Background

Sepsis and septic shock is one of the major causes for neonatal mortality. Damage Associated Molecular Pattern like High Mobility Group Box-1 (HMGB-1) protein play an important role in the progression of sepsis

Objectives

To compare HMGB1 levels in preterm neonates of ≤ 34 weeks’ gestation with septic shock with gestation and postnatal age matched controls without sepsis

Methods

Preterm neonates of ≤ 34 weeks’ gestation with septic shock were included.Exclusion: Intraventricular hemorrhage (≤ grade 3), severe birth asphyxia and moribund neonates. Primary outcome: HMGB1 level at onset of septic shock. HMGB1 levels were measured within 2 hours of onset of septic shock. Level of sickness at enrolment was assessed by score for neonatal acute physiology-II. All neonates were followed till 7 days from enrolment.

Results

Mean (SD) gestation and birth weight of neonates with septic shock were 30±2.7 weeks and 1192±409g respectively and were comparable with controls. Mean (SD) HMGB-1 levels was higher in neonates with septic shock in comparison to controls [10.95 (7.13) versus 8.98 (7.6); MD (95% C.I): 1.97(-2.23,6.17), p=0.065]. Mean (SD) HMGB1 levels were significantly different between neonates with septic shock, sepsis without shock and no sepsis [10.95 (7.13) versus 12.3 (9.2) versus 9.5 (7.8); Friedman’s p=0.009].

Conclusion

A trend towards higher HMGB-1 levels was observed in neonates with septic shock and sepsis without shock in comparison to neonates without sepsis. Larger, multicentric studies are required to study the role of this molecule in progression of neonatal sepsis

Background

In Intensive Care of the Bambino Gesù Pediatric Hospital in Palidoro, set in an 8 beds, from April to June, an increase in infections related to the use of midline (table 1) and cvc (table 2) was observed.

Objectives

Following a statistical analysis, strategies were implemented to standardize the individual management procedures among all staff and reach the zero target.

Methods

The interventions for quality improvement project included:

- central line management performed by a vascular access expert nurse

- inclusion of a cap dipped in isopropyl alcohol placed on the needle free connector of the infusion line, which allowed drugs administration and made blood tests more quick, signaling to the operator that access is already disinfected

- working group on the ward

- no-touch technique and standardization of medication preparation and administration

- use of Check lists to monitor positioning, dressing change, and management of the infusion line

Results

Startig from July 2018 a reduction in infections was immediately observed, but linked to a lower number of hospitalized patients and the need to use the devices.

Conclusion

Next months, with the increase of the number of patients and the consequent use of the cvc and midline (immagine 1 -2), the positive trend was confirmed thanks to the compliance of all staff to effectively apply techniques and tools tested.

Background

Mechanical ventilation (MV) may be required in paediatric severe sepsis (SS). The decision to initiate MV usually relies on clinician judgment. Studies in paediatric sepsis have shown rates of MV of up to 75% and adverse events in up to 60% tracheal intubations.

Objectives

In this retrospective observational study, we describe characteristics and outcomes of patients with SS admitted to a PICU in a tertiary hospital as well as their rates of MV.

Methods

We reviewed PICU discharge summaries from June 2015 to June 2018. Patients between 1 month and 18 years admitted to PICU with SS were included. Exclusion criteria were shock without sepsis cause, tracheostomy and long-term ventilation.

Results

We analysed 99 episodes of SS. Of them 78% had comorbidities (19% bone marrow, 7% solid organ transplants, 36% other immunosuppression), 30% received MV, 90% vasoactive support, 38% corticosteroids, 12% continuous renal replacement therapy, 6% plasmapheresis and 1% ECMO. Length of PICU stay was 4 days (IQR 2-8) and 28-d mortality 11%.

In patients on MV, 70% were intubated in the first 24 hours, mostly for a respiratory cause. MV days was 3.5 (IQR1-11.2). PIM3, PRISM, PICU length of stay, vasoactive-inotropic score and 28-d mortality was significantly higher. There were 8 cardio-pulmonary arrests within the first 24 hours post intubation.

Conclusion

We found low rates of MV and low overall mortality in patients with SS admitted to PICU. A large multicentre prospective study aiming to describe the impact of different clinical practices regarding initiation of MV in paediatric SS is needed.

Background

Influenza is generally a self-limited infection,however severe complications can be observed even in immunocompetent populations.

