Ahmet Yaramis

Central Nervous System Tuberculosis in Children: A Review of 214 Cases

Objective. To study the clinical, laboratory, and treatment features observed in pediatric patients with tuberculous meningitis in Turkey. Study Design. Retrospective case review study. Methods. Review of medical records for demographic data, medical history, clinical manifestations, auxiliary test results, complications, and treatment of 214 children with central nervous system tuberculosis (TB) admitted to Dicle Universitys hospital between August 1988 and February 1996. Results. Of the 214 patients with tuberculous meningitis, 112 (52%) were male. The mean age at presentation was 4.1 years, with 165 patients (77%) younger than 5 years. Twenty-two patients (10%) were in the first stage of the disease, 120 (56%) in the second, and 72 (34%) in the third. Our epidemiologic data showed that 141 (66%) of the patients had a family history of TB, and 64 (30%) had a Mantoux skin test result of >10 mm of induration. Radiographic studies demonstrated abnormal chest findings in 187 patients (87%) (hilar adenopathy, 33%; infiltrates, 33%; miliary pattern, 20%; and pleural effusions, 1%, and 172 (80%) cases with hydrocephalus, 26% with parenchymal disease, 15% with basilar meningitis, and 2% with tuberculomas. Only 22 (13%) of 164 children had a positive acid-fast bacilli smear in cerebrospinal fluid, andMycobacterium tuberculosis was isolated in 49 patients (30%). All the patients were treated with Isoniazid, rifampin, and streptomycin or pyrazinamide for 2 months, followed by 10 months of Isoniazid and rifampin alone. Also, all the patients received adjuvant treatment with steroids early in the course of treatment, and 140 of 172 cases with hydrocephalus had surgical intervention. The overall mortality rate was 23%. Conclusion. One or more of these findings: a family history of TB, positive tuberculin skin test results, abnormal cranial computed tomography, and/or cerebrospinal fluid analysis compatible with TBM were found in all but 3 children in our study. central nervous system, tuberculous meningitis, diagnosis, hydrocephalus, children.

Miliary Tuberculosis in Children: A Clinical Review

Miliary tuberculosis infection in childhood remains a significant health problem in developing countries. To characterize the clinical features of the disease, symptoms, signs and laboratory findings, associated infections and outcomes of the 23 children (14M, 9F) with miliary tuberculosis admitted to the Dicle University Hospital, Diyarbakir, Turkey from 1990 to 1997 were analysed. Mean age of the patients was 3.7 y ranging between 6 months and 11 y. All but 3 patients were below 6 y of age, and 5 of the patients were under 1 y of age. All of the children had not received BCG vaccination except for 1 who was immunized after the age of 5 y. Only 6 children had a positive reaction to 5 TU tuberculin test at admission to hospital. Eight of the 23 subjects were infected in the family, and all were nonHIV infected cases. All of the children were diagnosed clinically and by a miliary infiltrate visible on chest roentgenogram. Five cases had positive culture results for Mycobacterium tuberculosis. Duration of onset of symptoms prior to admission ranged between 15 d and 8 months with a mean of 58 d. The most frequently seen symptoms and clinical findings were fever in 17 cases, rales in 14, loss of appetite and weight in 10 and hepatosplenomegaly in 9 cases. Two cases had prior measles infection and 1 of the patients presented facial paralysis. Seven cases had also tuberculous meningitis. The outcome in general was good, with mortality in 2 cases.

Beneficial effect of human albumin on neonatal cerebral edema.

