Scientific Letter
Typical haemolytic uraemic syndrome: Report of the first case due to Escherichia coli O26:H11 in Spain
Síndrome hemolítico urémico típico: comunicación del primer caso producido por Escherichia coli O26:H11 en España
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Bardón Cancho, L. Butragueño Laiseca, O. Álvarez Blanco, A.J. Alcaraz Romero, A.B. Martínez López" "autores" => array:5 [ 0 => array:4 [ "nombre" => "E.J." "apellidos" => "Bardón Cancho" "email" => array:1 [ 0 => "edubc15@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Butragueño Laiseca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Álvarez Blanco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A.J." 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"apellidos" => "Martínez López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología Pediátrica, Hospital Materno-Infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Pediátricos, Hospital Materno-Infantil, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome hemolítico urémico típico: comunicación del primer caso producido por <span class="elsevierStyleItalic">Escherichia coli</span> O26:H11 en España" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Haemolytic uraemic syndrome (HUS), while rare, is one of the main causes of acute renal failure in the paediatric age group. It is characterised by the development of haemolytic anaemia, thrombocytopenia and acute renal failure.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Most cases present with diarrhoea (so-called typical HUS), with Shiga toxin (Stx)-producing <span class="elsevierStyleItalic">Escherichia coli</span> (<span class="elsevierStyleItalic">E. coli</span>), especially serotype O157:H7, being the most frequent aetiological agent. We are presenting a case caused by the O26:H11 strain of enterohaemorrhagic <span class="elsevierStyleItalic">E. coli</span>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a girl aged 2 years presenting with fever, vomiting and watery stools with fresh blood of three days’ duration, with asthenia and oligoanuria in the previous 48<span class="elsevierStyleHsp" style=""></span>h. The relevant findings of urgent laboratory testing were: haemoglobin, 9<span class="elsevierStyleHsp" style=""></span>g/dL; platelets, 67,000/μL; creatinine, 3.9<span class="elsevierStyleHsp" style=""></span>mg/dL; urea, 162<span class="elsevierStyleHsp" style=""></span>mg/dL, uric acid, 15.9<span class="elsevierStyleHsp" style=""></span>mg/dL; lactate dehydrogenase (LDH), 5397<span class="elsevierStyleHsp" style=""></span>IU/L; and 4–5 schistocytes per high-power field in the peripheral blood smear. The patient was admitted to the paediatric intensive care unit for suspected HUS, and her persistent anuria required initiation of continuous venovenous haemodiafiltration, which was followed by peritoneal dialysis for a total of 21 days of blood purification. The complement levels were decreased at diagnosis (C3, 62.1<span class="elsevierStyleHsp" style=""></span>mg/dL; C4, 10.5<span class="elsevierStyleHsp" style=""></span>mg/dL) and had normalised three days later, including properdin (28.6<span class="elsevierStyleHsp" style=""></span>mg/dL) and CH100 (1.125<span class="elsevierStyleHsp" style=""></span>U/mL) values. The detection of anti-ADAMTS13 antibodies was positive (43.9<span class="elsevierStyleHsp" style=""></span>AU/mL), although ADAMTS13 activity was normal (64.5%). The investigation was completed with a stool culture that was negative for enterohaemorrhagic <span class="elsevierStyleItalic">E. coli</span>. Due to this result, the sample was analysed by PCR and found to be positive for verotoxigenic <span class="elsevierStyleItalic">E. coli</span>, and genetic characterisation and serotyping identified the isolate as strain O26H:11.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">E. coli</span> strain O26:H11 has been an emergent pathogen in Europe since it was first isolated in Germany in 1990.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It has been increasingly isolated in cases of HUS to eventually become the second most frequent cause (15–19%) following serotype O157:H7, even surpassing this serotype in some countries between 2008 and 2012. It can also produce two types of Stx, of which Stx2a is strongly associated with the development of HUS.