Immunocompetent Children Research Articles

Stage IV Burkitt Lymphoma Presenting with Eyelid Swelling

Burkitt lymphoma is a rare and aggressive tumour which predominantly affects children. We report a case of Stage IV Burkitt lymphoma (non-endemic type) in a 5-year-old immunocompetent Malay child who initially presented with left upper eyelid swelling. Clinical examination revealed a soft solid swelling over the left upper lid, extending temporally up to the lacrimal gland. Computed tomography (CT) scan showed a homogenous mass of soft tissue density with intracranial and left orbital involvement. Incisional biopsy of the mass revealed histological changes suggestive of B lymphoblastic lymphoma or leukemia. She was treated with 6 cycles of chemotherapy. Post chemotherapy, the left temporal and upper eye lid swelling subsided. Clinicians need to be on alert when encountering children with eyelid swelling, as this could be an initial presenting feature of Burkitt lymphoma without other systemic symptoms. A delay in diagnosis can lead to aggressive orbital involvement followed by permanent visual loss.

Human Herpesviruses 6A and 6B in Brain Diseases: Association versus Causation.

Human herpesvirus 6A (HHV-6A) and human herpesvirus 6B (HHV-6B), collectively termed HHV-6A/B, are neurotropic viruses that permanently infect most humans from an early age. Although most people infected with these viruses appear to suffer no ill effects, the viruses are a well-established cause of encephalitis in immunocompromised patients. In this review, we summarize the evidence that the viruses may also be one trigger for febrile seizures (including febrile status epilepticus) in immunocompetent infants and children, mesial temporal lobe epilepsy, multiple sclerosis (MS), and, possibly, Alzheimer's disease. We propose criteria for linking ubiquitous infectious agents capable of producing lifelong infection to any neurologic disease, and then we examine to what extent these criteria have been met for these viruses and these diseases.

The pediatric solid organ transplant experience with COVID-19: An initial multi-center, multi-organ case series.

The clinical course of COVID‐19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi‐center, multi‐organ cohort analysis of COVID‐19‐positive transplant recipients ≤ 18 years at time of transplant. Data were collected via institutions’ respective electronic medical record systems. Local review boards approved this cross‐institutional study. Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. Six were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n = 12 (46%)), fever (n = 9 (35%)), dry/sore throat (n = 3 (12%)), rhinorrhea (n = 3 (12%)), anosmia (n = 2 (8%)), chest pain (n = 2 (8%)), diarrhea (n = 2 (8%)), dyspnea (n = 1 (4%)), and headache (n = 1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post‐transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Our multi‐institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID‐19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required.

Tubercular splenic abscess and recurrent acute on chronic tubercular pancreatitis: a rare coincidence in an immune competent child

Tubercular splenic abscess in association with chronic tubercular pancreatitis is scarcely reported in an immune competent child. 12 years old boy had presented with recurrent attacks of upper abdominal pain radiating towards left shoulder. He had multiple hospitalizations with similar complaints. The child had associated anorexia and significant weight loss during the period of his illness. Clinical examination revealed tenderness and muscle guard over the epigastric region. The pancreatic enzymes were markedly raised. Abdominal CT scan had suggested chronic pancreatitis with multiple splenic abscesses. The cartridge- based nucleic acid amplification test (CBNAAT) of the pus aspirated from the abscess confirmed the presence of pan sensitive mycobacterium tuberculosis. Image guided fine needle aspiration biopsy revealed the presence of caseating granulomatous lesion. Treatment with anti-tubercular drugs led to complete clinical recovery and normalization of pancreatic enzymes at follow up. An immunocompetent child had chronic tubercular pancreatitis associated with tubercular splenic abscess.

Orbital mucormycosis in immunocompetent children; review of risk factors, diagnosis, and treatment approach

BackgroundOrbital mucormycosis is a rare but potentially severe and troublesome invasive fungal infection that could be occurred even in healthy individuals. The initial clinical presentation is similar to bacterial pre-septal or septal cellulitis, especially in early stages.Case presentationHerein, we describe the successful management of a series of five cases presenting with orbital mucormycosis in previously healthy children.ConclusionsOrbital mucormycosis is extremely rare in healthy children and maybe life-threatening when diagnosis delayed given a similar clinical presentation with bacterial septal cellulitis. Intravenous antifungal therapy with amphotericin B and timely surgical drainage is live-saving.

