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Since the 2007 French guidelines on imported Falciparum malaria, the epidemiology, treatment, and prevention of malaria have changed considerably requiring guidelines for all Plasmodium species to be updated. Over the past decade, the incidence of imported malaria has decreased in all age groups, reflecting the decrease in the incidence of malaria in endemic areas. The rates of severe pediatric cases have increased as in adults, but fatalities are rare. The parasitological diagnosis requires a thick blood smear (or a rapid immunochromatographic test) and a thin blood film. Alternatively, a rapid antigen detection test can be paired with a thin blood film. Thrombocytopenia in children presenting with fever is highly predictive of malaria following travel to a malaria-endemic area and, when detected, malaria should be strongly considered. The first-line treatment of uncomplicated P. falciparum malaria is now an artemisinin-based combination therapy (ACT), either artemether-lumefantrine or artenimol-piperaquine, as recommended by the World Health Organization in endemic areas. Uncomplicated presentations of non-falciparum malaria should be treated either with chloroquine or ACT. The first-line treatment of severe malaria is now intravenous artesunate which is more effective than quinine in endemic areas. Quinine is restricted to cases where artesunate is contraindicated or unavailable. Prevention of malaria in pediatric travelers consists of nocturnal personal protection against mosquitoes (especially insecticide-treated nets) combined with chemoprophylaxis according to the risk level.

Pulmonary embolism is a life-threatening and potentially lethal disease. Its incidence in children with sickle cell disease is probably underestimated and pediatric case reports in the literature are rare. Moreover, symptoms can mimic an acute chest syndrome. We report on the case of a 17-year-old boy with SS sickle cell disease, admitted for chest pain with dyspnea and tachycardia. Pulmonary angiography revealed a partial bilateral obstructive pulmonary embolism. We did not find any deep venous thrombosis or thrombophilia. The progression was rapidly favorable with anticoagulant therapy. We recommend a pulmonary angiography for any chest pain that does not evolve favorably in a child with sickle cell disease. Large series of pediatric patients would be useful to establish diagnostic and therapeutic guidelines.

Résumé Un groupe de médecins généralistes et multidisciplinaire de spécialistes contribue à définir les différentes formes de sinusites ou rhinosinusites aiguës de l'enfant à partir des principaux symptômes et signes cliniques. Le rôle des pathologies associées telles que l'allergie, les troubles immunitaires est envisagé. L'incidence, la présentation clinique et la prise en charge des complications sont présentées. Les indications des examens radiologiques et biologiques sont analysées. La prise en charge médicale en particulier, la place et le type des antibiotiques sont discutés. Des propositions de prise en charge selon des situations cliniques rencontrées en pratique sont présentées.

International travel is growing, but few data exist on prevention for children traveling. The aim of this study was to describe a population of children traveling from France to countries outside Europe and to evaluate the quality of prevention and healthcare services provided for these travelers.We conducted a retrospective epidemiological study in three pediatric emergency departments in Paris from August to October 2009 and 2012. Data were collected retrospectively from anonymous questionnaires proposed to families consulting emergency services, irrespective of their reason, who had recently traveled (in the year preceding travel outside the European Union).Of the 166 children included, who for the most part had traveled to visit relatives and friends in Sub-Saharan Africa and North Africa, 76% of their families were from the destination countries, 78% had received prevention counseling, mostly with their doctor. They had been vaccinated against yellow fever, but the hepatitis A vaccine was neglected. The preventive measures had been difficult to achieve in practice. During travel, 54% of children had health problems (39% diarrhea, 29% vomiting, 31% fever) prompting medical care in 28%, 5% were admitted to a hospital, and 4% had return to France earlier than planned. In epidemic areas, 13% of children had malaria.There is poor counseling on basic prevention (hygiene, diarrhea, malaria, immunization). Time constraints in pediatricians and competing priorities could explain this problem. The challenge for healthcare providers to reduce these pathologies is to provide services of sufficient quality and clarity. All medical stakeholders have an important role to play.

We report a very rare case of disseminated pharyngo-laryngeal histoplasmosis with systemic spread in a 10-year-old, immunocompetent child from Guyana. The main signs were a marked deterioration in his general condition, hepato-splenomegaly, multiple lymphadenopathy and ulcerated pharyngo-laryngeal lesions. The diagnosis was made from brushings of the ulcerative lesions, a lymph node biopsy and serological tests performed in the national reference center for histoplasmosis. The initial treatment was with amphotericin B, which was then replaced by oral itraconazole. We report here the main epidemiological, clinical and therapeutic characteristics.

Children are often victims of dog or cat bites, but human bites are rarer. Infection is the most frequent complication. A very large number of bacterial species, anaerobic and aerobic often associated, are found in local samples. Antibiotic therapy is not systematic and should be discussed on a case-by-case basis taking into account the risk factors: the type of animal bite, the location and depth of the bite, and the time to treatment. Immunodepressed patients or those having undergone splenectomy are at a high risk of severe infections or from unusual bacteria and should be treated preventively. The association of amoxicillin and clavulanic acid is the most active antibiotic on the majority of bacteria responsible for infections. Treatment should be initiated rapidly and continue for 3-5 days with monitoring of local signs.

