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Background: In developed countries, the introduction of highly active antiretroviral therapy (HAART) has greatly improved survival and quality of life in HIV-infected children. Nevertheless, worrisome metabolic and bone alterations are beginning to be observed., Objective: To evaluate the prevalence of alterations in bone mineral density and possible associated factors in a cohort of HIV-infected children receiving HAART., Patients and Methods: Bone dual energy X-ray absorptiometry (DEXA) was performed in 50 HIV-infected children in a tertiary hospital in Madrid after a median length of HAART of 54 months. Subsequently, the group with bone mineral loss was compared with the group without bone mineral loss., Results: Forty percent of the children studied had decreased bone mineral density, of which 36 % had osteopenia (18/50) and 4 % had osteoporosis (2/50). No statistically significant differences were found between the two groups in any of the factors analyzed., Conclusions: The prevalence of decreased bone mineral density in our cohort of HIV-infected children receiving HAART is high. The etiology and factors associated with this alteration are still not well known.

Background: Highly active antiretroviral therapy (HAART) slows the progression of HIV disease and lowers mortality and morbidity in adults. The impact on the disease course in children has not been still completely elucidated. Furthermore the effect of HAART on organ-specific complications of HIV is unknown., Objectives: To assess the effect of HAART on the progression of HIV infection, mortality, organ-specific complications, number of infections and hospitalizations in HIV-1-infected children., Patients and Methods: Records of HIV-1-infected children were reviewed in a large referral pediatric hospital. Patients were divided into three groups: children who did not receive antiretroviral therapy (Group 1); children who received mono- or bitherapy (Group 2); and patients who received HAART (Group 3). Endpoints analyzed were progression to AIDS and mortality among AIDS patients and overall., Results: One hundred seven children have been evaluated. Actuarial survival at 5 years of age was 33% in Groups 1 and 2 compared with 100% in Group 3 (P < 0.01). At 5 years of age, the proportion of children progressing to AIDS was 76% in Groups 1 and 2, compared with 26% in Group 3 (P < 0.01). At 5 years of follow-up, there were 45 cases of organ-specific complications in patients without HAART. No children without organ-specific complications when HAART was started have developed them after 5 years (P < 0.01). In patients without HAART there were 9 cases of lymphoid interstitial pneumonia, and there was none in Group 3 (P < 0.01). The incidence rates of infections and hospitalizations were 2.83 and 0.52 per patient-year, respectively, in children who did not receive HAART and 0.75 and 0.17 when they were managed with HAART (relative risk, 0.26 and 0.32)., Conclusions: HAART is associated with a marked decline in the progression to AIDS, improved survival in HIV-1-infected children, reduced incidence of infections and hospitalizations and decreased incidence of some organ-specific complications of HIV.

Myiasis is caused by infestation of the skin by the larvae of flies. This entity has specific epidemiological characteristics. Although it is highly unusual in our environment, imported cases can be found because of increased traveling and immigration. The usual clinical manifestations are subcutaneous abscesses, where the larvae develop. Differential diagnosis includes common disorders such as cellulitis and furunculosis, but knowledge of this entity makes diagnosis and treatment simple. We describe the life cycle of the human botfly and the typical clinical presentation and management of this entity. We also highlight the increasing importance of greater awareness of imported diseases.

Introduction: There are few reports of Streptococcus pneumoniae as a cause of septic arthritis. The aim of this study was to describe our experience with five documented cases of pneumococcal arthritis over 14 years., Methods: The medical histories of infectious septic arthritis in our center between January 1986 and December 2000 were retrospectively reviewed. Cases of pneumococcal etiology were analyzed while those occurring in the neonatal and immediate postoperative periods were excluded., Results: Among the 39 documented cases of septic arthritis, 5 (12.8 %) were caused by Streptococcus pneumoniae. Four of the patients were younger than 15 months old. Fever without localizing signs as an antecedent was present in four patients; of these, one patient had concurrent otitis media. The most common localization was the hip (four patients) and the knee (one patient). In three patients simple radiology showed no abnormalities while in four ultrasonography showed abnormalities. Etiologic diagnosis was established by isolation of S. pneumoniae from blood culture and synovial fluid (one patient), from blood culture (one patient), from synovial fluid (two patients), and by detection of pneumococcal antigen in urine (one patient). Of the germs isolated, two showed reduced susceptibility to penicillin (CMI 0.125-1 mg/l) and all were susceptible to cefotaxime. Open drainage was performed in all patients with hip involvement. None of the patients presented sequelae., Conclusions: In our experience, S. pneumoniae should be taken into account as a cause of septic arthritis that mainly affects children younger than 15 months. The hip was the most frequently involved joint. Joint fluid culture was the method providing the best diagnostic yield. A high proportion of strains are not susceptible to penicillin. Early diagnosis and management lead to a good prognosis.