Immune Response against Adenovirus in Acute Upper Respiratory Tract Infections in Immunocompetent Children.

During acute upper respiratory tract infections (AURTIs) caused by Adenoviruses, the mix of severe clinical presentation, together with elevation of white blood cells (WBCs) and C-reactive protein (CRP), often mimicking bacterial infection, leads to an inappropriate use of antibiotics. We studied 23 immunocompetent children admitted to our Pediatric Emergency Unit with signs of acute Adenoviral AURTIs, aiming at better clarifying the biological background sustaining this clinical presentation. Infection etiology was tested with nasopharyngeal swabs, serology, and DNA-PCR. During fever peaks and subsequent recovery, we assessed WBC count with differential, CRP, procalcitonin, serum concentration of six inflammatory cytokines, and lymphocyte subset populations. Results: IL-6 and IL-8 were found elevated in the acute phase, whereas a significant decrease during recovery was found for IL-6 and IL-10. We highlighted an increase of B lymphocytes in the acute phase; conversely, during recovery, an increase in T regulatory cells was noted. Monocytes and leukocytes were found markedly elevated during fever peaks compared to convalescence. All patients recovered uneventfully. The composition of lymphocyte population subsets and serum alterations are the main drivers of an overprescribed antibiotic. Examination of hospital admissions and performance is needed in further investigations to rule out bacterial infections or inflammatory syndromes.

Peripheral blood histoplasmosis in an immunocompetent child with disseminated disease.

Peripheral blood histoplasmosis in an immunocompetent child with disseminated disease.

An Emerging Food Borne Listeriosis (L. Monocytogense) in Society, a Mini Review World Wide and in India

Listeriosis is a rare but potentially serious and harmful infection caused by Listeria monocytogenes. The main route of transmission is through the consumption of contaminated food (Food borne). It generally affects elderly people, pregnant women and immunosuppressed hosts, although cases are also seen in immunocompetent adults and children. Listeria monocytogenes is a short, non-spore-forming gram-positive bacillus. It is a facultative intracellular pathogen, and therefore it shows a complex pathogenesis. L. monocytogenes has the ability to cross the intestinal barrier, the placenta and the blood-brain barrier producing gastroenteritis (GI), maternal-fetal infections and meningoencephalitis. It is most commonly diagnosed from a positive culture of a sterile site. L. monocytogenes cause very serious invasion and often life threatening disease.

Chronic suppurative otomastoiditis due to nontuberculous mycobacteria: A case series

IntroductionEight new cases of chronic otomastoiditis due to nontuberculous mycobacteria were reported at Center Hospitalier Universitaire Sainte-Justine (CHUSJ) between 2008 and 2018. In the literature, only 89 cases have been described since 1972. This case series aims to define the clinical presentation, infectious pathogens, as well as diagnostic and therapeutic means employed in cases of nontuberculous mycobacteria otitis media encountered in our tertiary pediatric reference center. MethodsAll cases of otitis media caused by nontuberculous mycobacteria diagnosed at Sainte-Justine between 2008 and 2018 were reviewed. Species identification was retrieved from the Laboratoire de Santé Publique du Québec, Quebec's provincial public health and reference laboratory. ResultsAll 8 cases occurred in immunocompetent children. Clinical features on presentation were chronic tympanostomy tube otorrhea with abundant granulation tissue in 7 cases. CT scan demonstrated coalescent mastoiditis in 3 cases. The median delay between initial presentation and identification of nontuberculous mycobacteria was 81 days. Seven patients had a Mycobacterium (M.) abscessus complex infection. Treatment consisted of weekly microscopic granulation debridement, a combined systemic antibiotic therapy for an average duration of 21 weeks, as well as instillation of boric acid into the middle ear. While 3 cases required at least one mastoidectomy, 2 cases were treated only medically. ConclusionNontuberculous mycobacteria otitis media is a rare clinical entity, for which high clinical suspicion and specific microbiological analyses could minimize diagnostic delay. The use of boric acid as a desiccating agent may allow for a better local control.

Human Herpes Virus 6 Detection in Children With Suspected Central Nervous System Infection.

Human herpes virus 6 (HHV-6) infection is considered a self-limited disease in immunocompetent children. However, HHV-6 could be associated with various neurologic diseases. We describe 8 children with suspected central nervous system infection and detection of HHV-6 in cerebrospinal fluid. The clinical significance of HHV-6 detection is controversial because it may be caused by primary infection, reactivation or latency.

