Abstract Congenital tracheal stenosis (CTS) is a rare and life-threatening condition, defined as an intrinsic narrowing of the tracheal lumen caused by complete tracheal cartilage rings. The diagnosis is almost always established during childhood, due to airway obstruction. CTS is usually associated with other congenital anomalies, the vast majority being cardiovascular. Computerized tomography (CT) plays an important role in the diagnosis of CTS, as well as in determining the length of the stenosis and the caliber of the tracheal lumen, fundamental elements for the management and increase in survival. The typical imaging findings are circumferential narrowing of the trachea and fusion of the cartilaginous tracheal rings posteriorly, giving an appearance of an O-shaped trachea on an axial image. We report a case of CTS diagnosis in a child with Tetralogy of Fallot, that was admitted to the emergency room with severe respiratory distress, requiring invasive mechanical ventilation.

Resumo A estenose traqueal congénita (ETC) é uma entidade rara e com significativa mortalidade. É definida como um estreitamento intrínseco do lúmen traqueal, devido à presença de anéis cartilagíneos traqueais completos. Por causar obstrução respiratória, o diagnóstico é feito na infância estando, geralmente, associada a outras anomalias congénitas, sobretudo cardiovasculares. A Tomografia computorizada desempenha um papel importante no diagnóstico desta entidade, bem como na determinação da extensão da estenose e do calibre luminal, elementos fundamentais para a decisão terapêutica e aumento da sobrevida. Os achados típicos na imagem são um estreitamento circunferencial da traqueia e fusão dos anéis traqueais cartilaginosos posteriormente, dando uma aparência em traqueia em forma de O em corte axial. Relatamos um caso de estenose traqueal congénita diagnosticada numa criança com história de tetralogia de Fallot, que foi admitida na sala de emergência por quadro de dificuldade respiratória grave, com necessidade de ventilação mecânica invasiva.

RESUMO Objetivo: Alertar para a patogenicidade do Streptococcus anginosus que, apesar de raro em pediatria, pode causar infeções graves que necessitam de tratamento invasivo e antibioterapia de longo curso para obter um melhor prognóstico. Descrição do caso: Criança de seis anos, com atraso do desenvolvimento psicomotor, avaliado no serviço de urgência por febre e dificuldade respiratória. O exame físico, juntamente com os exames complementares, revelou uma pneumonia complicada com empiema no hemitórax esquerdo, tendo iniciado antibioterapia e sido submetido à drenagem do líquido pleural. Foi identificado Streptococcus anginosus nesse líquido. No 11º dia de doença, a criança agravou o seu estado clínico, com recidiva da febre, hipoxemia e dificuldade respiratória. Considerando-se o microrganismo identificado, o paciente foi submetido à decorticação pulmonar por videotoracoscopia, com boa evolução clínica posterior. Comentários: Streptococcus anginosus é uma bactéria comensal da cavidade oral humana, que pode causar infecções sistêmicas graves. Apesar de serem raros os casos descritos em pediatria, têm sido cada vez mais descritas infecções torácicas complicadas em adultos. Esse microrganismo também tem a capacidade de formar abcessos e empiemas, que precisam de intervenções terapêuticas diferentes, quando comparados a pneumonias complicadas causadas por outros agentes.

ABSTRACT Objective: To highlight the pathogenicity of Streptococcus anginosus, which is rare in pediatric patients, but can cause severe infections that are known to have a better outcome when treated early with interventional procedures and prolonged antibiotic therapy. Case description: The patient is a 6-year-old boy with global developmental delay, examined in the emergency room due to fever and respiratory distress. The physical examination and diagnostic workout revealed complicated pneumonia with empyema of the left hemithorax; he started antibiotic therapy and underwent thoracic drainage. Pleural fluid cultures grew Streptococcus anginosus. On day 11, the child had a clinical deterioration with recurrence of fever, hypoxia, and respiratory distress. At this point, considering the causative agent, he was submitted to video-assisted thoracoscopic decortication, with good progress thereafter. Comments: Streptococcus anginosus is a commensal bacterium of the human oral cavity capable of causing severe systemic infections. Although reports of complicated thoracic infections with this agent are rare in the pediatric population, they have been increasing in adults. Streptococcus anginosus has a high capacity to form abscess and empyema, requiring different therapeutic approaches when compared to complicated pneumonia caused by other agents.

Posaconazole Histoplasmosis Salvage therapy African histoplasmosis is a granulomatous mycosis caused by Histoplasma capsulatum var. duboisii. Treatment is usually extrapolated from guidelines for classical histoplasmosis, and includes 2-4 weeks of amphotericin B followed by a step-down maintenance therapy with itraconazole. Pediatric usage of posaconazole, an oral second-generation azole, remains off-label, but recent surveys show that it is safe and well tolerated in children. We report a case of disseminated African histoplasmosis in a 12-year-old boy from Guinea-Bissau. Therapy with amphotericin B and itraconazole led to a progressive clinical deterioration. A dramatic and lasting improvement was observed using posaconazole. He completed 12 months of therapy. No relapse was noted during or 3 months after treatment. We report that posaconazole may be a safe and efficacious drug in the salvage management of disseminated AH, either in patients with disease refractory to conventional anti-fungal therapy, or in patients whose serious adverse effects of first-line drugs preclude its use.

Objectivo: Caracterizar os doentes que tendo sido directamente reencaminhados da triagem de uma Urgência Pediátrica de um Hospital Central para o médico assistente, foram readmitidos nas 72 horas seguintes. Materiais e métodos: No período entre 1/1/2005 e 31/12/2007 foram analisados todos os registos de triagem de crianças com idade inferior a treze anos admitidas na triagem, que recorreram novamente à UPP nas setenta e duas horas seguintes e destas, as que necessitaram de internamento hospitalar. Resultados: Foram readmitidos no total 2.082 doentes e destes, apenas 149 foram hospitalizados. O motivo principal do novo recurso à urgência foi a persistência dos sintomas.

Objective: Characterize the patients who were directly from the Paediatric triage of Central Hospital, referred to the Primary Health Care, and returned to the Emergency Department in the first 72 hours. Methods: In the period between 1/1/2005 and 31/12/2007, were reviewed all medical admission records of children under the age of thirteen, who were screening and then returned in the first 72 hours to the emergency department and those whom were hospitalized. Results: During the study time 2.082 patients were readmitted, from these, only 149 were hospitalized. The main cause for the readmission was the persistence of the symptoms.