Objective: To study the clinical characteristics and susceptibility to antimicrobial agents of Streptococcus pneumoniae invasive infection in our neonatal unit., Methods: Data from newborns with Streptococcus pneumoniae invasive infection in the last 12 years were retrospectively collected., Results: Eight cases of invasive infection were identified. Gestational age ranged from 30 to 38 weeks (median: 34 weeks) and birth weight ranged from 1,680g to 4,460g (median: 2,480g). Risk factors related to infection were identified in 7 patients. Although infection manifested as shock in 4 patients and meningitis in 1, evolution was favorable in all patients. Penicillin resistance was found in 3 patients., Conclusions: Streptococcus pneumoniae produces serious disease in neonates. Because of the increasing prevalence of penicillin-resistant pneumococci, the relationship between the percentage of mothers colonized with pneumococci and neonatal infection should be determined to develop new prevention and treatment strategies in newborn infants.

Background: Despite the proven efficacy of zidovudine (ZDV) for reducing perinatal transmission of HIV-1, questions remain about its implementation and effectiveness in routine practice. The aims of this study were to assess the impact of ZDV administered during pregnancy in preventing perinatal HIV-1 transmission, and to determine the proportion of early identification of maternal HIV-1 infection over time., Patients and Methods: We prospectively followed from birth a cohort of children born between 1/1/1987 and 31/10/1997 to HIV-1-infected mothers. Infant infection status was assessed by follow-up beyond 18 months or HIV-PCR up to 3 months of age., Results: 229 mothers and 248 infants were identified in the cohort. ZDV was administered during pregnancy as monotherapy to 34 mothers for a mean of 4.7 (3.1) months prior to delivery. There were no differences in baseline characteristics between the treated and untreated groups. Mean (SD) CD4 cell count was 465 (261) cells x 10(6)/l. Factors associated with transmission were a more prolonged time of rupture of obstetric membranes (median 6 vs 1.04 hours; p = 0.023) and ZDV treatment. Among the ZDV-treated mothers only one child was infected (2.9%), whereas 37 children born to 212 untreated women became infected. (OR: 0.14; 95% CI: 0.07-0.92). The estimated prevalence of HIV-1 in pregnant women in our area is about 0.39% (95% CI: 0.34-0.45). From 1987 to 1991, 9.7% of infected women were nor identified at the perinatal period, as compared to 2.5% in the last 5 years of the study period (p = 0.034)., Conclusions: In this study, the estimated prevalence of HIV-1 infection is high. ZDV during pregnancy is significantly associated with a decrease in perinatal transmission in our setting. The awareness of an effective treatment might have contributed to the increased identification of HIV-infected mothers prior to delivery observed over time in our cohort of children born to HIV-infected mothers.

Objective: To study the characteristics, treatment and follow-up of patients with ventriculitis in our neonatal unit., Patients and Methods: Retrospective study of patients diagnosed with ventriculitis from January 1990 to December 1997. Diagnostic criteria were the identification of any bacteria in the ventricular fluid and pleocytosis (> or = 100 leukocytes per microl). Personal history, clinical and analytical findings and evolution after diagnosis were studied., Results: We recorded ten cases of ventriculitis in nine patients. Six of them occurred as a complication of previous meningitis and four occurred after neurosurgical treatment. The mean age at diagnosis was of 38.8 days (range 8-130), and mean gestational age was 29.4 weeks (range 25-38). Clinical and ventricular fluid anomalies were seen in six cases and in four the diagnosis was made at autopsy. Treatment was systemic antibiotics. In two cases intraventricular antibiotics were added. Six patients died, ventriculitis being the direct cause of death in five. Of the three survivors, one had mental retardation and cerebral palsy and the other two had minor disabilities., Conclusions: During the neonatal period, a high degree of clinical suspicion and techniques for an early diagnosis and treatment are needed for ventriculitis.

Objective: Our objective was to determine the utility of urine cultures collected by sterile perineal bags as a method of diagnosis of urinary tract infection in infants., Patients and Methods: Forty-two patients, aged 0 to 27 months, were diagnosed with urinary tract infections based on the growth of more than 100,000 colonies/ml in two urine cultures collected by sterile bags. Confirmation of the infection was done by urine cultures obtained by suprapubic aspiration or urethral catheterization. A urinalysis was simultaneously performed., Results: Urinary tract infection was confirmed in only 6 out of 42 patients. The positive predictive value of the sterile bag was 14%, increasing to 42% combined with an abnormal urinalysis., Conclusions: The sterile perineal bag is not an accurate method to collect urine for diagnosis of urinary tract infections in febrile infants or those who need prompt diagnosis and treatment.

