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Special Article Artigo Especial Pneumonia adquirida na comunidade e derrame pleural parapneumônico relacionados a Mycoplasma pneumoniae em crianças e adolescentes* Mycoplasma pneumoniae-related community-acquired pneumonia and parapneumonic pleural effusion in children and adolescents Letícia Alves Vervloet, Vitor Earl Cardoso Vervloet, Mário Tironi Junior, José Dirceu Ribeiro Resumo Objetivo: Determinar a prevalência e as características da pneumonia adquirida na comunidade (PAC) e derrames pleurais parapneumônicos (DPP) relacionados a Mycoplasma pneumoniae em um grupo de crianças e adolescentes. Métodos: Estudo observacional retrospectivo com 121 pacientes hospitalizados com PAC e DPP em um hospital de referência terciária, entre 2000 e 2008, divididos em seis grupos (G1 a G6) segundo o agente etiológico: M. pneumoniae com ou sem coinfecção, em 44 pacientes; outros agentes que não M. pneumoniae, em 77; M. pneumoniae sem coinfecção, em 34; Streptococcus pneumoniae, em 36; Staphylococcus aureus, em 31; e coinfecção M. pneumoniae/S. pneumoniae, em 9, respectivamente. Resultados: Na comparação entre os grupos, G1 apresentou frequências maiores em gênero feminino, tosse seca, uso prévio de beta-lactâmicos e na duração dos sintomas até a admissão, assim como menor uso de assistência ventilatória e de drenagem torácica que G2, enquanto G3 teve maiores frequências em uso prévio de beta-lactâmicos e tosse seca, maior duração dos sintomas antes da admissão e menor frequência de uso de drenos torácicos que G4 e G5, ao passo que G3 teve média de idade maior e menor frequência de náuseas/vômitos que G4, assim como menor uso de assistência ventilatória que G5. A coinfecção M. pneumoniae/S. pneumoniae aumentou a duração dos sintomas até a admissão. Conclusões: Nesta amostra, a prevalência de PAC e DPP por M. pneumoniae foi de 12,75%. Embora a doença apresentasse quadros mais leves que aquela por outros organismos, a evolução foi mais prolongada. Nossos dados sugerem a necessidade de uma maior diligência na investigação de M. pneumoniae em crianças e adolescentes com PAC e DPP em nosso meio. Descritores: Derrame pleural; Empiema pleural; Pneumonia; Mycoplasma pneumoniae. Abstract Objective: To determine the prevalence and the characteristics of Mycoplasma pneumoniae-related community- acquired pneumonia (CAP) and parapneumonic pleural effusion (PPE) in children and adolescents. Methods: This was a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, divided into six groups according to the etiologic agent (G1 to G6, respectively): M. pneumoniae with or without co-infection, in 44 patients (group 1); etiologic agents other than M. pneumoniae, in 77 (group 2); M. pneumoniae without co-infection, in 34 (group 3); Streptococcus pneumoniae, in 36 (group 4); Staphylococcus aureus, in 31 (group 5); and M. pneumoniae/S. pneumoniae co-infection, in 9 (group 6). Results: In comparison with group 2, group 1 showed higher frequencies of females, dry cough, and previous use of beta-lactam antibiotics; longer duration of symptoms prior to admission; and lower frequencies of use of mechanical ventilation and chest tube drainage. In comparison with groups 4 and 5, group 3 showed higher frequencies of previous use of beta-lactam antibiotics and dry cough; longer duration of symptoms prior to admission; a lower frequency of use of chest tube drainage; a higher mean age and a lower frequency of nausea/ vomiting (versus group 4 only); and a lower frequency of use of mechanical ventilation (versus group 5 only). M. pneumoniae/S. pneumoniae co-infection increased the duration of symptoms prior to admission. Conclusions: In this sample, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP and PPE in children and adolescents should be more thoroughly investigated in Brazil. Keywords: Pleural effusion; Empyema, pleural; Pneumonia; Mycoplasma pneumoniae. * Trabalho realizado na Universidade Federal do Espírito Santo e no Hospital Infantil Nossa Senhora da Glória, Vitória (ES), e na Universidade Estadual de Campinas, Campinas (SP) Brasil. Endereço para correspondência: Letícia Alves Vervloet. Rua Eugenio Netto 488, sala 712, Edifício Praia Office, Praia do Canto, CEP 29065-270, Vitória, ES, Brasil. Tel. 55 27 3325-0489. E-mail: [email protected] Apoio financeiro: Nenhum. Recebido para publicação em 19/8/2011. Aprovado, após revisão, em 1/1/2012. J Bras Pneumol. 