Staphylococcus aureus and Streptococcus pyogenes are the two main bacteria involved in skin infections in children. Mild infections like limited impetigo and furonculosis should preferentially be treated by topical antibiotics (mupirocine or fucidic acid). Empiric antimicrobial therapy of dermohypodermitis consists in amoxicillin-clavulanate through oral route (80 mg/kg/d) or parenteral route (150 mg/kg amoxicillin per d. in 3-4 doses) for complicated features: risk factors of extension of the infection, sepsis or fast evolution. Clindamycin (40 mg/kg/d per d. in 3 doses) should be added to the beta-lactam treatment in case of toxinic shock, surgical necrotizing soft tissues or fasciitis infections.

International audience; During the 2011 measles outbreak in Paris (France), patients with clinical suspicion of measles were tested for virological confirmation of measles virus (MV) infection. To assess the practical value of molecular diagnosis in an epidemic setting, 171 oral fluid samples and 235 serum samples collected from 270 patients were tested prospectively for MV-RNA using a novel one-step real-time RT-PCR assay including an internal control. Serum samples were also tested for MV-specific IgG and IgM antibodies. MV infection was confirmed by detection of MV-RNA and/or MV-IgM for 229 of the 270 patients. The results for the 102 cases with both serum and oral fluid samples available were used to compare the techniques. The detection rate of MV-RNA by RT-PCR was 98% (100/102) for oral fluid and 95% (97/102) for serum samples. The detection rate of MV-IgM was 85% (87/102). Negative MV-IgM results were observed mostly for serum samples collected early after the onset of the rash. A MV-RNA standard of known concentration obtained by in vitro transcription was used to quantify MV-RNA in samples. MV-RNA copy numbers were significantly higher in oral fluid than in serum samples, but did not correlate with time of sampling (within 1 week after the onset of the rash), patient age, or vaccination status. During the early stage of infection, the MV-RNA viral load in serum was lower in patients positive than in those negative for MV-IgG. In conclusion, the one-step real-time RT-PCR assay is a simple and sensitive tool suitable for MV diagnosis within hours. J. Med. Virol. © 2013 Wiley Periodicals, Inc.

Vaso-occlusive crises are the most common complication of sickle cell disease. Orbital bone infarction is an unusual manifestation of sickling disorders. It is suspected in patients with acute painful periorbital swelling. Orbital compression syndrome with possible optic nerve injury is a rare but serious complication; therefore, this diagnosis should be considered. Orbital infarction can be difficult to distinguish from osteomyelitis or skin infections. Imaging can be helpful in differentiating infection from infarction. We report a case of orbital bone infarction in a 14-year-old boy with sickle cell disease. Under medical treatment, the clinical course resolved with no sequelae.

Lyme borreliosis should be considered in any child affected with acute peripheral facial palsy without obvious cause in endemic areas, especially if it happens from May to November, with a history of erythema migrans, tick bite, or possible exposure during the previous weeks. The clinical appearance of Lyme borreliosis differs between adults and children and according to the geographical origin of the infection: therefore it is difficult to interpret and follow the recommendations for the management and treatment of this disease. Neuroborreliosis is more frequent in Europe than in the United States, and meningitis associated to facial palsy occurs earlier and is more frequent among the European pediatric population, too. When peripheral facial palsy occurs and there is suspicion of Lyme borreliosis, it seems necessary to perform a lumbar puncture in order to support the diagnosis with detection of intrathecal synthesis of specific antibodies, sometimes more abundant than in the serum, and thus to adapt the antibiotic therapy modalities. Parenteral antibiotherapy is recommended if any involvement is detected in the cerebrospinal fluid, while oral antibiotherapy should be prescribed for isolated facial palsies. Follow-up should be made according to clinical symptoms with a close collaboration between pediatricians, infection disease specialists, and ENT specialists.

We report a case of congenital nephrotic syndrome with acute renal failure associated with multiple organ injury requiring peritoneal dialysis. Maternal serology, including hepatitis B, HIV, and Treponema pallidum hemagglutination (TPHA) and the Venereal Disease Research Laboratory (VDRL) tests were all negative at 10 weeks of gestational age (GA). At 34 weeks of gestation, the ultrasound examination showed hydrops fetalis. The umbilical cord puncture found anemia, with hemoglobin at 8.4 g/dl, thrombocytopenia at 43,000/mm, cytomegalovirus (CMV)-polymerase chain reaction (PCR) and parvovirus-PCR were negative. The child was born at 35 weeks of gestational age and immediately transferred to an intensive care unit because of septic shock. The clinical findings were sclerema neonatorum with blisters, hepatomegaly, splenomegaly, and macroscopic hematuria. The initial blood analysis showed hemoglobin 11 g/dl, thrombocytopenia 22,000/mm (despite intrauterine blood and platelets transfusion), reticulocytes >150,000/mm, C-reactive protein (CRP) 233 mg/L, urea 4 mmol/L, serum creatinine 72 μmol/L, proteins 56 g/L, serum glutamic oxaloacetic transaminase (SGOT) 482 UI/L, serum glutamic pyruvic transaminase (SGPT) 224 UI/L, haptoglobin 600 μg/dl. Symptomatic treatment was initiated by albumin, anticoagulation, and recombinant erythropoietin. At the 9th day of life, CRP was 51 ng/ml, and hemoculture showed Staphylococcus epidermidis, motivating vancomycin treatment. Serum creatinine increased concomitantly to 262 μmol/L.

