Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease worldwide and a key-model to illustrate dysregulation of innate immunity, etiologically determined by pathogenic variants in the MEFV gene, encoding pyrin, leading to uncontrolled interleukin-1β and interleukin-18 release. Despite its genetic basis, FMF shows marked clinical heterogeneity in all-aged patients, mostly in children, suggesting a role of potential environmental modifiers which are far to be exactly unraveled. Recent medical literature has increasingly illuminated the importance of gut microbiota in maintaining overall health and immune functions, and its contribution has been claimed also to explain both FMF inflammatory activity and heterogeneous disease expression. This narrative review summarizes current evidence on the interaction between gut microbiota and FMF, with a specific focus on differences between children and adults. Pediatric studies dedicated to FMF have reported intestinal dysbiosis in terms of reduced microbial diversity and depletion of short-chain fatty acid-producing bacteria, with subsequent enrichment of pro-inflammatory taxa: such alteration could modulate pyrin-inflammasome activation and contribute to systemic inflammation, disease phenotype, and response to colchicine or to other drugs specifically used in colchicine-resistant FMF. Geographic and lifestyle factors may shape intestinal microbiota composition early in life, reinforcing the relevance of gut flora and confirming its activity as a crucial tessera to determine FMF sceneries, mostly in children, and a potential target for future add-on therapeutic strategies. In addition, colchicine therapy appears to partially remodel the gut microbiome, empowering a local beneficial anti-inflammatory microbial profile.

Background: Bilateral facial nerve palsy (BFNP) is a rare clinical entity in children and is more often associated with systemic or infectious diseases than unilateral facial palsy. Epstein–Barr virus (EBV) infection is an uncommon but recognized cause of facial nerve palsy and may present with bilateral involvement. Case presentation: We report the case of a 3-year-old boy who presented with progressive bilateral facial weakness following a febrile illness with pharyngitis and cervical lymphadenopathy. Neurological examination revealed complete bilateral facial paralysis (House–Brackmann grade VI). Laboratory investigations showed lymphocytosis and confirmed acute EBV infection through positive viral capsid antigen IgM and detectable EBV DNA in peripheral blood. Cerebrospinal fluid analysis demonstrated mild pleocytosis with negative EBV DNA. Brain magnetic resonance imaging revealed unilateral enhancement of the left facial nerve. Audiologic evaluation supported peripheral facial nerve dysfunction. The patient was treated with systemic corticosteroids, vitamin B complex supplementation, artificial tears, and speech therapy, resulting in gradual and substantial clinical improvement over five months. Discussion: A review of the pediatric literature identified only six previously reported cases of EBV-associated BFNP. The pathogenesis may involve either direct viral neurotropism or a post-infectious immune-mediated mechanism. Diagnostic evaluation is essential to exclude other serious causes of BFNP, particularly Lyme disease and Guillain–Barré syndrome. Conclusions: EBV infection should be considered in the differential diagnosis of BFNP in children. Prognosis is generally favorable, although recovery may be prolonged. Further studies are needed to clarify optimal diagnostic and therapeutic approaches.

Background: Pediatric pleural empyema remains a major complication of community-acquired pneumonia despite vaccination and advances in minimally invasive treatment. This narrative review summarizes current evidence on etiology and microbiology, diagnosis and imaging, antimicrobial therapy, supportive care, pleural drainage, fibrinolysis, surgery, complications, and short- and long-term outcomes. Methods: This structured narrative review searched PubMed from inception through 30 July 2026. No formal risk-of-bias assessment was performed. Of 42 publications assessed in full, 38 were included in the narrative synthesis. Results: Streptococcus pneumoniae, particularly serotype 3, Staphylococcus aureus, and Streptococcus pyogenes remain the principal pathogens. Chest ultrasound is preferred for characterizing pleural collections and guiding intervention, whereas computed tomography is reserved for atypical disease or suspected complications. Small pediatric comparative trials report broadly similar outcomes for catheter drainage with fibrinolysis and video-assisted thoracoscopic surgery (VATS), but differences in sample size, eligibility, treatment protocols, and outcome definitions limit conclusions about comparative effectiveness. Image-guided small-bore catheter drainage with protocol-based urokinase or tissue plasminogen activator is effective for many loculated effusions. Pediatric evidence does not support routine addition of DNase. Comparative trials show broadly similar clinical outcomes for fibrinolysis and video-assisted thoracoscopic surgery, although heterogeneous protocols and limited sample sizes preclude identification of a universally superior strategy. Thoracotomy is rarely required. Conclusions: Management should integrate respiratory and septic severity, pleural anatomy, microbiology, adequacy of drainage, clinical trajectory, and local expertise rather than rely on rigid staging. Long-term recovery is excellent in most previously healthy children receiving timely treatment. Standardized definitions, pediatric outcome sets, multicenter comparative trials, validated predictors of treatment failure, and studies of antimicrobial duration remain important research priorities.

Background: Pediatric pleural empyema remains a major complication of community-acquired pneumonia despite vaccination and advances in minimally invasive treatment. This narrative review summarizes current evidence on etiology, diagnosis, antimicrobial therapy, pleural drainage, fibrinolysis, and surgery. Methods: PubMed was searched from inception through July 2026 for English-language studies involving patients aged 0–18 years. Pediatric trials, observational studies, surveillance reports, guidelines, reviews, and relevant case series were considered. Of 42 publications assessed in full, 38 were included in the narrative synthesis. Results: Streptococcus pneumoniae, particularly serotype 3, Staphylococcus aureus, and Streptococcus pyogenes remain the principal pathogens. Chest ultrasound is preferred for characterizing pleural collections and guiding intervention, whereas computed tomography is reserved for atypical disease or suspected complications. Small, uncomplicated effusions may respond to antibiotics alone; large, purulent, or clinically significant collections generally require source control. Image-guided small-bore catheter drainage with protocol-based urokinase or tissue plasminogen activator is effective for many loculated effusions. Pediatric evidence does not support routine addition of DNase. Comparative trials show broadly similar clinical outcomes for fibrinolysis and video-assisted thoracoscopic surgery, although heterogeneous protocols and limited sample sizes preclude identification of a universally superior strategy. Thoracotomy is rarely required. Conclusions: Management should integrate respiratory and septic severity, pleural anatomy, microbiology, adequacy of drainage, clinical trajectory, and local expertise rather than rely on rigid staging. Long-term recovery is excellent in most previously healthy children receiving timely treatment. Standardized definitions, pediatric outcome sets, multicenter comparative trials, validated predictors of treatment failure, and studies of antimicrobial duration remain important research priorities.