ABSTRACT This study investigated the potential use of the String Test (ST) for the diagnosis of pulmonary tuberculosis (PTB) in children and adolescents. This is a case series of patients aged 4-15 years presenting with clinically presumed PTB and submitted to ST in three pediatric TB referral centers in Brazil, between November 2017 and July 2020. The ST was performed in the morning, after 4-12 h of fasting, followed by ingestion of the capsule by the patient, which was attached to the patient’s malar region. The material was collected for simultaneous smear microscopy (acid-fast bacilli - AFB), culture and the molecular investigation by the GeneXpert MTB/RIF®. Thirty-three patients with presumed PTB were included and ST was performed in 26 (78.8%) of them and 7 (21.2%) patients could not swallow the cord. The diagnosis of PTB was established in 11 (42.3%) of the 26 patients who underwent the ST. The diagnosis of PTB was confirmed (by culture or GeneXpert MTB/RIF®) in 5 patients, 4 of whom were also positive by the ST. Two of them showed positivity by the GeneXpert MTB/RIF® only in the ST sample. Two other patients had a positive ST following the induced sputum test (AFB, GeneXpert MTB/RIF®, and positive culture in both specimens). Thus, ST was positive in 36.4% of the patients in whom PTB was diagnosed. ST could be a useful test for diagnosing PTB in children and adolescents.

Resumo Objetivos Descrever as características das infecções oportunistas em pediatria em seus aspectos clínicos, bem como a estratégia diagnóstica e o tratamento. Fonte dos dados Revisão de trabalhos de literatura de forma não sistemática na base de dados Pubmed. Síntese dos dados São apresentadas as infecções oportunistas causadas por micobactérias não tuberculosas, fungos, herpervírus e as infecções que acometem indivíduos em uso de imunobiológicos. Por se tratar de doenças graves e de evolução rápida, a suspeita diagnóstica deve ser precoce, associada à clínica do paciente e aos dados de história que apontam para infecções oportunistas. Sempre que possível, amostras de secreções, sangue e outros fluidos e de tecidos devem ser coletadas, com instituição precoce de terapia. Conclusões Apesar da melhoria do diagnóstico de infecções oportunistas nos últimos anos, elas ainda são um desafio para o pediatra pouco habituado a essas infecções. Ele deve fazer a suspeita e iniciar a condução do caso, mas recorrer a especialistas com prática no manejo dessas infecções de modo a propiciar um melhor desfecho para esses pacientes que ainda apresentam alta mortalidade.

Abstract Objectives To describe the characteristics of opportunistic infections in pediatrics regarding their clinical aspects, as well as the diagnostic strategy and treatment. Source of data Non-systematic review of literature studies in the PubMed database. Synthesis of data Opportunistic infections caused by non-tuberculous mycobacteria, fungi, Herpesvirae, and infections affecting individuals using immunobiological agents are analyzed. Because these are severe diseases with a rapid evolution, diagnostic suspicion should be early, associated with the patient's clinical assessment and history pointing to opportunistic infections. Whenever possible, samples of secretions, blood, and other fluids and tissues should be collected, with early therapy implementation. Conclusions Despite the improved diagnosis of opportunistic infections in recent years, they remain a challenge for pediatricians who are not used to these infections. They should raise the suspicion and start treating the case, but should also resort to specialists in the management of these infections to provide a better outcome for these patients, who still have high mortality.

RESUMO Objetivo: verificar a ocorrência e o tipo mais frequente de alteração auditiva em crianças expostas a toxoplasmose durante a gestação. Métodos: estudo retrospectivo longitudinal realizado em instituição pública de saúde de São Paulo. Análise de prontuários de crianças nascidas entre 2010 e 2015 distribuídos em dois grupos: grupo estudo, composto por 48 crianças de mães com diagnóstico de toxoplasmose durante a gestação; e grupo controle, composto por 43 crianças sem infecção congênita que foram acompanhadas por apresentar baixo peso ao nascimento. As crianças foram avaliadas de duas a quatro vezes durante os dois primeiros anos de vida, por meio de testes que avaliam a função auditiva periférica e central. Resultados: 47 crianças fizeram apenas duas avaliações e apenas 11 completaram todas as avaliações até 24 meses. No grupo controle 58,1% apresentaram audição normal, 37,2% perda condutiva, 4,7% perda coclear e ausência de alteração retrococlear, enquanto o grupo estudo apresentou 56,3% de audição normal, 20,8% de perda condutiva, 2,1% de perda coclear e 20,8% de alteração retrococlear. Conclusão: crianças expostas à toxoplasmose durante a gestação não diferiram das não expostas em relação à ocorrência de perda auditiva coclear e condutiva. Entretanto, apresentaram maior ocorrência de alteração retrococlear.

