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Although most of the cases of infection by <span class="elsevierStyleItalic">A&#46; schaalii</span> described to date in the literature have occurred in adult patients&#44; the paediatric population seems to be susceptible as well&#46; We present the first case in which <span class="elsevierStyleItalic">A&#46; schaalii</span> was isolated in a paediatric patient with balanoposthitis&#44; who was managed in the outpatient paediatric emergency department of the Hospital Universitario San Cecilio of Granada&#44; Spain&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a boy aged 7 years that presented in the emergency department with inflammation of the penis that had become apparent that day&#46; He did not have urinary symptoms or systemic manifestations&#46; The most relevant finding of the history taking was that the patient had spent the weekend at the beach&#46; He also had a history of phimosis and balanopreputial adhesions treated with topical corticosteroids at age 5 years&#46; He was correctly vaccinated and had no other personal or family history of interest&#46; The physical examination revealed inflammation and erythema in the glans&#44; foreskin and shaft of the penis&#44; with pain on retracting the foreskin and appearance on manipulation of an abundant yellow-green purulent exudate&#46; The rest of the physical examination was unremarkable&#46; A sample of the exudate was collected for microbiological testing&#44; and the patient was treated with a rinse with physiological saline followed by application of bacitracin&#44; neomycin and polymyxin B cream&#46; The discharge diagnosis was balanitis&#44; and the prescribed treatment consisted of rinses with physiological saline and topical application of mupirocin cream&#46; Three days after discharge&#44; the patient had a follow-up appointment at his primary care clinic&#44; with evidence of significant clinical improvement&#44; and was instructed to continue with the current treatment until completing a total of 7 days&#46; The PCR tests of the balanopreputial exudate were negative for <span class="elsevierStyleItalic">Chlamydia trachomatis</span>&#44; <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>&#44; <span class="elsevierStyleItalic">Mycoplasma</span> spp&#46; and <span class="elsevierStyleItalic">Ureaplasma</span> spp&#46; At 48<span class="elsevierStyleHsp" style=""></span>h&#44; culture on blood agar plates with elevated CO<span class="elsevierStyleInf">2</span> had produced very small colonies &#40;&#60;1<span class="elsevierStyleHsp" style=""></span>mm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; of a gram-positive&#44; slightly curved rod with features compatible with the corynebacteria&#44; slow-growing&#44; non-haemolytic and oxidase and catalase negative&#46; The bacterium was identified by means of MALDI-TOF mass spectrometry as <span class="elsevierStyleItalic">A&#46; schaalii</span> &#40;score&#44; 2&#46;4&#41;&#46; The results of the antibiogram and estimated minimum inhibitory concentrations &#40;mg&#47;L&#41; were&#58; sensitivity to vancomycin &#40;0&#46;25&#41;&#44; ampicillin &#40;0&#46;016&#41;&#44; amoxicillin-clavulanic acid &#40;0&#46;016&#41; and cefotaxime &#40;0&#46;016&#41;&#44; and resistance to clindamycin &#40;&#62;256&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">A&#46; schaalii</span> is a bacterium whose natural habitat is not well known&#44; although it can be part of the microbiota in the genitourinary tract&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It is suspected that it is an underdiagnosed cause of genitourinary infections&#44; partly due to technical difficulties in its isolation&#44; as it grows weakly in culture in room air and its identification sometimes requires the use of molecular methods&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> This bacterium is usually associated with UTIs in older adults with underlying diseases of the kidney or urinary system&#44; and it has also been described in association with endocarditis&#44; osteomyelitis and soft-tissue infections&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Infection by <span class="elsevierStyleItalic">A&#46; schaalii</span> has been associated with the increased moisture that results from the use of diapers in children and from incontinence in older adults&#44; a factor that may promote colonization by this bacterium and lead to a higher incidence of UTIs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To date&#44; 7 cases of infection by this bacterium in the paediatric age group have been reported &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#8211;6</span></a> of which 5 corresponded to UTIs&#44; 1 to an intradural abscess and the last one to the case presented here&#46; Five of these patients had a history of urogenital disease and 4 had risk factors such as use of diapers&#44; enuresis or&#44; in the case we present here&#44; wetness due to prolonged wearing of swimming trunks&#46; <span class="elsevierStyleItalic">A&#46; schaalii</span> is an emerging uropathogen whose presence should be considered in paediatrics&#44; especially in children aged less than 4 years with kidney or urinary system diseases&#44; who use diapers or who have enuresis or other conditions that lead to increased moisture in the genital area&#44; and specifically in cases of suspected UTI with negative results of routine cultures&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> This