The presence of autoantibodies and autoimmune diseases was tested in all available members of five families with at least one member affected with X-linked chronic granulomatous disease. Patients and carriers relatives possess autoantibodies more frequently than non-carriers relatives (95% vs 10%, p < 1.0 x 10(-5), Fisher test). Further, a survey of the literature revealed that in X-linked immunodeficiencies with X-chromosome random inactivation, clear features of autoimmunity are observed, not found in those with non-random inactivation. It appears then as if random inactivation of the X-chromosome in these pathologies, may favor the expression of an autoimmune phenotype in patients and carriers.

Objective: Our objectives were to assess the clinical and microbiological aspects of septic osteoarthritis in children admitted to our center from 1987 until July 1997 and to determine the sensitivity of ultrasound in this age group., Patients and Methods: The medical records of 36 children diagnosed as having septic osteoarthritis of the hip were reviewed retrospectively. The diagnosis had been based on clinical criteria, along with synovectomy and drainage of purulent material from the affected joint. An X-ray and/or ultrasound had been performed when the diagnosis was suspected., Results: Nineteen children were diagnosed during the neonatal period, 8 between the ages of 1 and 12 months and 9 older than one year of age. Mean age at diagnosis was 16.8 +/- 6.2 months (median 29 days, range 6 days to 13 years). The hip was involved in 32 children, the ankle in 3 and the elbow in 1. A microbiological diagnosis was achieved in 22 cases (61%) by culture from blood, CSF, and/or synovial fluid. The most common isolates were Gram positive cocci (S. aureus in 9 cases and coagulase negative Staphylococcus in 3). The diagnostic value of the X-rays was very low (18%). The ultrasound was initially considered abnormal in 64.5% of the patients, with a lower sensitivity in the neonatal period. After a mean follow-up period of 36 months, the outcome was good in 86% of the cases, although three children continue with sequelae. Two preterm infants died due to sepsis associated with the osteoarthritis., Conclusions: At the time of diagnosis of septic arthritis of the hip, the ultrasound is frequently normal. Due to the poor outcome when there is a delay in surgery, we suggest immediate synovectomy and drainage when there is clinical suspicion of septic arthritis despite an apparently normal ultrasound.

Objective: The objective of this study was to determine the incidence of surgical wound infection and the impact of this on the implementation of an antibiotic protocol according to the type of surgery and the prevailing endogenous flora in our neonatology unit., Patients and Methods: Patients' charts were retrospectively reviewed in order to assess the effectiveness of a protocol of surgical prophylaxis, comparing the incidence of postsurgical wound infection in two periods of time. Surgical interventions were classified according to the period of the study in which they were performed, before (period A) and after (period B) the protocol was undertaken. In addition, if the antibiotics administered fit or not those indicated in the protocol, it was classified as correct or not., Results: A total of 31 (37%) of the interventions were performed in period A, whereas 53 (63%) were carried out in period B. No statistically significant differences were found between periods with regard to the proportion of infections 925.8% vs 15%). When prophylactic antibiotics were administered correctly, infection occurred in 10.2%, as compared to 31.4% when they did not fit the protocol (p < 0.05). The duration of the antibiotics was longer in period A, in infected wounds and when prophylaxis was not correct., Conclusions: The correct adjustment to the protocol significantly decreases the incidence of wound infections, as well as the duration of antibiotic use. An appropriate policy of antibiotic prophylaxis in surgery is advantageous in terms of economic cost and might prevent antibiotic resistance and avoid unnecessary toxicity.

Objectives: The purpose of this study was to assess the incidence of respiratory involvement in HIV-infected children, along with the radiological manifestations of the various HIV-related diseases., Material and Methods: A retrospective review of the medical records of 65 HIV-infected children (63 vertically-infected and 2 through blood transfusion) has been carried out. The mean time of follow-up since the diagnosis of HIV infection was 32 +/- 27 months, beginning January 1987. Patients have been classified into 5 categories: Pneumocystis carinii (PC) pneumonia, lymphoid interstitial pneumonitis (LIP), lobar pneumonia, acute respiratory distress and a miscellaneous group. Plain chest radiographies were performed according to clinical criteria and at least every 6 months in asymptomatic patients. Diagnosis into categories was based upon chest X-ray findings, along with several etiological diagnostic criteria depending on the category., Results: Respiratory involvement occurred in 32 children (49%). The most common diseases were PC pneumonia in 7 patients, LIP in 8 children, and lobar pneumonia and acute respiratory distress in 6 and 7 cases, respectively. PC pneumonia in children younger than one year had a good clinical and radiological correlation. LIP diagnosis has been based only on radiological criteria with the typical pattern. We want to highlight the disappearance of the radiological findings in 3 cases over time. Interestingly, several patients had other etiologic diagnosis, such as S. pneumoniae pneumonia, miliary tuberculosis, and two patients had acute respiratory distress, one caused by adenovirus and the other by enterovirus., Conclusion: Respiratory involvement is common in HIV-infected children. Clinical and radiological manifestations are variable. Plain chest radiography plays a very important role in the management and follow-up of these patients.

