Epicentre, 8 Rue Saint Sabin, 75011, Paris, France.
UMR 8257, Université Paris Descartes, Paris, France.
BMC Pediatr. 2020 Mar 30;20(1):139. doi: 10.1186/s12887-020-2008-3.
A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children's caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case-control study.
The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case-control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community).
Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1-21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 μg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two.
In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.
在利比里亚蒙罗维亚的巴德内斯维尔交叉口医院（BJH），报告了一群原因不明的多器官功能衰竭的儿童病例。在入院之前，儿童的护理人员报告了抗生素、抗疟药、扑热息痛和传统治疗的使用情况。由于我们不能排除中毒的病因，特别是扑热息痛过量，我们实施了前瞻性综合征监测，以更好地定义这些儿童的临床特征。为了调查危险因素，我们进行了病例对照研究。
该调查于 2015 年 7 月至 2016 年 1 月在 BJH 进行。住院期间的综合征监测确定了至少有以下两种症状的儿童：在呼吸正常脉搏血氧饱和度的情况下呼吸急促；意识改变；低血糖；黄疸；和肝肿大。在对病例定义进行细化以更好地反映肝功能障碍的潜在危险因素后，我们选择了从综合征监测中识别出的病例进行匹配的病例对照研究。病例通过年龄、性别、发病/入院月份、严重程度（院内）和居住地点的接近程度（社区）与院内和社区对照组进行匹配。
2015 年 7 月至 12 月期间，通过综合征监测捕获了 77 例病例患者；其中 68 例（88%）年龄在 3 岁以下，35 例（46%）在住院期间死亡。在这 77 例中，有 30 名儿童符合我们的病例定义，并与 53 名院内和 48 名社区对照组相匹配。扑热息痛是病例和两组对照组中最常报告的药物。与对照组相比，护理人员报告入院前服用超治疗剂量扑热息痛的可能性更高（OR 6.6，95%CI 2.1-21.3）。入院当天采集了 19 例病例的血浆扑热息痛浓度，在入院第一天采集的 13 个样本中，有 10 个样本的浓度超过 10μg/mL，在入院第二天采集的 9 个样本中，有 4 个样本（44%）的浓度超过 10μg/mL。
在诊断能力有限的情况下，本研究强调了超治疗剂量扑热息痛作为 BJH 收治的一组儿童多器官衰竭的一个因素的可能性。在这种情况下，即使无法进行确认性实验室分析，对入院前扑热息痛使用情况的仔细病史也可能提醒临床医生注意药物过量的可能性。进一步的研究可能有助于在这种情况下确定其他毒理学特征，以改善诊断。