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Furthermore, there is evidence that children are more frequently infected by <span class="elsevierStyleItalic">stx</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2a</span></span>-harbouring strains, and thus are more likely to develop HUS.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The detection of enterohaemorrhagic <span class="elsevierStyleItalic">E. coli</span> O26:H11 by PCR in our patient constitutes the first time that this strain is found in a child with HUS in Spain. This serotype is associated with infection in younger children, and the form of HUS that it causes may have a similar severity and clinical course to the form produced by O157:H7. The patient was kept in isolation during the early weeks of hospitalisation, and is currently awaiting negative stool culture results to resume her schooling.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our patient did not receive antibiotic therapy, as it is not indicated for HUS; furthermore, antibiotic use has been associated with an increased risk of developing HUS in enteroinvasive diarrhoeas,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> and experimental studies have shown that it may induce the expression and release of Stx.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We have only found references to other two cases of diarrhoea-associated HUS<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> with presence of anti-ADAMTS13 antibodies and preserved normal ADAMTS13 activity, as observed in our patient. The role of these antibodies in these patients has not been clearly established, so their presence alone would not indicate a specific intervention insofar as activity continues to be normal.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Our patient only required one red blood cell transfusion after her haemoglobin level had reached a minimum of 5.7<span class="elsevierStyleHsp" style=""></span>g/dL four days after admission; the platelet levels dropped to 64,000 in the first 24<span class="elsevierStyleHsp" style=""></span>h and then increased gradually from the fifth day of hospitalisation. The concentration of haptoglobin at diagnosis was less than 10<span class="elsevierStyleHsp" style=""></span>mg/dL and the LDH levels were reduced by half in the first three days, normalising two weeks later.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We should also note the absence of neurologic manifestations in our patient (save for mild confusion), the presence of which is variable in the early stages of HUS.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our purpose in presenting this case is to emphasise, on one hand, that a high degree of suspicion is essential, as this disease can cause severe sequelae or even death in 5% to 10% of the cases, and on the other, that an exhaustive microbiological diagnosis is imperative, promptly submitting samples for the early identification of emerging strains so that appropriate preventive measures can be implemented. This requires the support of reference centres, which in our case was the Centro Nacional de Microbiología (Instituto de Salud Carlos III).</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-08" "fechaAceptado" => "2015-09-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bardón Cancho EJ, Butragueño Laiseca L, Álvarez Blanco O, Alcaraz Romero AJ, Martínez López AB. Síndrome hemolítico urémico típico: comunicación del primer caso producido por <span class="elsevierStyleItalic">Escherichia coli</span> O26:H11 en España. An Pediatr (Barc). 2016;84:171–172.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Haemolytic uraemic syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Kaur" 1 => "L. Kerecuk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Paediatr Child Health" "fecha" => "2012" "volumen" => "22" "paginaInicial" => "332" "paginaFinal" => "336" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enterohemorrhagic <span class="elsevierStyleItalic">Escherichia coli</span> O26:H11/H-: a new virulent clone emerges in Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Bielaszewska" 1 => "A. Mellmann" 2 => "S. Bletz" 3 => "W. Zhang" 4 => "R. Köck" 5 => "A. Kossow" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cit055" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2013" "volumen" => "56" "paginaInicial" => "1373" "paginaFinal" => "1381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23378282" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0886335011007681" "estado" => "S300" "issn" => "08863350" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enterohemorrhagic <span class="elsevierStyleItalic">Escherichia coli</span> as causes of hemolytic uremic syndrome in the Czech Republic" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Marejková" 1 => "K. Bláhová" 2 => "J. Janda" 3 => "A. Fruth" 4 => "P. Petráš" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0073927" "Revista" => array:5 [ "tituloSerie" => "PLOS ONE" "fecha" => "2013" "volumen" => "8" "paginaInicial" => "e73927" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24040117" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for the hemolytic uremic syndrome in children infected with <span class="elsevierStyleItalic">Escherichia coli</span> O157:H7: a multivariable analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.S. Wong" 1 => "J.C. Mooney" 2 => "J.R. Brandt" 3 => "A.O. Staples" 4 => "S. Jelacic" 5 => "D.R. Boster" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cis299" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2012" "volumen" => "55" "paginaInicial" => "33" "paginaFinal" => "41" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22431799" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ADAMTS13 autoantibodies in patients with thrombotic microangiopathies and other immunomediated diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Rieger" 1 => "P.M. Mannucci" 2 => "J.A. Kremer Hovinga" 3 => "A. Herzog" 4 => "G. Gerstenbauer" 5 => "C. 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| 2024 July | 34 | 24 | 58 |
| 2024 June | 48 | 23 | 71 |
| 2024 May | 39 | 29 | 68 |
| 2024 April | 36 | 30 | 66 |
| 2024 March | 31 | 22 | 53 |
| 2024 February | 25 | 24 | 49 |
| 2024 January | 31 | 23 | 54 |
| 2023 December | 22 | 12 | 34 |
| 2023 November | 20 | 22 | 42 |
| 2023 October | 33 | 23 | 56 |
| 2023 September | 17 | 14 | 31 |
| 2023 August | 26 | 22 | 48 |
| 2023 July | 24 | 31 | 55 |
| 2023 June | 31 | 21 | 52 |
| 2023 May | 38 | 17 | 55 |
| 2023 April | 23 | 16 | 39 |
| 2023 March | 44 | 21 | 65 |
| 2023 February | 13 | 11 | 24 |
| 2023 January | 16 | 17 | 33 |
| 2022 December | 36 | 28 | 64 |
| 2022 November | 43 | 30 | 73 |
| 2022 October | 30 | 52 | 82 |
| 2022 September | 28 | 31 | 59 |
| 2022 August | 30 | 42 | 72 |
| 2022 July | 27 | 41 | 68 |
| 2022 June | 25 | 32 | 57 |
| 2022 May | 23 | 27 | 50 |
| 2022 April | 21 | 49 | 70 |
| 2022 March | 32 | 34 | 66 |
| 2022 February | 24 | 23 | 47 |
| 2022 January | 28 | 38 | 66 |
| 2021 December | 25 | 30 | 55 |
| 2021 November | 45 | 49 | 94 |
| 2021 October | 36 | 47 | 83 |
| 2021 September | 37 | 42 | 79 |
| 2021 August | 20 | 30 | 50 |
| 2021 July | 24 | 37 | 61 |
| 2021 June | 17 | 38 | 55 |
| 2021 May | 20 | 35 | 55 |
| 2021 April | 45 | 47 | 92 |
| 2021 March | 30 | 29 | 59 |
| 2021 February | 21 | 13 | 34 |
| 2021 January | 22 | 18 | 40 |
| 2020 December | 26 | 22 | 48 |
| 2020 November | 14 | 17 | 31 |
| 2020 October | 14 | 14 | 28 |
| 2020 September | 22 | 23 | 45 |
| 2020 August | 9 | 18 | 27 |
| 2020 July | 17 | 14 | 31 |
| 2020 June | 16 | 10 | 26 |
| 2020 May | 30 | 19 | 49 |
| 2020 April | 25 | 13 | 38 |
| 2020 March | 25 | 18 | 43 |
| 2020 February | 26 | 14 | 40 |
| 2020 January | 22 | 11 | 33 |
| 2019 December | 27 | 23 | 50 |
| 2019 November | 28 | 11 | 39 |
| 2019 October | 24 | 17 | 41 |
| 2019 September | 17 | 7 | 24 |
| 2019 August | 34 | 26 | 60 |
| 2019 July | 15 | 31 | 46 |
| 2019 June | 28 | 24 | 52 |
| 2019 May | 47 | 28 | 75 |
| 2019 April | 31 | 56 | 87 |
| 2019 March | 17 | 22 | 39 |
| 2019 February | 28 | 16 | 44 |
| 2019 January | 28 | 14 | 42 |
| 2018 December | 27 | 17 | 44 |
| 2018 November | 64 | 29 | 93 |
| 2018 October | 44 | 26 | 70 |
| 2018 September | 32 | 15 | 47 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 15 | 0 | 15 |
| 2018 March | 15 | 0 | 15 |
| 2018 February | 10 | 0 | 10 |
| 2018 January | 7 | 0 | 7 |
| 2017 December | 12 | 0 | 12 |
| 2017 November | 13 | 0 | 13 |
| 2017 October | 13 | 0 | 13 |
| 2017 September | 13 | 0 | 13 |
| 2017 August | 14 | 0 | 14 |
| 2017 July | 9 | 2 | 11 |
| 2017 June | 20 | 6 | 26 |
| 2017 May | 16 | 7 | 23 |
| 2017 April | 5 | 3 | 8 |
| 2017 March | 3 | 1 | 4 |
| 2017 February | 6 | 8 | 14 |
| 2017 January | 7 | 3 | 10 |
| 2016 December | 19 | 6 | 25 |
| 2016 November | 16 | 5 | 21 |
| 2016 October | 21 | 8 | 29 |
| 2016 September | 28 | 4 | 32 |
| 2016 August | 20 | 1 | 21 |
| 2016 July | 14 | 4 | 18 |
| 2016 May | 1 | 0 | 1 |
| 2016 March | 2 | 0 | 2 |
Show all