An outbreak of colonization and infection with an Escherichia coli strain producing extended-spectrum beta-lactamase (ESBL) occurred in a neonatal unit : a high rate of cases was observed, 27/59 neonates were colonized : one of them developed meningitis with favourable outcome and another baby developed conjunctivitis. Despite intensive efforts to control the outbreak by standard methods of hand hygiene, patients screening and isolation, the spread was uncontrolled and the unit was closed to all admission in order to stop the outbreak. The investigation was not able to identify a single outbreak's source. Emergence and spread of ESBL producing E. coli strains from community and hospital acquired infections are a significant public health problem with difficult choice of treatment for serious infections.

The skin infections are common in pediatrics, ranging from furonculosis or impetigo to the severe forms of necrotizing dermohypodermitis. The general antibiotic treatments are not always indicated but when they are, they must take into account the resistance of two main species of bacteria (Staphylococcus aureus and Streptococcus pyogenes), the pharmacokinetics-pharmacodynamic parameters and the severity and type of infection. Two situations should be treated by topical treatements: limited impetigo and furonculosis. The two topical antibiotics used preferentially are mupirocine and fucidic acid. Soon, a third topical antibiotic, reptamuline will complete these. For uncomplicated superficial skin infections justifying an oral antibiotic, amoxicillin-clavulanate offers the best guarantee of efficiency. Poor pharmacodynamic-pharmacokinetic must lead to not prescribe oral M penicillins. In case of allergy, a first-generation cephalosporin, a macrolide (if the susceptibility of the strain was checked) or pristinamycine (after 6 years of age) are acceptable alternatives. For dermohypodermitis bacterial antibiotic of choice remains amoxicillin-clavulanate through IV route, to be active against S. pyogenes but also S. aureus and anaerobic bacteria. The IV route is maintained until regression general signs and a relay orally by the same drug is then possible. For toxinic syndromes and necrozing fascitis clindamycin should be added to a beta-lactam because of its action on protein synthesis in particular reducing the toxins production.

Kawasaki disease is a form of idiopathic systemic vasculitis. Diagnosis is based upon specific clinical parameters. Cardiac manifestations explain the mortality rate. They can be reduced by early treatment using intravenous immunoglobulin. Atypical Kawasaki disease is difficult to diagnose and can delay diagnosis. We report a case of Kawasaki disease with arthritis in a 4-year-old girl whose initial presentation was a febrile torticollis. A literature review details the atypical early signs of Kawasaki disease revealed by torticollis.

Condyloma, also known as venereal warts, are caused by human papillomavirus (HPV). Conventional wart therapies destroy infected keratinocytes rather than directly inhibiting viral infection or replication. No available drug therapy effectively eliminates HPV. Treatments are often disappointing for the patient, the family and the physician due to the duration of the disease and the frequency of recurrences in spite of treatment.

Vestibular syndrome is not frequently described in patients with sickle cell disease. We report the case of a teenager with sickle cell disease who had a vestibular syndrome with vertigo that successfully responded to exchange transfusion. We discuss guidelines and review the literature in view of this case report. Sensorineural disorders should be considered as stroke syndromes. They require urgent treatment consisting of exchange transfusion or maintaining optimal hydration associated with blood withdrawal. Treatment of vestibular syndrome in sickle cell disease is urgent.

In France, annual influenza vaccination is recommended and free of charge for children with chronic disease (chronic lung, heart or kidney disease, diabetes, haemoglobinopathy, immune deficiency). The national goal is to reach 75% influenza vaccination coverage by 2008, but data on coverage in high risk children are limited.To estimate the influenza vaccination coverage in children with an underlying chronic health condition in the Paris region, during in- or out-patient visit at hospital.A multicentre cross-sectional descriptive study was carried out over 2 months before the 2004-2005 flu vaccination campaign in 7 French paediatric hospitals (Paris region). Inclusion criteria for this survey were: children aged 6 months to 18 years, with an underlying chronic disease requiring annual influenza vaccination, with a vaccination card available, so as to check their vaccination status. Reasons for non vaccination were recorded.Data from 239 children were analysed. 56% of patients were males (mean age: 8.1 years). Two patients had 2 separate underlying chronic disorders; 69% had a haemoglobinopathy, 16.3% had a chronic respiratory disease, and 7.5% had diabetes. The influenza vaccination rate for 2003-2004 was 43.7% (haemoglobinopathy: 55.5%; chronic respiratory diseases: 12.8%). This rate increased from 20.4% to 43.7% between 1999 and 2003. Less than 16% of parents remembered having received a voucher for free vaccination from the National Health Insurance Agency.Efforts are still needed to achieve the 2008 objectives of 75% coverage.