Clinico-immunological profile in a case of hepatic tubercular abscess: A rare manifestation of extrapulmonary TB in an immunocompetent child

Tubercular liver abscess is a rare entity even in an endemic area for TB. We report here a rare case of pediatric tuberculous liver abscess, the etiology of which was established using recently introduced Cartridge based nucleic acid amplification test (CBNAAT). A 7 years old male child presented with vomiting, pain abdomen and fever. Hepatomegaly was found on examination. Ultrasound of abdomen revealed two liver abscesses in the right lobe. Patient remained symptomatic even after empirical antimicrobial therapy. On diagnostic tap Gram stained smear of the pus showed polymorphs with negative culture. CBNAAT was positive for Mycobacterial tuberculosis and sensitive to rifampicin. Subjecting difficult extrapulmonary specimens to relevant microbiological investigations along with CBNAAT and other newer methods may improve diagnosis of tuberculosis in such rare cases thus leading to an early management and decrease in morbidity.

Pediatric Bartonella henselae Infection: The Role of Serologic Diagnosis and a Proposed Clinical Approach for Suspected Acute Disease in the Immunocompetent Child.

Bartonella henselae serology is commonly used to diagnose cat-scratch disease (CSD). Titers above a threshold for positivity suggest either a recent or remote infection. Recent infection can be confirmed by a 4-fold rise in the convalescent titer in some cases. Many atypical presentations attributed to CSD utilize a low threshold for positivity without supportive evidence from convalescent sera or supplemental testing, raising a concern for the overdiagnosis of CSD. We conducted a retrospective chart review of immunocompetent pediatric patients at the Hospital for Sick Children, Toronto, spanning an 11-year period. A total of 154 cases were included with serologic titers ≥1:128. These were divided into 3 groups: group 1 = 1:128, group 2 = 1:256, and group 3 ≥ 1:512. Cases within groups were evaluated with respect to cat contact, clinical presentation, further testing, and final diagnosis. One-third of patients with a titer of 1:128 had an alternative diagnosis. Most cases with a titer of 1:128 or 1:256 did not have convalescent serologic testing performed. Within these 2 groups, only 1 case had a 4-fold rise in the convalescent titer. A trend of decreasing number of cases with alternative diagnoses (P = 0.03) and increasing number of cases presenting with regional lymphadenopathy (P = 0.07) was associated with higher titers in group 3 compared with group 1. Concerns about the serologic diagnosis of CSD include the use of low titers for positivity, incomplete diagnostic evaluation, and the lack of convalescent serologic testing. We propose a clinical guide to assist in managing suspected cases of CSD.

Adenovirus Infections in Immunocompetent Children

The focus of this review is on human adenovirus (HAdV) infections in immunocompetent children. HAdV infections are ubiquitous among children under 5 years of age. To date, over 100 different HAdV genotypes have been identified using genomic and bioinformatic analyses. While the vast majority of infections are mild or asymptomatic, severe, life-threatening manifestations including respiratory failure, meningoencephalitis, myocarditis, and disseminated disease can occur in otherwise healthy infants and children. Neonates are at highest risk of severe or disseminated infection, especially within the first 2 weeks of life. Microbiologic diagnosis of HAdV infection is helpful in cases of severe or disseminated disease or in outbreak settings. Molecular detection is the preferred diagnostic method. Evidence for antiviral therapy is limited, but may be warranted in immunocompetent children with severe disease. Hand hygiene, droplet/contact measures, and use of disinfectants are the mainstay for infection prevention in institutional settings. While a live, oral vaccine for types 4 and 7 is available, its use is restricted to military personnel. HAdV infections in immunocompetent children encompass a wide spectrum of clinical disease. Further research is required in understanding host and viral factors that predispose immunocompetent children to severe infection and to determine what treatments are most effective in those with severe disease.

