Background Telehealth (TH) practices among pediatric infectious disease specialists prior to the coronavirus disease 2019 (COVID-19) pandemic are largely unknown. Methods In 2019, the Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group surveyed PIDS members to collect data on the use of TH modalities, adoption barriers, interest, extent of curbside consultations (CC), and reimbursement. Results Of 1,213 PIDS members, 161 (13.3%) completed the survey, and the responses of 154 (12.7%) from the US were included in our report. Medical school (63.6%) and hospital (44.8%) were the commonest work settings with 16.9% practicing in both of them. The most common TH modalities used were synchronous provider-patient virtual visits (20.8%) and synchronous provider-provider consultations (13.6%). TH services included outpatient consultations (48.1%), vaccine recommendations (43.5%), inpatient consultations (39.6%) and travel advice (39.6%). Barriers perceived by respondents included reimbursement (55.8%), lack of experience with TH (55.2%), lack of institutional support (52.6%), lack of administrative support (50%), and cost of implementation (48.7%). Most respondents (144, 93.5%) were interested in implementing a wide range of TH modalities. CCs accounted for 1-20 hours/week among 148 respondents. Conclusions Most of the PIDS survey respondents reported low utilization of TH and several perceived barriers to TH adoption before the COVID-19 pandemic. Nonetheless, they expressed a strong interest in adopting different TH modalities. They also reported spending considerable time on non-reimbursed CCs from within and outside their institutions. Results of this survey provide baseline information that will allow comparisons with post-COVID-19 changes in the adoption of TH in PID.
Background Rat-bite fever (RBF) is a rare, systemic illness caused by infection with Streptobacillus moniliformis. RBF has a case-fatality risk of 7%-10% among untreated patients. Over 200 cases of RBF have been documented in the United States, but this is likely a significant under-representation because RBF is not a reportable disease. The diagnosis of these infections can be limited by: (1) Streptobacillus moniliformis fastidious nature and difficulty to culture; (2) the nonspecific manifestations of the infections and clinical overlap with a broad differential diagnosis; and (3) the unreliability of rat exposure history. We demonstrate use of unbiased microbial cell free DNA (mcfDNA) next-generation sequencing (NGS) to overcome these diagnostic limitations. Method The Karius Test (KT) was developed and validated in Karius’s CLIA certified/CAP accredited lab (Redwood City, CA) to detect and interpret mcfDNA in plasma. After mcfDNA is extracted and NGS performed, mcfDNA sequences are aligned to a curated database of > 1000 organisms. McfDNA from organisms observed above background at statistical significance are reported and quantified in molecules/µL (MPM). KT detections of Streptobacillus moniliformis were reviewed from January 2017 - June 2021; clinical information was obtained with test requisition or consultation upon result reporting. Results KT detected 7 cases of Streptobacillus moniliformis at an average of 673 MPM (35-3078; SD 1185) with an average turnaround time of 28.5 hours (SD 8.4) from sample receipt from 6 unique institutions (Table 1). Six patients were children; all were immunocompetent. Fever and rash were the most common presentation in the majority of the cases. Five of seven patients had arthritis or osteomyelitis while the remaining two patients had arthralgia. A history of rat exposure was elicited in all cases (some after microbiological diagnosis). In all patients blood cultures were negative and mcfDNA NGS was the only means of microbiological diagnosis. Conclusion Unbiased plasma-based mcfDNA NGS provides a rapid, non-invasive test to diagnose diverse clinical infections by Streptobacillus moniliformis. These cases highlight the potential of the KT to effectively identify infections caused by fastidious/unculturable pathogens with non-specific clinical manifestations and broad differential diagnoses.
Background Children with nephrotic syndrome are at increased risk of infections, including bacterial peritonitis, pneumonia, and cellulitis. However, bacterial meningitis, a potentially life-threatening complication, has not been highlighted as an infectious complication of nephrotic syndrome in recent reviews. We report a very subtle and unusual presentation of bacterial meningitis in a child with nephrotic syndrome, which without a high index of suspicion, would have been missed. Case presentation A 9-year-old African-American male with a history of steroid-dependent nephrotic syndrome presented to the nephrology clinic for routine follow-up. His medications included mycophenolate mofetil and alternate-day steroids. His only complaint was neck pain and stiffness that the mother attributed to muscle tightness relieved by massage. There was no history of fever, vomiting, headache, photophobia, or altered mental status. On physical examination, he was afebrile (99 °F), but had mild periorbital swelling and edema on lower extremities. He appeared ill and exhibited neck rigidity, and demonstrated reflex knee flexion when the neck was bent. Laboratory evaluation revealed leukocytosis, elevated C-reactive protein, hypoalbuminemia, and proteinuria. Cerebrospinal fluid suggested bacterial meningitis. The patient was treated with ceftriaxone and vancomycin. Both cerebrospinal and blood cultures grew Streptococcus pneumoniae; vancomycin was discontinued. The child completed a 2-week course of ceftriaxone and was discharged home. Conclusions A high index of suspicion is necessary in children with nephrotic syndrome treated with corticosteroids, as symptoms may be masked, and thus, a life-threatening disease be missed. Bacterial meningitis should be highlighted as a serious infection complication in children with nephrotic syndrome.
Neonatal hyperpigmentation secondary to chikungunya infection is very common in tropical countries where chikungunya is endemic. Acquired infection in the perinatal period should be suspected in all neonates presenting with neurological or dermatological manifestations in the immediate postnatal period. We present a newborn baby who had hyperpigmentation which started from day 5 of life with lethargy and on extensive evaluation was found to have neonatal chikungunya. Babies with perinatal chikungunya infection are prone to developmental delay and require long term neuro-developmental follow-up. Hence the importance of following appropriate preventative vector measures and prompt diagnosis of infective conditions in tropical countries.
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