of multiple interventions, finally HSCT was performed successfully. Currently he is two months post HSCT, with haematological recovery and no active infectious processes.

Key Learning Points

Should discharge colostomy had been performed earlier?

Is there a role for recently-approved in children antibiotics in the treatment of these patients?

Title of Case(s)

Abdominal pain and fever: non-specific features of an uncommon diagnosis.

Background

Paediatric Inflammatory Multisystem Syndrome, temporally associated with SARS-CoV-2 (PIMS-TS) is a clinical diagnosis that emerged in April 2020. The Royal College of Paediatrics and Child Health case definition includes persistent fever, inflammation and evidence of organ dysfunction with the exclusion of another microbial cause. Common clinical manifestations include rash, conjunctivitis, mucositis and abdominal pain; these are non-specific features of many other paediatric illnesses.

Case Presentation Summary

A 9-year-old girl presented in June 2020, with 14 days of fever, reduced appetite and weight loss. She described 6-months of episodic abdominal pain and had travelled to Pakistan 8 months earlier. On arrival she was febrile, had cracked lips, conjunctivitis and a facial rash. Her abdomen was distended and diffusely tender with right lower quadrant fullness but no discrete mass. Her blood tests were remarkable for neutrophils of 5.5x10^9/L; lymphocytes 1.2x10^9/L; CRP 78mg/L; Ferritin 155ug/L; Albumin 27g/L; LDH 359unit/L; D-dimer 2227mg/mL; Troponin <5ng/L and BNP 41ng/L. She was initially treated with ceftriaxone, metronidazole and gentamicin. Intravenous immunoglobulin, low dose aspirin and prophylactic tinzaparin were added due to possible PIMS-TS. Her echocardiogram was normal. Computerised tomography(CT) abdomen showed significant peritoneal thickening, a mass of mesentery in the lower abdomen and sub-phrenic lymphadenopathy. CT chest showed subtle tree and bud appearance of the left apex with necrotic lymphadenopathy. Omentum obtained by diagnostic laparoscopy was both polymerase chain reaction and culture positive for Mycobacterium tuberculosis. Her recovery was complicated by post-operative colonic perforation requiring paediatric intensive care unit admission. She has since improved and been discharged home following initiation of anti-tuberculous treatment.

Key Learning Points

Abdominal tuberculosis occurs in an estimated 1-3% of paediatric tuberculosis cases and can be difficult to diagnose due to its non-specific and insidious presentation. This case highlights the challenges of making uncommon diagnoses during the emergence of a new clinical syndrome with an evolving case definition.

Title of Case(s)

Sick or Sickling?

Background

The Multisystem Inflammatory Syndrome in Children (MIS-C) was first reported in May 2020 at the start of the SARS-CoV-2 pandemic. MIS-C occurs 4-6 weeks after primary SARS-CoV-2 infection and appears to represent a delayed immune reaction to the virus. The diagnosis is a more challenging when there are comorbidties that can mimic the presenting features of MIS-C.

Case Presentation Summary

A 13 year old Sudanese boy with sickle cell disease was admitted with headache and dyspnoea and was found to be SARS-CoV-2 PCR positive. He developed an oxygen requirement and received a blood transfusion, enoxaparin and dexamethasone.

On day 5 he developed severe leg and abominal pain and fever. Differential diagnoses included sickle cell crises, bacterial infection and MIS-C. Bloods: CRP 220, D dimer 15,000, ferritin 566, blood cultures negative.

Initial echocardiogram and ECG were normal. Concerns over the risk of high dose steroids were raised (posterior reversible encephalopathy syndrome or intracranial haemorrhage) and as such 2mg/kg methylprednisolone was commenced together with aspirin. He defervesced after 3 days and was discharged with prednisolone.

He represented with fever, leg pain and CRP of 20. Echocardiogram now showed coronary artery dilation and reduced left ventricular function. To reduce thrombosis risk, IVIg was given as 1g/kg over two days and prednisolone was doubled. His pain persisted and an exchange transfusion performed to reduce the HbS fraction with good effect.

He is currently awaiting cardiology review.

Key Learning Points

This complex case highlights the difficulties in interpreting laboratory values (D dimer, ferritin) when MIS-C is supspected in children with sickle cell disease, which is already a hyperinflammatory and procoagulant state.

It also reminds us to carefully consider the risk-benefit balance of giving IVIg in a child who is already hyper-viscous with sickle cell disease and the concerns of using high dose methylprednisolone in this population with respect to stroke risk.