ABSTRACT Purpose: to verify the occurrence and the most frequent type of auditory disorders in children exposed to toxoplasmosis during pregnancy. Methods: a retrospective, longitudinal study carried out in a public health institution of São Paulo. Records of children born between 2010 and 2015 were analyzed and distributed into two groups: study group, composed of 48 children born to mothers with a diagnosis of toxoplasmosis during their pregnancy; and control group, composed of 43 children without congenital infection, who were accompanied due to low birth weight. The children were evaluated two to four times during their first two years of life, by means of peripheral and central auditory function assessment. Results: 47 children underwent only two evaluations and only 11 completed all the evaluations up to 24 months. In the control group, 58.1% had normal hearing, 37.2% conductive loss, 4.7% cochlear loss and absence of retrocochlear disorder. In the study group, 56.3% presented normal hearing, 20.8% conductive loss, 2.1% cochlear loss, and 20.8% retrocochlear disorder. Conclusion: children exposed to toxoplasmosis during pregnancy did not differ from non-exposed children in relation to the occurrence of conductive or cochlear hearing loss. However, they showed a higher occurrence of retrocochlear disorder.

Resumo Objetivo: Relatar um caso de artrite séptica de etiologia rara em uma criança imunossuprimida. Descrição do caso: Paciente masculino, seis anos, transplantado hepático havia cinco anos e meio devido à atresia de vias biliares, em uso de tacrolimus 1 mg de 12/12 horas, iniciou dor em pé e tornozelo esquerdo e um episódio de febre três dias antes da internação. Ao exame físico, peso 17kg, estatura 109cm, temperatura de 36,4°C, com dor, edema e calor no tornozelo esquerdo e sem outras alterações. Exames da entrada: hemoglobina 11,7g/dL, hematócrito 36,4%, leucócitos, 17.600/uL (7% bastões, 70% segmentados, 2% eosinófilos, 1% basófilo, 13% linfócitos, 7% monócitos), proteína C reativa 170,88mg/L. Ultrassonografia articular evidenciou moderado derrame no recesso tíbio talar anterior esquerdo. Feita limpeza cirúrgica com o isolamento do S. multivorum na cultura do líquido articular, suscetível a um amplo espectro de cefalosporinas (cefepime e ceftriaxone) e fluoroquinolonas (ciprofloxacino e levofloxacino), esistente a carbapenêmicos e aminoglicosídeos. Tratado com oxacilina por 15 dias e ceftriaxone 13 dias intravenoso e ciprofloxacina via oral por mais 15 dias com boa evolução. Comentários: O Sphingobacterium multivorum é um bacilo gram negativo, pertencente à família Flavobacteriaceae, considerado não patogênico, tem sido raramente descrito como etiologia de infecções em seres humanos principalmente em ambientes hospitalares e em imunossuprimidos. O relato deste caso é relevante por sua etiologia incomum e pelo sítio acometido, pode ser este o primeiro caso de artrite séptica descrito.

Abstract Objective: To report a case septic arthritis with a rare pathogen in a immunosuppressed child. Case description: Male patient, 6 years old, had liver transplant five and half years ago due to biliary atresia. Patient was using tacrolimus 1mg q.12h. This patient started to have pain in left foot and ankle and had one episode of fever 3 days before hospital admission. Physical examination showed weight 17kg, height 109cm, temperature 36.4°C, with pain, swelling and heat in the left ankle, without other clinical signs. Initial tests: hemoglobin 11.7g/dL hematocrit 36.4%, leukocyte count 17,600µL-1 (7% banded neutrophils, 70% segmented neutrophils, 2% eosinophils, basophils 1%, 13% lymphocytes, 7% monocytes) C-reactive protein 170.88mg/L. Joint ultrasound showed moderate effusion in the site. Patient was submitted to surgical procedure and Sphingobacterium multivorum was isolated from the effusion. The germ was susceptible to broad spectrum cephalosporins (ceftriaxone and cefepime) and fluoroquinolones (ciprofloxacin and levofloxacin), and it was resistant to carbapenemic antibiotics and aminoglycosides. He was treated intravenously with oxacillin for 15 days and ceftriaxone for 13 days, and orally with ciprofloxacin for 15 days, with good outcome. Comments: The S. multivorum is a gram negative bacillus that belongs to Flavobacteriaceae family and it is considered non-pathogenic. It has rarely been described as a cause of infections in humans, especially in hospital environment and in immunosuppressed patients. This case report is relevant for its unusual etiology and for the site affected, which may be the first case of septic arthritis described.