First insight into the whole-genome sequence variations in Mycobacterium bovis BCG-1 (Russia) vaccine seed lots and their progeny clinical isolates from children with BCG-induced adverse events

BackgroundThe only licensed live Bacille Calmette-Guérin (BCG) vaccine used to prevent severe childhood tuberculosis comprises genetically divergent strains with variable protective efficacy and rates of BCG-induced adverse events. The whole-genome sequencing (WGS) allowed evaluating the genome stability of BCG strains and the impact of spontaneous heterogeneity in seed and commercial lots on the efficacy of BCG-vaccines in different countries. Our study aimed to assess sequence variations and their putative effects on genes and protein functions in the BCG-1 (Russia) seed lots compared to their progeny isolates available from immunocompetent children with BCG-induced disease (mainly, osteitis).ResultsBased on the WGS data, we analyzed the links between seed lots 361, 367, and 368 used for vaccine manufacture in Russia in different periods, and their nine progeny isolates recovered from immunocompetent children with BCG-induced disease. The complete catalog of variants in genes relative to the reference genome (GenBank: CP013741) included 4 synonymous and 8 nonsynonymous single nucleotide polymorphisms, and 3 frameshift deletions. Seed lot 361 shared variants with 2 of 6 descendant isolates that had higher proportions of such polymorphisms in several genes, including ppsC, eccD5, and eccA5 involved in metabolism and cell wall processes and reportedly associated with virulence in mycobacteria. One isolate preserved variants of its parent seed lot 361 without gain of further changes in the sequence profile within 14 years.ConclusionsThe background genomic information allowed us for the first time to follow the BCG diversity starting from the freeze-dried seed lots to descendant clinical isolates. Sequence variations in several genes of seed lot 361 did not alter the genomic stability and viability of the vaccine and appeared accumulated in isolates during the survival in the human organism. The impact of the observed variations in the context of association with the development of BCG-induced disease should be evaluated in parallel with the immune status and host genetics. Comparative genomic studies of BCG seed lots and their descendant clinical isolates represent a beneficial approach to better understand the molecular bases of efficacy and adverse events during the long-term survival of BCG in the host organism.

Human adenoviruses associated with respiratory illness in neonates, infants, and children in the Sousse area of Tunisia

BackgroundThe human Adenovirus (HAdV) is a common agent of acute respiratory infections (ARIs). Its clinical impact in immunocompetent children and in the context of coinfections remains unclear in Tunisia.Material and methodsHAdV‐ARIs were studied in hospitalized patients from birth to the age of 5 years from 2013 to 2014. Clinical and demographic characteristics, coinfections, and molecular characterization of HAdV were established.ResultsHAdV‐positivity was detected in 114/583 specimens (19.6%) including 6.1% single infections and 93.9% coinfections. Adenoviral coinfections mostly comprised human Rhinovirus (50.9%), Streptococcus pneumoniae (34.2%), human Respiratory Syncytial virus A/B (29.8%), and human Coronaviruses (21.9%). HAdV infection was predominant in the pediatric population (25.0% vs 10.0% in neonates, P < .001) and peaked in February 2014 (21.1%). HAdV severity of pediatric cases is characterized by low saturation of oxygen (<94%, 33.8%, P = .05) and long duration of oxygen support (≥5 days, 32.7%, P = .02). Severe HAdV infections were described with S. pneumoniae coinfection, which seemed to increase the risk of death. HAdV genotyping identified HAdV‐C as the most common species. Severe ARIs were observed in all HAdV‐identified types. Phylogenetic analysis revealed that sequences were variable suggesting the circulation of different HAdV strains sharing more similarities to strains circulating in Europe or Asia than those from Africa.ConclusionThis first molecular study of HAdV in Tunisia demonstrated that it has an important role in severe ARIs with HAdV‐C being the most common species. S. pneumoniae codetection seems to increase the severity of HAdV‐ARIs.

The etiologic, microbiologic, clinical and outcome characteristics of immunocompetent young children