2012;38(2):226-236 Pneumonia adquirida na comunidade e derrame pleural parapneumônico 227 relacionados a Mycoplasma pneumoniae em crianças e adolescentes Introdução broncopulmonar, neoplasia, bronquiolite obliterante, fibrose cística e tuberculose, assim No Brasil, a prevalência de Mycoplasma como aqueles cujos dados estavam incompletos. pneumoniae como agente etiológico do Durante o período do estudo, foram incluídos derrame pleural parapneumônico (DPP) ainda todos os pacientes hospitalizados no HINSG, é desconhecida. Esse fato decorre da dificuldade com idade entre 3 meses e 16 anos de vida, de se correlacionar esse micro-organismo com de ambos os sexos, com diagnóstico clínico e as características clínicas, do pouco crescimento de imagem (radiografia simples de tórax em em meios de cultura e da carência de exames incidência posteroanterior, perfil e decúbito rápidos e específicos na fase inicial da pneumonia lateral) de PAC e DPP. Foram incluídos no estudo adquirida na comunidade (PAC) associada ao apenas os pacientes com identificação etiológica (1) DPP. bacteriana (germes típicos ou M. pneumoniae) As apresentações clínicas das infecções por e sem outras bactérias atípicas isoladas como M. pneumoniae são bastante variáveis. O curso único micro-organismo. (2-4) clínico é geralmente moderado e autolimitado, Foi considerado o diagnóstico de pneumonia e ocorre pneumonia em 3-10% dos pacientes. por M. pneumoniae quando foi detectada IgM Entretanto, são descritos quadros graves de positiva para M. pneumoniae em sangue periférico pneumonia, com a presença de DPP em 4-20% por ELISA. O kit utilizado (ImmunoWELL; GenBio, dos casos, geralmente pequeno e do lado do San Diego, CA, EUA) apresenta uma especificidade infiltrado pulmonar, mas podendo ser maciço de 90% e uma sensibilidade de 92% (IgM na (5-7) e bilateral. fase aguda), quando comparado a PCR.(10) O A importância de pensarmos em M. pneumoniae diagnóstico para bactérias típicas foi definido nas PAC com DPP, de forma isolada ou em pela ocorrência de hemocultura positiva para o coinfecção, é que esse micro-organismo não patógeno ou o seu isolamento em líquido pleural. responde aos antibióticos usados habitualmente Entre 2000 e 2008, deram entrada no (8,9) no tratamento, como os beta-lactâmicos. O HINSG 496 pacientes com PAC e DPP. Após a tratamento adequado evita o prolongamento utilização dos critérios de exclusão, 345 crianças das manifestações clínicas e o surgimento de (6) e adolescentes hospitalizados foram inicialmente sequelas pulmonares. avaliados e, dentre esses, 121 casos foram incluídos O objetivo do presente estudo foi determinar no estudo devido à identificação do agente as características dos DPPs associados a etiológico (germes típicos ou M. pneumoniae) e M. pneumoniae, quando comparados àqueles sem a presença de outras bactérias atípicas como associados a outros agentes etiológicos, em um único micro-organismo (Figura 1). Os pacientes grupo de crianças e adolescentes atendidos em foram divididos em seis grupos, de acordo com um centro de referência regional no Brasil. os seguintes diagnósticos: Métodos • G1: PAC e DPP por M. pneumoniae, com ou sem coinfecção por outro agente Este é um estudo com delineamento • G2: PAC e DPP por outros agentes observacional e retrospectivo, envolvendo um etiológicos, exceto M. pneumoniae grupo de crianças e adolescentes com diagnóstico • G3: PAC e DPP por M. pneumoniae sem de PAC e DPP, hospitalizado no Hospital Infantil coinfecção Nossa Senhora da Glória (HINSG), em Vitória, • G4: PAC e DPP por Streptococcus pneumoniae ES, Brasil, entre 2000 e 2008. O HINSG é um • G5: PAC e DPP por Staphylococcus aureus centro de referência regional de ensino, de nível • G6: PAC e DPP por M. pneumoniae e terciário, ligado à Secretaria Estadual de Saúde. S. pneumoniae O presente estudo foi aprovado pelo Comitê de Os dados dos pacientes foram codificados e Ética em Pesquisa do Hospital Infantil Nossa armazenados em planilhas do programa estatístico Senhora da Glória, protocolo nº 34/04. Excel 2007 para Windows e foram analisados Foram excluídos pacientes portadores de através do Epi Info, versão 6.0. Foram utilizados doença neurológica, doença neuromuscular, o teste do qui-quadrado e o teste exato de Fisher malformação congênita, imunodeficiência para avaliar variáveis categóricas e ordinais, OR adquirida, cardiopatia congênita, displasia para avaliar a magnitude de associações, o teste J Bras Pneumol. 2012;38(2):226-236 228 Vervloet LA, Vervloet VEC, Tironi-Júnior M, Ribeiro JD Figura 1 - Fluxograma de inclusões, perdas e exclusões da população estudada. Estudo comparativo entre pacientes com pneumonia adquirida na comunidade (PAC) e derrame pleural parapneumônico (DPP) por Mycoplasma pneumoniae e por outros agentes etiológicos. HINSG: Hospital Infantil Nossa Senhora da Glória. t de Student para comparar variáveis contínuas estatisticamente significativa quanto à idade. e ANOVA para comparar mais de duas
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