Objectives

Clinicians need to have increased awareness and manage these complications promptly.

Methods

We present 3 paediatric cases of rare and serious complications of influenza infection admitted in PICU.

Results

Case 1:A previously healthy 3,5year-old girl presented with hypovolemic shock,significant hemoconcentration(Hgb20,5g/L),hypoalbuminemia(2g/dL),hyponatraemia and metabolic acidosis.She was resuscitated requiring crystalloid fluids,albumin and started on antibiotics and oseltamivir.NPA tested positive for influenza B virus.Based on the classic triad of hypotension,hypoalbuminemia and hemoconcentration Systemic Capillary Leak Syndrome triggered from Influenza B virus was diagnosed.She was treated with iv albumin&furosemide which led to eventual recovery and she continued treatment with IVIG.

Case 2:An 18-month old toddler with history of failure to thrive presented with prolonged fever,diarrhea and rash with positive PCR for Influenza B virus on oseltamivir,required admission to PICU due to seizures.A marked increase in ferritin,triglycerides,liver enzymes with concurrent aplastic bone marrow &coagulopathy led to the diagnosis of virus-associated hemophagocytic syndrome(VAHS)triggered by Influenza B,treated as per HLH-2004 protocol.Congenital HS was excluded by genetic screening.Despite full support she suffered cerebral edema and expired on day 6 of hospitalization.

Case 3:A previously healthy 3year-old girl presented with fever,haematuria and acute haemolytic anaemia(Hb 5gr/dl)with positive PCR for Influenza A virus and was admitted to our Unit for monitoring and management.She received blood transfusions,antibiotics,oseltamivir and corticosteroids showing rapid improvement and post-discharge she remained without relapses.

Conclusion

Influenza virus doesn’t always have a benign and self-limited course so high index of suspicion is important to avoid life-threatening complications.

Background

Anaplastic large cell lymphoma(ALCL)is an aggressive neoplasm of T- or null cell phenotype, recognized as a distinct clinicopathologic subtype of non-Hodgkin lymphoma which is difficult to diagnose pre-mortem.

Objectives

To increase awareness of a rare clinical entity.

Methods

We present a 12 year old patient with the unusual clinical presentation of ALCL mimicking fever of unknown origin(FUO)and sepsis.

Results

The patient presented with a 2-month history of prolonged FUO,joint pain and increased inflammation markers and was started on broad spectrum antibiotics.One month later,he showed clinical features consistent with Kawasaki syndrome with liver involvement.He was started on IVIG and aspirin as per guidelines,he received methylprednisolone pulses with temporary improvement whereas the liver lesions and the enlarged lymph nodes persisted.The extended investigations(infectious,rheumatologic and autoimmune diseases,cancer markers,bone marrow aspiration, abdominal CT)didn’t confirm any diagnosis. While he was stable on antibiotics and cortisone,he suddenly deteriorated in the paediatric ward with high fever,abdominal pain,abnormal blood tests with leukaemoid reaction,coagulation disorders, renal failure, hypoglycaemia and profound lactic acidosis so he was admitted to our Unit. Upon his admission bone marrow biopsy was taken and antibiotics were continued but with ongoing clinical deterioration which quickly resulted in respiratory and haemodynamic compromise requiring intubation and inotropic support.Despite full support, the patient couldn’t recover from multiple organ failure and he suffered cardiac arrest within 48 hours form addmision.Bone marrow biopsy and post-mortem liver biopsy revealed Non- Hodgkin ALCL.

Conclusion

Early recognition of ALCL is of great importance in order to prevent the rapid clinical decline and facilitate potentially timely pre-mortem diagnosis and therapy.

Background

Use of RBC exchange in severe malaria is unclear from current literature. RBC exchange in severely ill patients with hyperparasitemia (i.e. >10%) appears to ‘improve blood rheological properties, capillary perfusion and microcirculatory flow’.

Objectives

Review current guidance for RBC exchange transfusion in severe paediatric malaria.

Methods

Case presentation and review of published guidance.

Results

A 19 month old Nigerian infant was admitted extremely unwell, tachypnoeic, tachycardic and encephalopathic, following focal seizure.