Despite advances in biophysical and biochemical monitoring of the fetus in labor and delivery, neonatal asphyxia, hypoxic ischemic encephalopathy (HIE), and related brain edema (BE) still contribute heavily to neonatal mortality and morbidity rates. The therapeutic dilemma that confronts physicians in the management of HIE and associated BE in the newborn infant is not entirely bleak. In animal models, brain damage is diminished by early intervention (free radical scavengers, brain cooling, etc.), but only few regimens have been applied to the care of asphyxiated infants. On the purely physiologic basis that maintenance of adequate plasma volume is preserved and controlled by plasma protein levels, therapy with human albumin solutions theoretically would increase plasma oncotic pressure and prevent loss of intravascular volume. Certainly, then, it should facilitate increased transcapillary fluid absorption from the interstitial spaces and removal of the excess fluid already present. In experimental studies, human serum albumin was found to significantly reduce BE. Treatment with albumin infusion in posttraumatic BE has been reported to reduce both mortality and morbidity rates. Albumin is a physiologic agent and has no antigenic properties, there is no risk of hepatitis virus contamination, and it may improve binding of bilirubin with a half-life of 19 days. Use of mannitol and other diuretics in neonatal BE may cause deterioration of the hemodynamic state. On the basis of this concept, 18 newborn infants (mean ± SD gestational age: 38.8 ± 1.9; mean ± SD birth weight: 3010 ± 480 gr; male-to-female ratio: 13/5) diagnosed with neonatal asphyxia and BE were enrolled in a clinical trial conducted in the neonatology unit of Dicle University Hospital, Turkey. All patients had restricted fluid administration and adequate delivery of oxygen in addition to supportive management. On the second day of treatment, nine of the neonates were assigned randomly to receive 20% human albumin solution (0.5 gr/kg), and the others were administered the routine fluid. Caretakers of the patients were blinded to albumin administration, and informed consent was obtained from parents. Clinical symptom scores modified from the Apgar scoring system were serially recorded (Table 1). Wilcoxon Matched-pairs, Mann–Whitney U, and Fisher Exact tests were used for statistical analysis. There were no significant differences between the two groups in birth weight, gestational age, gender, and baseline clinical and laboratory variables. Compared with the control group, the group receiving human Department of Pediatrics, Dicle University Medical School Hospital, Diyarbakir, Turkey. *Address for correspondence: Department of Pediatrics, Dicle University Medical School Hospital, Diyarbakir, Turkey; e-mail: fuatgurkan@hotmail.com

Infantile iatrogenic Cushing's syndrome.

High potency or/and extended use of topical corticosteroids, particularly in children, may cause suppression of the hypothalamopituitary-adrenal axis. However, iatrogenic Cushings syndrome in infantile age group is very rare and only a few patients have been reported to date in the literature. Here, we report a case of iatrogenic Cushings syndrome in a 6-month-old male child whose parents have admitted to the hospital for overweight and skin fragility.

Cranial magnetic resonance imaging findings of nutritional vitamin B12 deficiency in 15 hypotonic infants.

BACKGROUND Nutritional vitamin B(12) deficieny is common among infants in the developing and underdeveloped countries. There is limited information concerning neuroimaging findings in infants with vitamin B(12) deficiency in the literature. AIMS The aim of this study is to evaluate the cranial magnetic resonance imaging (MRI) changes and clinical characteristics of hypotonic infants due to vitamin B(12) deficiency. MATERIALS AND METHODS A total of 15 infants with neuroradiologic investigations were diagnosed with nutritional B(12) vitamin deficiency. Cranial MRI was performed on all infants. RESULTS Five infants were female (33%) and the mean age of infants was 12.3 ± 5.5 months. Hypotonia and neurodevelopmental retardation were present in all patients. MRI demonstrated thinning of the corpus callosum in 6 (40%), cortical atrophy in 5 (33.3%), large sylvian fissures in 5 (33.3%), ventricular dilatation in 3 (20%), asymetric large lateral ventricle in 2 (13.3%) and delayed in myelination in 2 (13.3%) patients. Four infants had normal MRI findings. CONCLUSION Because of the importance of vitamin B(12) in the development of the brain, MRI findings may be detected and useful in infants with vitamin B(12) deficiency.