Purpose: The objective of this article was to present the diagnosis of a fatal infection by Mycobacterium avium complex (MAC) in a child with acute myelogenous leukemia, a disease rarely reported in non-HIV infected children., Methods: Specific identification of MAC was made by culture in BACTEC system from an open lung biopsy., Results: A 5-year-old girl diagnosed with acute nonlymphoblastic leukemia was admitted because of fever during the maintenance phase after achieving a complete remission of her malignancy. A mild dry cough started on day 4 of admission, and a chest roentgenogram revealed a pulmonary infiltrate. An insidious respiratory distress developed and mechanical ventilation was undertaken. An open-lung biopsy, carried out on day 10 of ventilatory support, revealed acid-fast bacilli subsequently grown as MAC. In spite of combined antimycobacterial treatment, the patient followed a downhill course and died on day 41 of hospitalization., Conclusion: This report describes a new case of fatal MAC infection in an immunocompromised, non-HIV infected child. MAC must be added to the list of infectious microorganisms that can infect children with acute nonlymphoblastic leukemia. As modern immunosuppressive therapeutic modalities evolve, it is likely that MAC will become a more common and recognized pathogen in the immunocompromised child.

We retrospectively checked 53 paediatric patients suffering from infection with human immunodeficiency virus (HIV) registered in our Centre between the years 1987 and 1993, and evaluated the appearance of HIV encephalopathy. We noted important neurological signs in eleven patients (20.7%) ten of whom had HIV infection via vertical transmission and one as a result of contamination from haemoderivatives. In this review we give a detailed description of neurological signs, the moment of onset of these signs and their possible relationship with the state of the HIV infection. We also analyzed the resulting neuroradiological findings as well as any abnormalities in cerebrospinal fluid. Follow-up period ranged from one month to two and a half years from the moment of onset of the appearance of encephalopathy. Although most of our patients showed a clear improvement after oral or intravenous treatment with zidovudine, this improvement generally proved to be short-lived. The mortality rate in our HIV encephalopathy series was 81.8%, this figure being reached two and a half years after encephalopathy. The appearance of neurological signs in HIV patients therefore represents a very gloomy prognostic factor in the evolution of the disease.

Cytomegalovirus (CMV) infection is reported to cause transient immunosuppression in man. In this study we have analysed the effect of CMV on T lymphocyte function in 29 children diagnosed for acute CMV infection. Peripheral blood mononuclear cells (PBMC) obtained from the patients showed a significant specific impairment in their proliferative response to enterotoxins A and C1, to concanavalin A and to the anti-CD3 MoAb OKT3. The impaired responses were corrected with exogenous IL-2. In contrast, stimulation using phytohaemagglutinin, as well as activation signals delivered through the surface molecules CD26 or CD28, elicited normal proliferative responses in CMV PBMC. The results indicate that the T cell anergy associated with CMV infection is restricted to the T cell receptor/CD3 activation pathway.

Objective: To describe clinical profiles of Q fever in children., Design: Retrospective study., Setting: Tertiary teaching hospital., Participants: Thirteen children aged 2 to 14 years, with a mean +/- SD age of 9.6 +/- 3.6 years., Selection Procedures: Review of the medical records of all children with Q fever admitted from 1986 to 1990. The diagnosis was made by detection of phase II antibodies to Coxiella burnetii by the complement fixation test., Measurements/main Results: Clinical profiles consisted of a self-limited illness characterized by high fever (mean +/- SD, 39.9 degrees C +/- 0.66 degrees C) of 5 to 10 days' duration (mean +/- SD, 7.4 +/- 1.6 days), constitutional symptoms, and mild liver dysfunction. Eleven patients had gastrointestinal manifestations (vomiting and/or abdominal pain). Respiratory symptoms were not prominent. Most patients had normal or low white blood cell counts, and seven showed a relative increase of band forms. Their erythrocyte sedimentation rates ranged from 8 to 23 mm/h. All patients did well without specific therapy for C burnetii., Conclusion: In children with the symptoms described above, tests to detect antibodies to C burnetii should be performed.

Recently some cases of AIDS and AIDS-related disorders in children have been published. Some of them had received blood transfusions, others were secondary to AIDS in the mother (vertical transmission). Authors report a case of an 18-month old male infant who became seriously ill when he was 13-month old, and which proved particularly difficult to diagnose until specific serology for HTLV-III, was performed at the age of 16 months. Authors believe that due to growing incidence of AIDS and AIDS-related diseases it is essential to dismiss this diagnosis in infants with a history of transfusion, maternal transfusions or family drug abuse or promiscuity.