Initial results confirmed profound metabolic acidosis (pH 6.86), high lactate (21mmol/l), normal blood sugar (5.7mmol), anaemia (haemoglobin 54g/dl), thrombocytopenia (platelet 16x10⁹/l), and coagulopathy with hepatorenal impairment. Peripheral blood smear showed plasmodium falciparum with 35% parasitaemia. CT head was normal with typical retinal haemorrhages on fundoscopy.

Following PICU admission he commenced intravenous artesunate and broad spectrum antibiotics.

Due to disease severity, after multi agency discussion with UK colleagues, he received an automated RBC exchange transfusion with good effect. He completed 5 days of IV artesunate and 6 doses of Artemether with Lumefantrine.

At discharge, his MRI Brain and neurological examination was normal.

The CDC recommends that exchange transfusion be strongly considered in hyperparasitaemia if complications such as cerebral malaria, pulmonary oedema, or renal compromise exist. Automated RBC exchange is safe and well tolerated and has advantages of retaining plasma with antimalarial drugs, clotting factors and platelets.

Conclusion

This case highlights good response to exchange transfusion in addition to artesunate. We suggest the theoretical advantages of RBC exchange transfusion should merit consideration in extremely ill patients with high parasite load, in a resource rich setting. .

Background

Neonatal Infective Endocarditis (IE), both bacterial and fungal is a rare and usually fatal disease. Its incidence appears to be on the rise due to an increase in invasive techniques used for neonatal management.

Objectives

We share our experience in treating three such cases.

Methods

A 5 day old term male was referred for worsening sepsis. He had early onset sepsis requiring intravenous (iv) Piperacillin tazobactum and multiple inotropes. Two Dimensional Echocardiography (2 D Echo) showed vegetations on tricuspid and pulmonary valves and two blood cultures grew Staphylococcus epidermidis. He was treated with iv Vancomycin for six weeks.

19 day old 32 weeker preterm twins were referred for large patent ductus arteriosus, signs of failure and fungal sepsis. 2D Echo of first twin showed a small vegetation in Right Atrium. Two Blood cultures were positive for Candida tropicalis. 2D Echo of second twin showed a large vegetation in Inferior Vena Cava extending into Right Atrium. Her blood cultures showed Enterococcus fecium and Candida tropicalis growth. She received iv Tigecycline, Colistin and Ofloxacin for three weeks followed by iv Vancomycin for six more weeks. Both the twins received iv Caspofungin for two weeks followed by oral Fluconazole for six more weeks for the fungal IE.

All three babies had history of Umbilical Venous Catheterisation at birth.

Results

Repeat Echocardiogram of the babies was free of vegetations. They were developmentally normal until recent follow up.

Conclusion

Neonatal IE is rare but a high index of suspicion with reliable echocardiography will facilitate prompt treatment reducing morbidity and mortality.

Background

Naegleria fowleri is a thermophilic ameba. It can be the causative agent of Primary Amoebic Menintoencephalitis (PAM), a rare and lethal disease which mortality rate is over 97%.

Objectives

We report a survival case of Primary Amoebic Meningoencephalitis for Naegleria fowleri infection in a 10-year-old girl from Spain.

Methods

Ten-year-old girl arrived to the Emergency Care Unit reporting progressive and persistent left ear pain, retroocular headache with diminution of consciousness level, Glasgow 14/15 with focal neurological symptoms. Blood analysis and Cerebroespinal fluid (CSF), after conducting a Computed Tomografy (CT), suggested bacterial infection.

She was admitted to Intensive Care Unit with the diagnostic of complicated otomastoiditis with cavernous sinus thrombophlebitis and meningitis. She was treated with meropenem and vancomycin. After eight days without response to treatment a MRI was performed, showing hemorrhagic infarction on the left cerebral peduncle, left hemiprotuberance and right thalamus.

Results

As all bacterial cultures, tuberculosis PCR and microbiology tests were negative, and she was swimming in an indoor pool, an amoebic meningoencephalitis was suspected. N.fowleri was detected in CSF and pool water.

Treatment using combination drug therapy (Amphotericin B deoxycholate, azithromycin, fluconazole, rifampicin and miltefosine) and management of intracranial pressure, allowed survival.

Conclusion

To the best of our knowledge, this is the first reported case of PAM in Spain. In our case, the clinical suspicion allowed an appropriate action. In meningitis with negative bacteriology and poor response to conventional treatment should be suspected rare microorganisms such as amoeba. The source of infection was identified, so Health authorities could be alerted.