To describe the characteristics of paediatric varicella in patients admitted through the emergency department (ED) of the Armand-Trousseau Children hospital in Paris and the evolution of the causes of admission during the study period.Retrospective longitudinal cohort study from March 1990 to February 2001.One hundred and eight children were hospitalized for varicella during these 11 years. Sixty per cent were under 2 years of age and all but one were immunocompetent. The first cause of admission was the presence of at least 1 complication (83,3%) classified as: cutaneous (34%), digestive (19,8,%), respiratory (17,6%), neurological (15,3%) and ENT complications (8,8%). Over 11 years, the rate of overall complications remained stable but there was an important increase in varicella cases admitted through the ED mainly due to increase in cutaneous superinfections.These data confirm the potential severity of varicella and underline the emerging problem of increasing cutaneous complications. Additional studies are necessary to address this phenomenon and to determine optimal prophylactic measures.

Since 1987, in France, Legionella infection is a notifiable disease. Notification should be transmitted by the clinician to the referent public health physician in the Direction départementale des Affaires sanitaires et sociales. Criteria for certain and probable cases have been defined. From this level, nationwide information is centralised in the institut de veille sanitaire. The public health physician is responsible for the inquiry in the health care facility or community setting and for action taking as appropriate. After isolation, Legionella strains are further studied in the Centre national de référence in Lyon. This center is also responsible for typing of environmental strains. In 2002, the incidence of notified legionellosis was 1,7 per 100,000 inhabitants and the mortality rate of 13%. Median age was 61 years and the sex-ratio M/F of 2.9. Only 39 cases were nosocomial. Very few cases have been observed in children, almost all in immunocompromised patients. Legionellosis is of exceptional occurrence in neonates, but the lethality is high. Treatment guidelines have been published in France only for adult patients.

Although systematic vitamin D supplementation in adolescents remains debated, rickets is nevertheless a well recognized pathology in this age group. Adolescence is an at-risk period because of rapid growth, insufficient calcium intake and/or vitamin D status. Surveys have shown that calcium intake is insufficient (1000 mg a day) in 45% of boys and 71% of girls and that vitamin D status is deficient (25-OH-D10 ng/ml). The aims of the study carried out by the Calcium Group of the Société Française de Pédiatrie, were to evaluate the frequency of rickets, and to define the criteria for the adolescent population at risk. Forty-one adolescents with rickets were hospitalized between 1985 and 2000. Most of the cases were from the Northern France: 20 from Paris and suburbs, eight from the North-West, four from the North, four from the North-East; five were from the Center of France. The mean age was 13 years and two months for the 28 girls, and 14 years and four months for the 13 boys. Eighty per cent of the adolescents were from immigrant families (33/41): 15 were from sub-Saharan Africa, ten from North Africa, six from Pakistan and two from Turkey. Two thirds of the adolescents were hospitalized in the 2nd quarter of the year. Some adolescents suffered from lower limb pain, 16 had deformations of lower limbs, particularly genu valgum, associated with pain; seven others had either muscle spasms (4), tetany (3). Serum calcium level was low (average 1.84 mmol/l: [1.1-2.5]), and serum 25-OH D level was extremely low. Radiographic characteristics observed were metaphyseal strips on the knees, with condensed edges at times, with the presence of bone demineralization. The treatment combined calcium and vitamin D, and was often administered intravenously when a hypocalcemia was detected. Rickets is not frequent in adolescents, but nonetheless this pathology is not exceptional, and the number of cases is probably under-estimated. Rickets affects immigrant adolescents in particular but nevertheless could also present a certain risk period for the general population.

Halofantrine is the first regimen used for the treatment of uncomplicated Plasmodium falciparum malaria in children in France according to the recommendations of the French Consensus Conference held in 1999 and pending additional data in this population. In 1999, a high rate of clinical relapse after a single cure of halofantrine led us to switch to mefloquine for first line treatment of uncomplicated malaria. The aims of this study were to evaluate this change of attitude and to compare the efficacy of halofantrine and mefloquine in the treatment of uncomplicated P. falciparum malaria in children.We retrospectively analysed 118 pediatric cases of malaria treated at Armand-Trousseau Children hospital in Paris between January 1st, 1999 and December 31st, 2000.93 patients were treated for an uncomplicated case of P. falciparum malaria: 48 received a unique cure of halofantrine and 21 were treated with mefloquine. Nine patients relapsed, all having previously received halofantrine. No patient treated with mefloquine relapsed.These results and other recent published data suggest to recommend mefloquine instead of halofantrine as first line treatment of uncomplicated P. falciparum malaria in children with respect to specific contra-indications. A larger evaluation of mefloquine is however necessary. The association atovaquone-proguanil (Malarone) is promising but needs to be evaluated in large pediatric studies in comparison with other treatments. Its indication as a curative treatment of uncomplicated malaria is, to date, restricted to adults and children over 12 years in France.