BackgroundTo describe the etiologic, microbiologic, clinical and outcome characteristics of acute neutropenia (absolute neutrophil count, ANC, <1.5 × 109/L) in hospitalized immunocompetent children.MethodsSerious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, alveolar pneumonia, Brucellosis and Rickettsiosis.Results431/671 (64.2%) healthy infants and children hospitalized with acute neutropenia were <2 years of age; 176 (40.8%), 167 (38.8%) and 88 (20.4%) patients were aged 0–3, 4–12 and 13–24 months, respectively. There were 19 (4.4%), 53 (12.3%), 140 (32.5%) and 209 (50.8%) patients with ANC count <200, 200–500, 501–1000 and 1001–1500 × 109 cells/L, respectively. Severe neutropenia (<500 × 109/L) was recorded in 72 (16.7%) patients. Fever >38 °C was present in 208/431 (48.3%) patients. Blood cultures were positive in 10 (2.3%), with Brucella melitensis, Staphylococcus aureus and Enterobacter spp. identified in 4, 3 and 2 patients, respectively; 5/10 patients with positive blood cultures were <3 months of age. Overall, 55/431 (12.7%) and 65/431 (15.1%) patients were diagnosed with SBIs and bacterial infections, respectively. Nasal washings-PCR for respiratory viruses was positive in 139/293 (47.4%) patients tested. An infectious etiology (bacterial and/or viral) was diagnosed in 190/431 (44.1%) patients. Three patients were diagnosed with acute lymphocytic leukemia. Resolution of neutropenia was achieved in 111/208 (53.4%) evaluable patients (63%, 50.6% and 48% of patients aged 0–3, 4–12 and >12 months, respectively and 56.8%, 53.5% and 52% of patients with severe, moderate and mild neutropenia, respectively).ConclusionAcute neutropenia is common in immunocompetent children <2 years of age and is frequently associated with viral infections. We showed a substantial involvement of bacterial infections and particularly SBIs in the etiology of acute neutropenia. After a 1-month follow-up, resolution of neutropenia occurred in half of the patients, without association with age subgroups and with neutropenia severity.

Community-Acquired Pseudomonas Aeruginosa Wrist Joint Arthritis in a Child - A Case Report

Pseudomonas aeruginosa is a rare cause of bone and joint infection in an immunocompetent child. Rapid diagnosis and prompt therapy are required to prevent serious joint damage. We hereby present our experience with a case of septic arthritis involving distal radioulnar joint with associated distal radius osteomyelitis in a previously healthy six years old girl who presented with fever, swelling and pain of the right lower forearm. Pseudomonas aeruginosa was isolated from both joint fluid and blood. The child was successfully treated with a combination of surgical debridement and two weeks of intravenous and four weeks of oral antibiotic therapy.

Parvovirus Encephalitis: Looking Through the Eyes

Parvovirus B19 usually causes less severe symptomatic infections. Its severity depends upon the affected cells of a particular organ system. Whereas diseases affecting the skin and haematological systems tend to be milder, affection of CNS may turn serious. Direct invasion or NS1 toxicity of Parvo virus B19 has been postulated behind CNS tropism. Here we depict Parvovirus B19 causing acute encephalitis and ophthalmoplegia in an immunocompetent male child, taking an eventful course, responded with IVIG &amp; steroids, reversed the symptoms except some VEP abnormalities. This explores the need for timely intervention with immunotherapy in such cases to prevent permanent sequelae.

Listeria meningitis complicated by hydrocephalus in an immunocompetent child: case report and review of the literature

BackgroundListeria monocytogenes is a Gram-positive bacteria transmitted to human by animal stools, contaminated water and food.In children, Listeria monocytogenes typically affects newborns and immunocompromised patients often leading to invasive syndromes including sepsis, brain abscesses, meningitis, meningoencephalitis and rhombencephalitis.In healthy and immunocompetent children, Listeria meningitis is rare, but can progress rapidly and may be associated with severe complications (hydrocephalus, ventriculitis, cranial nerves palsy and cerebrospinal abscesses) and high mortality rate.Case presentationWe describe a very uncommon case of meningoencephalitis due to Listeria monocytogenes in a 11-month-old immunocompetent girl. Cerebrospinal fluid (CSF) culture was positive on the second day. Antibiotic therapy was promptly started but the disease was complicated by neurological deterioration and decompensated hydrocephalus. The child required a very demanding pediatric and neurosurgical management and was discharged after 40 days without major sequelae.ConclusionListeria is difficult to isolate and it is not susceptible to first-line treatment for bacterial meningitis with extended-spectrum cephalosporins. Early recognition is therefore crucial for a positive outcome. Pediatricians have to perform close clinical monitoring of these children and be aware of possible complications.A review of all cases of Listeria meningitis complicated by hydrocephalus in healthy children has been performed, to provide an overview on clinical features, treatment options and outcome.

Disseminated Echinococcus multilocularis Infection without Liver Involvement in Child, Canada, 2018.

An immunocompetent child in Canada received a diagnosis of disseminated alveolar Echinococcus multilocularis infection. The case lacked typical features of liver involvement and was possibly related to a rare congenital portosystemic shunt. We summarize the rapidly evolving epidemiology of E. multilocularis parasites in Canada.