A multinational survey on actual diagnostics and treatment of subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a chronic infection of the central nervous system caused by the measles virus (MV). Its prevalence remains high in resource poor countries and is likely to increase in the Northern Europe as vaccination rates decrease. Clinical knowledge of this devastating condition, however, is limited. We therefore conducted this multinational survey summarizing experience obtained from more than 500 patients treated by 24 physicians in seven countries. SSPE should be considered in all patients presenting with otherwise unexplained acquired neurological symptoms. In most patients, the diagnosis will be established by the combination of typical clinical symptoms (characteristic repetitive myoclonic jerks), a strong intrathecal synthesis of antibodies to MV and typical electroencephalogram findings (Radermecker complexes). Whereas the therapeutic use of different antiviral (amantadine, ribavirin) and immunomodulatory drugs (isoprinosine, interferons) and of immunoglobulins has been reported repeatedly, optimum application regimen of these drugs has not been established. This is partly due to the absence of common diagnostic and clinical standards focusing on neurological and psychosocial aspects. Carbamazepine, levetiracetam, and clobazam are the drugs most frequently used to control myoclonic jerks. We have established a consensus on essential laboratory and clinical parameters that should facilitate collaborative studies. Those are urgently needed to improve outcome.

Role and Clinical Significance of Plasma N-Terminal Brain Natriuretic Peptide Measurement in Children with Brain Edema.

OBJECTIVE Brain natriuretic peptide (BNP) is a potent natriuretic and vasodilator factor. BNP plasma concentrations were found to be elevated in patients with brain edema. The purpose of the present study is to evaluate the relationship between plasma NT-proBNP concentration and the presence of brain edema in patients with intracranial pathology. MATERIALS AND METHODS The plasma NT-proBNP levels of 50 patients and 25 healthy subjects were measured. The NT-proBNP levels of the patient group were measured during admission and after 7 days of treatment. RESULTS NT-proBNP plasma concentrations were found to be significantly higher in the patient group with brain edema than in the control group (p < 0.005). There were no significant differences in the NT-proBNP plasma concentrations between patients with intracranial pathology without brain edema and the control group (p > 0.005). NT-proBNP plasma concentrations were found to be significantly higher in patients with brain edema as compared with patients without brain edema before treatment (p < 0.005). CONCLUSION These results suggest that excessive secretion of plasma NT-proBNP is related to brain edema. Plasma NT-proBNP levels may serve as a marker to guide the early-diagnostic and therapeutic management in children with brain edema. Further studies are required to evaluate the role of BNP in brain edema pathophysiology.

Evaluation of brainstem auditory evoked response audiometry findings in children with tuberculous meningitis at admission

OBJECTIVE To determine the characteristics of Brainstem auditory evoked response (BAER) findings in children with tuberculous meningitis (TBM) at admission. METHODS Twenty-seven children with highly probable TBM were admitted to the University Hospital. The control group was 23 healthy, age and sex matched subjects. Brainstem response audiometry recording was performed in all patients and controls. Ninety dB sound pressure level (SPL) was used for comparisons. The main BAER measurements analysed were the I-III, III-V, I-V interpeak intervals. In statistical analysis, t-test for independent groups were performed. At the same time, for interpeak intervals, values exceeding 2.5 standard deviations (S.D.) above the means of the normal controls were considered abnormal. To the result of BAER findings, HL was classified as mild (until 40 dBHL), severe (until 80 dBHL) and total HL (no hearing was detected). RESULTS The latencies of interpeak intervals (except III-V latency at 10 per s) have significantly prolonged in comparison with controls. Mild HL was detected in four ears. In eight ears, any wave form could not be obtained at 110 dBSPL. Abnormal BAER result was seen in 13 of 54 ears (24%) at the click of 10 per s and five ears (12%) at the click of 50 per s. CONCLUSION Abnormal BAER result was seen in 24% of patients with TBM before treatment. Depending on these findings, it can be inferred that hearing impairments must be lower than those values which was detected by BAER during the acute phase of TBM, since the abnormal BAER may be reversible following the illness, returning to normal with recovery.