Eighty children were treated at the hospital Armand-Trousseau (Paris, France) for a malaria attack from 1999-01-01 to 2000-02-01.The parasites were: Plasmodium falciparum: 87.5%, Plasmodium malariae: 12.6%, Plasmodium ovale: 10%, Plasmodium vivax: 6.3%. Mean age was 8.1 years (range: three months to 15 y). The origin of patients was: West Africa for 60 children, Central Africa for ten children and Comores for seven. Sixty-six patients suffered from common malaria attack and seven children were admitted with a presentation of severe malaria. The severe attacks were cerebral malaria for six cases, associated with severe anemia in five cases; the 7th child had a respiratory distress (ARDS) and died. The other six cases were cured without sequelae. Relapses were observed for eight patients: one after a severe cerebral malaria, six after a common P. falciparum attack, one after a P. ovale attack. Parasitemia was higher than in preceding years (mean 2.9%) and more than 5% in 11 cases, but without clear link with severity. Treatment by halofantrine with a single cure was followed by five relapses. None of those children received an effective prophylaxis during and after travel (55/80 without any prophylaxis).These data emphasize the importance of a good appraisal of criteria of severe malaria and lead to advice hospitalization of children with malaria in temperate zone.

Gallstones are frequently encountered in sickle cell disease. Their complications are difficult to distinguish from vaso-occlusive abdominal pain and they can sometimes threaten the patient's life. The aim of this study was to describe our local experience with cholelithiasis in children with sickle cell disease.We analyzed the follow-up records and abdominal sonography results of 185 children with sickle cell anemia, aged zero to 18 years, followed up in Trousseau Children's Hospital (Paris) from 1982 to 1998.Cholelithiasis was detected in 26 patients. The youngest patient was five years old. Cholelithiasis was discovered because of clinical manifestations in 12 patients. Asymptomatic cholelithiasis patients developed clinical manifestations in 28% cases in a maximum delay of two and a half years after its diagnosis. Laparoscopic cholecystectomy was performed in nine cases and open cholecystectomy in 17 cases. The mean postoperative length of stay was significantly shorter in the group of patients with laparoscopy in comparison with the group with open cholecystectomy. Histologic analysis of the gallbladders noted 85% of acute or chronic cholecystis.We suggest that cholelithiasis should be carefully sought in the presence of abdominal manifestations in sickle cell patients. We recommend that annual abdominal sonography be performed in sickle cell patients as early as seven years of age and elective cholecystectomy be performed on patients with cholelithiasis.

A subset of 299 patients with homozygous sickle cell anaemia, enrolled in the cohort of the French Study Group on sickle cell disease (SCD), was investigated in this study. The majority of patients were children (mean age 10.1 +/- 5.8 yr) of first generation immigrants from Western and Central Africa, the others originated from the French West Indies (20.2%). We report the frequency of the main clinical events (mean follow-up 4.2 +/- 2.2 yr). The prevalence of meningitis-septicaemia and osteomyelitis was, respectively, 11.4% and 12% acute chest syndrome was observed in 134 patients (44.8%). Twenty patients (6.7%) developed stroke with peak prevalence at 10-15 yr of age. One hundred and seventy-two patients (58%) suffered from one or more painful sickle cell crises, while the others (42.5%) never suffered from pain. The overall frequency of acute anaemic episodes was 50.5%, (acute aplastic anaemia 46%; acute splenic sequestration 26%). A group of 27 patients were asymptomatic (follow-up3 yr). Epistatic mechanisms influencing SCD were studied. Coinherited alpha-thalassemia strongly reduced the risk of stroke (p0.001) and increased that of painful crises (p0.02). There was a low prevalence of Senegal and Bantu (CAR) betas-chromosomes in patients with meningitis (p0.04) and osteomyelitis (p0.03). Prevalence of Senegal betas-chromosomes was lower in the asymptomatic group of 27 patients (p0.02). The patients come from a population of unmixed immigrants in whom the beta-globin gene haplotype strongly reflects the geographic origin and identifies subgroups with a homogenous genetic background. Thus the observed effects might result more from differences in as yet unidentified determinants in the genetic background than from the direct linkage with differences in the beta-globin gene locus.

In France, the vaccination program has changed through the last years. We report a study on immunization rates of children who underwent a complete health checkup at a Well Child Clinic in Paris. We studied three groups of children (children at the ages of 10 months, 2 years and 4 years) regarding types of daycare and medical care.Nine hundred children who underwent a health checkup between April and June 1997 were included in the study. Data were collected from immunization records and parents' interviews.In 10-month-old children, prevalence rates of immunization against diphtheria, tetanus, poliomyelitis and pertussis (DTPP) and immunization against Haemophilus influenzae type b (Hib) disease were 98% and 96%, respectively. Only 1.7% were immunized against measles. Forty-two percent of children had complete or ongoing immunization against hepatitis B. The vaccination coverage for BCG was 94%. In two-year-old children, boostering for DTPP vaccine had been performed by 90%, more than 90% were immunized against measles and 50% had received at least one shot to prevent hepatitis B. At the age of 4 years, 99% were immunized against DTPP, 78% were immunized against Hib disease, 98% against measles and 48% for hepatitis B. All children were immunized with BCG, and 98% were BCG-controlled (22% had tuberculin intradermal reaction). The highest immunization rates were observed in children who had preventive care in 'Maternal and Infantile Protection Centres.' Immunization rates were not influenced by the type of daycare, except for measles in two-year-old children managed by private pediatricians.We observed high immunization rates of children who underwent health checkups. Late immunization against measles and low immunization rates against hepatitis B reflect the difficulties encountered in mobilising physicians and families for these vaccinations.