organism should also be considered as a possible aetiological agent in balanopreputial infections&#46; It is important to remember that <span class="elsevierStyleItalic">A&#46; schaalii</span> is usually resistant to fluoroquinolones and cotrimoxazole&#44; the latter of which is commonly used for UTI treatment and prophylaxis in paediatric practice&#46; At present&#44; the recommended treatment for a known or suspected infection by <span class="elsevierStyleItalic">A&#46; schaalii</span> is amoxicillin or a cephalosporin&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In infections of the glans or foreskin&#44; topical treatment with mupirocin may suffice&#44; although further research is required to determine the prognosis&#44; associated complications and appropriate treatment of infections by <span class="elsevierStyleItalic">A&#46; schaalii</span>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Ruiz-Garc&#237;a C&#44; Mu&#241;oz-Hoyos A&#44; Lara-Oya A&#44; Navarro-Mar&#237; JM&#44; Guti&#233;rrez-Fern&#225;ndez J&#46; Balanopostitis por <span class="elsevierStyleItalic">Actinotignum</span> en ni&#241;os&#46; Revisi&#243;n bibliogr&#225;fica y presentaci&#243;n de un caso&#46; An Pediatr &#40;Barc&#41;&#46; 2018&#59;89&#58;246&#8211;248&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Picture of <span class="elsevierStyleItalic">Actinotignum schaalii</span> colonies in culture media&#46; Growth in blood agar after 48<span class="elsevierStyleHsp" style=""></span>h of culture under anaerobic conditions &#40;left&#41; and aerobic conditions &#40;right&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Specimen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Concomitant microbiota&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Urogenital problems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other predisposing conditions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pyelonephritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ureteropelvic junction obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital left hemiplegia&#44; epilepsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin-clavulanic acid &#40;2 days&#41; followed by vancomycin &#40;14 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pajkrt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cauda equina syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intradural abscess fluid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-haemolytic <span class="elsevierStyleItalic">Streptococcus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Syringomyelia&#44; use of diapers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgical drainage&#44; penicillin&#44; metronidazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Reinhard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurrent UTIs&#44; use of diapers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cotrimoxazole &#40;7 days&#41; followed by amoxicillin &#40;10 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Andersen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cystitis&#46; Reinfection at 1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurogenic bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Enuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pivampicillin &#40;20 days&#41; followed by mecillinam &#40;10 days&#41; followed by pivampicillin &#40;14 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurogenic bladder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myelomeningocele&#44; use of diapers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cotrimoxazole &#40;7 days&#41; followed by amoxicillin &#40;14 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Zimmermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurogenic bladder&#44; vesicoureteral reflux&#44; bladder diverticulum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myelomeningocele&#44; paraplegia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin-clavulanic acid &#40;7 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Balanoposthitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Balanopreputial exudate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Phimosis&#44; balanopreputial adhesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wetness&#44; swimming trunks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical mupirocin &#40;7 days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Case presented in this article&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Personal communication&#44; Dr Reto Lienhard&#44; microbiologist at the Laboratoire de R&#233;f&#233;rence Borrelia &#40;ADMED Microbiologie&#41; in La-Chaux-de-Fonds&#44; France&#46;</p> <p class="elsevierStyleNotepara" id="npar0010">Table adapted from Zimmermann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Infections by <span class="elsevierStyleItalic">Actinotignum schaalii</span> in paediatric patients&#46;</p>"
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      "titulo" => "References"
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          "identificador" => "bibs0015"
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                      "titulo" => "<span class="elsevierStyleItalic">Actinotignum schaalii</span> &#40;formerly <span class="elsevierStyleItalic">Actinobaculum schaalii</span>&#41;&#58; a newly recognized pathogen &#8211; a review of the literature"
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