Urinary tract infections (UTI) encompass a spectrum of clinical and pathological conditions involving various parts of the urinary tract. Differentiating the syndromes associated with UTI has important implications for treatment and prognosis. To effectively communicate information on the subject, terminology should be standardized and precise--a challenge as it is difficult to strictly adapt the terms into French and subsequently apply them to practice.

The pulmonary complications remain the prime cause of morbidity and mortality in sickle cell disease. The pathogenetic mechanisms consists both of an alteration of the rheological properties of the blood, the existence of a hypercoagulability state and above all specific interactions between the abnormal sickle cells and the vascular endothelium and a dysregulation of the vascular reactivity in which nitrous oxide intervenes. The acute chest syndrome (ACS) is characterised by chest pain with dyspnoea and recent radiological abnormalities and it is an acute lung complication whose problem is one of aetiology. The infectious pneumonias are rarely documented. On the other hand, alveolar hypoventilation linked to infarcts of the thoracic ribs, thoracoabdominal trauma, subdiaphragmatic pain, the administration of analgesics causing respiratory depression, obesity or sleep disturbance are frequent causes of ACS. Bronchoalveolar lavage has revealed a frequency of fat emboli following infarcts in the long bones. Pulmonary emboli is rarely a cause. Pulmonary thrombosis is a serious complication, the diagnosis is difficult and is seen in a predisposed clinical setting. The treatment of ACS rests on controlled hydration and antibiotic therapy, oxygen therapy and controlled analgesic therapy. The indications for blood transfusion and for exchange transfusion merits a better evaluation. In the long term patients with sickle cell disease present with a failure of normal thoracopulmonary growth with a restrictive ventilatory defect and progressive diminution in the transfer factor of carbon monoxide with age. A history of ACS favours chronic lung disease. Pulmonary arterial hypertension is less frequent.

Acute diarrhoea is one of the major causes of outpatient paediatric consultation, especially during infancy. An infectious cause should be suspected on the acute onset of diarrhoea associated with fever. The specific pathogen is seldom investigated and individualized. Rotavirus has been recognized as the most important enteric pathogen, particularly in infants during winter months. It may be responsible for nosocomial infections in hospital and outbreaks in day-care centers. Bacteria may cause a diarrhoea by elaboration of enterotoxins, by invasiveness, or both. Use of antibiotic is usually not necessary even in bacterial infections because they are self-limited. Choice of the antibiotic is complicated by the rapid emergence of resistant pathogenic strains. The first step is rapid assessment of the hydratation status of the patient. Fluid and electrolytes replacement is the mainstay in the treatment of infectious diarrhoea of any cause.

BACKGROUND. Dengue is an acute febrile illness caused by several arthropod-born viruses and characterized by biphasic fever, myalgia or arthralgia, rash, leukopenia and lymphadenopathy. Its diagnosis is based on knowledge of the geographic distribution of dengue viruses. CASE REPORTS Case no 1: A 11 year-old boy suffered from sudden onset of fever accompanied by retro-orbital headache, arthralgia and diffuse myalgia. There was no rash. Hemogram showed: hemoglobin: 11.6 g%; leukocytes: 3,400/mm3 (PMN: 76%); platelets: 190,000/mm3. A diagnosis of viral infection was considered, but, as the boy had recently been to the French West-Indies, a serologic study was performed. This was negative 2 days after the onset of disease and positive (specific IgM for the 4 dengue types), 13 days later. Case no 2: A 7 year-old boy suffered from sudden onset of fever. Severe calf muscle pain 4 days later led to his admission. Creatine phosphokinase activity was very high: 83,100 units (N: 30-120). Hemogram showed: hemoglobin: 11.4 g%; leukocytes: 2,500/mm3 (PMN: 60%); platelets: 124,000/mm3. A diagnosis of acute myositis was considered, but as the patient had recently visited Venezuela, a serologic study was performed. This was negative 8 days after the onset of disease and positive (specific IgM for the 4 dengue types) 16 days later. CONCLUSION. The first case is characteristic of the classical form of dengue fever. The second patient presented with very localized myalgia. The diagnosis in both cases was facilitated by the knowledge that the patient had recently stayed in an endemic area.

Optimal treatment of bacterial meningitis raises three questions: which antibiotic? which dosage? which duration? The overall duration of antibiotherapy has been shortened since the last decade. If a short-course treatment shows similar efficacy and rate of relapse, unnecessary prolonged course of treatment exposes to increased cost, duration of hospitalization and secondary effects. From 1979, Gold et al in Toronto treated all uncomplicated cases of meningitis for seven days and obtained satisfactory results. The first randomized trials evaluating optimal duration of treatment in meningitis were performed in 1985 by Lin et al: they showed no difference in terms of efficacy and complications between conventional and short-term treatment. Current rules in meningococcal meningitis consist of seven days or less on therapy, and 7-10 days for pneumococcal or Haemophilus meningitis. The sequential follow-up of C-reactive protein (CRP) levels seems a useful tool for the management of bacterial meningitis.

Antibiotic concentrations in middle ear fluid can be determined in the purulent effusions of acute otitis media or in chronic effusions at the time of myringotomy with tympanostomy tube insertion. Measurements are usually made using microbiological methods. The concentration of betalactamines in middle ear fluid is 20 to 40% serum concentrations. Therefore, in the treatment of otitis media, it is necessary to use high doses of antibiotics, so that the concentration in the middle ear fluid is higher than the minimum inhibitory concentration (MIC) for the most frequent infecting organisms. Sulfamides penetrate well into the middle ear. On the other hand, the concentration of macrolides is not significant until two or three doses have been delivered and a steady state is reached. While direct measurements of the antibiotic concentrations in middle ear fluid can provide information concerning the effectiveness of the antibiotic relative to the MIC, they do not replace clinical trials in confirming the indications of new antibiotic molecules in the treatment of otitis media. In addition, direct measurements are delicate and show great interindividual variations.

Seventy children from 7 months to 15 years old have been treated for malaria at Hospital Trousseau (Paris) during years 1987 and 1988. Thirty nine of them were living in France usually. The infection was one chiefly in Africa (68 cases), and by P. falciparum in 78% of children. The digestive symptoms were frequent (40/70); splenomegaly was observed in 40 children and hepatomegaly in 31. Anemia was present in 59 cases and mild thrombopenia for 31 cases. The C. reactive protein raised in 92% of cases. The diagnosis was late in 31 patients. Only one cerebral malaria case was observed. The chemoprophylaxis was unfitted or absent in 74% of children living in Paris. The chloroquino-resistance was clinically present in 17 cases and the mefloquine was more often used during 1988 year.

All children returning from countries where parasitic diseases are endemic should be investigated for one or several of these diseases according to the region visited and the duration of the visit. Investigations should include at least a parasitological examination of the stools, sometimes completed by a search for urinary schistosomiasis and, at the slightest suspicion, an examination of the eye. The gastrointestinal and percutaneous modes of transmission of parasitoses are such that children are particularly at risk. The most frequently encountered diseases are ankylostomiasis, anguilluliasis, amoebiasis, urinary schistomiasis and filariasis. Side by side with these strictly tropical parasitoses, one may find massive infestation with ascarides and lamblias. Effective and well tolerated treatments are available for most of these diseases, but advice on prophylactic measures is essential to reduce the risk of contamination.

The management of children with sickle-cell disease in specialized centres may take place either during the intercritical phase of the disease or in the period of vaso-occlusive phenomena and acute complications. Without any doubt, a regular follow-up of these children, starting immediately after the diagnosis is made, improves the prognosis. Repeated visits enable the physician to inform the family and thereafter the child on the disease, its consequences and its transmission and to implement such prophylactic measures as preventive antibiotic therapy, specific immunizations and advice on hydration. As years go by, this monitoring is modified according to the patient's age, the course of the disease and the age-related complications. Acute accidents are frequent and often difficult to diagnose. In the immediate and well-adjusted management they require rehydration, rest, analgesics and antibiotics play a major role. The purpose of management is to avoid most complications and raise the child to adulthood in the best possible conditions.

In a prospective randomized open study, 111 young children with otitis media were orally treated during 10 days with Pediazole (50 mg/kg/day in 3 divided doses) or amoxicillin + clavulanic acid (40 mg/kg/day in 3 or 4 divided doses) for efficacy and safety evaluation. 51 children wer assigned to amoxicillin + clavulanic acid (group I) and 60 to erythromycin-sulfisoxazole (group II). Mean age was respectively 24.7 months in group I and 23.4 months in group II. Results of efficacy evaluation were as follows: (table; see text) there was no statistically significant difference between the two treatment groups for efficacy. Overall safety was good. The treatment was discontinued only in four cases (3 in the amoxicillin + clavulanic acid group and 1 in the EES-sulfisoxazole group). In conclusion, Erythromycin sulfisoxazole combination (Pediazole) fits in with current epidemiological profile of Acute Otitis Media and represents a therapy of choice in this indication.

A pharmacokinetic study of ceftazidime was conducted in 1983, together with a clinical study, on 7 neonates (3 of them premature), 4 infants and 3 children. The antibiotic was administered by slow intravenous injection in mean doses of 30 mg/kg twice in 24 h in neonates and thrice in 24 h in older children. Blood samples were collected by micropuncture, and assays were performed by the microbiological method on agar plates. Curves of plasma concentrations over time showed two slopes compatible with a two-compartment model. The alpha half-life was the same in neonates and infants; the beta half-life varied from 1.9 to 5 h. The highest values were observed in the 3 youngest and most immature neonates. In infants and older children the mean beta half-life was the same as in adults: 1.4 +/- 0.19 h. The results of several studies performed on neonates differed as regards the influence of term, post-natal age and bodyweight on the pharmacokinetic constants of ceftazidime. A dose of 25 to 50 mg/kg twice a day administered to premature and full-term neonates during the 1st week of life gives therapeutically effective concentrations. Doses of 30 to 50 mg/kg 3 or 4 times a day are necessary in infants and older children. Dosage should be adjusted to renal maturity and renal functions as well as to the infection treated.

The serum kinetics of intravenous cefotaxime was studied in 13 neonates and 5 infants presenting with bacterial infections in order to establish the dosage and route of administration. Average dosage was 66.6 mg/kg/day in neonates and 62 mg/kg/day in infants. Cefotaxime was given intravenously in 3 daily bolus injections in infants and 2 bolus injections in neonates under 8 days of age. In infants the average serum peak was 173 mcg/ml at 15 min. Serum half-life was between 0.45 and 0.50 hr (T 1/2 beta) close to the one found in adults. In neonates the average serum peak was 106.2 mcg/ml at 35 min. Serum half-life was 1.71 hr (T 1/2 beta). It is prolonged in neonates who are younger, more premature and have a lower weight. In full term neonates, during the first 8 days, the desirable dose seems to be 75 to 150 mg/kg/day in 3 injections, according to the severity of the infection. In premature neonates under 8 days of age, the interval between injections should be increased up to 12 hrs. Finally, in full term neonates older than 8 days and in infants, one injection every 6 hours seems to be advisable.

Cefixime was assayed by a microbiological method in the tonsils of 21 children (mean age 59 months). Tonsillectomy was performed 5 hours after a third dose of 4 mg/kg administered 12-hourly. Plasma cefixime levels were evaluated 10 hours after the second dose with a mean value of 0.84 mg/l (range: 0 to 1.35) and again after a third dose during amygdalectomy with a mean value of 1.24 mg/l (range: 0.1 to 3.9). Cefixime concentrations were 0.74 micrograms/g in the right tonsils and 0.53 micrograms/g in the left tonsils. The antibiotics could not be detected in both tonsils in 6 children and in one of the two tonsils in 11 children. The tissue penetration of cefixime in tonsils therefore was about 1 micrograms/g in those cases where cefixime was detectable. As with other beta-lactam antibiotics, this penetration is not regular, being dependent on the degree of tonsillar fibrosis inhibitin their diffusion.

Cefixime is a new oral cephalosporin antibiotic, with broad-spectrum of activity, near than of third generation cephalosporin, especially against betelactamase producers bacteria. Cefixime has been assayed with microbiological method in tonsils of 21 children (mean age 59 months). Tonsillectomy was performed 5 hours after a third dose of 4 mg/kg cefixime. Plasma levels were evaluated 10 hours after the second dose, with mean level of 0.84 micrograms/ml (0 to 1.35). Blood level was evaluated after third dose, during amygdalectomy was 1.24 micrograms/ml (0.1 to 3.9). Tonsils levels were: for right tonsils 0.74 micrograms/g and for left tonsils 0.53 micrograms/g. Cefixime was not detected in both tonsils of 6 children, and in one of the two tonsils in 11 of them. The tonsils penetration of cefixime was about 1 microgram/g in the case where cefixime was detectable. This penetration is not regular as for other betalactam antibiotics in relation with fibrosis of tonsils tissue inhibiting a good diffusion of antibiotic.

Ceftizoxime was evaluated in the treatment of 49 children and 15 neonates. The average dosage was 150 mg/kg/d for newborns and 115 mg/kg/d for children, administered IV, 3 or 4 times daily. Clinical and bacteriological cure was achieved in 93% children and 92% neonates. The clinical and biological tolerance was very good. Pharmacokinetic parameters were studied in 17 patients, including 2 neonates. In children the mean serum peak was 40 mug/ml and the mean half life was 2.2 +/- 0.6 H, after a dose of 30 mg/kg. In both neonates the half life was 3.1 H and 3.6 H. In urine, mean concentration of 4 g/l has been obtained in the first 2 hours after IV.

The pharmacokinetics and clinical efficacy of ceftazidime, a new cephalosporin with activity against Pseudomonas aeruginosa, were studied in children and neonates. Our studies suggest that ceftazidime should be considered for the treatment of sever infections in pediatric patients (neonatal septicemia and meningitis, urinary tract infections due to multiresistant bacteria) and for the empirical therapy of febrile episodes in immunocompromised children. Ceftazidime appears to be effective and safe, alone or associated with an aminoglycoside, in the treatment of acute exacerbation in cystic fibrosis. The dosage recommended on the basis of our pharmacokinetic studies is 30 to 50 mg/kg intravenously every eight hours for infants and children and 30 mg/kg every 12 hours for neonates. Larger doses should be used in cystic fibrosis patients, immunosuppressed children, meningitis, and bacterial infections due to organisms with high MICs.