Athanassios Chatzimichael

Comparative Efficacies of Procalcitonin and Conventional Inflammatory Markers for Prediction of Renal Parenchymal Inflammation in Pediatric First Urinary Tract Infection

OBJECTIVES To compare the reliability of procalcitonin (PCT) with conventional laboratory parameters in predicting for renal parenchymal inflammation (RPI). METHODS The study cohort consisted of 57 children who were admitted for a first-episode urinary tract infection. All patients underwent measurement of the leukocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum PCT. RPI was evaluated by technetium-99m dimercaptosuccinic acid (DMSA) scintigraphy within 7 days of admission. If the first DMSA findings were abnormal, another analysis was performed 6 months later. The cutoff points for ESR, CRP, and PCT were established by comparing the areas under their receiver operating characteristic curves. Statistical analysis was performed using 1-way analysis of variance. RESULTS Of the 57 children, 27 were diagnosed with RPI on the basis of positive DMSA results. The ESR, CRP, and PCT levels were significantly greater (P < .001) in the patients with RPI than in those without RPI. In contrast, the leukocyte count was the same in both groups (P > .05). PCT was a more sensitive and specific marker for differentiating upper and lower urinary tract infection than ESR and CRP. Persistent lesions at the site of previous RPI were found in 12 patients in the follow-up DMSA analysis, with total regression evident in the remaining 15. The PCT levels were significantly greater in those with persistent renal lesions than in those with total regression (P = .005). CONCLUSIONS Serum PCT is a more reliable biologic marker than the ESR, CRP, or leukocyte count for the early prediction of RPI in children with a first episode of urinary tract infection. In addition, the greater the elevation of PCT at admission, the more positive the correlation for subsequent permanent renal damage.

Acute Tc-99m DMSA Scan for Identifying Dilating Vesicoureteral Reflux in Children: A Meta-analysis

Controversy exists regarding the type and/or sequence of imaging studies needed during the first febrile urinary tract infection (UTI) in young children. Several investigators have claimed that because acute-phase Tc-99m dimercaptosuccinic acid (DMSA) renal-scan results are abnormal in the presence of dilating vesicoureteral reflux, a normal DMSA-scan result makes voiding cystourethrography (VCUG) unnecessary in the primary examination of infants with UTI. To evaluate the accuracy of acute-phase DMSA scanning in identifying dilating (grades III through V) vesicoureteral reflux documented by VCUG in children with a first febrile UTI, we performed a meta-analysis of the accuracy of diagnostic tests as reported from relevant studies identified through the PubMed and Scopus databases. Patient-based and renal unit–based analyses were performed. Overall, 13 cohort studies were identified. Nine studies involved patients younger than 2 years, 3 involved children aged 16 years or younger, and 1 involved exclusively neonates. Girls constituted 22% to 85% of the involved children. Pooled (95% confidence intervals) sensitivity and specificity rates of DMSA scanning were 79% and 53%, respectively, for the patient-based analysis (8 studies) and 60% and 65% for the renal unit–based analysis (5 studies). The respective areas under the hierarchical summary receiver operating curves were 0.71 and 0.67. Marked statistical heterogeneity was observed in both analyses, as indicated by I2 test values of 91% and 87%, respectively. Acute-phase DMSA renal scanning cannot be recommended as replacement for VCUG in the evaluation of young children with a first febrile UTI.

Deep venous thrombosis in children with musculoskeletal infections: the clinical evidence.

BACKGROUND Clinical manifestations of deep venous thrombosis (DVT) tend to overlap with those of deep-seated musculoskeletal infections (MSIs). Consequently, the incidence of DVT as a complication of MSI may be underestimated. The objective of this study was to evaluate the incidence, clinical features, and outcomes of MSI-related DVT in children. METHODS We systematically reviewed relevant studies retrieved from PubMed and Scopus databases. RESULTS Overall, 93 children with MSIs who developed DVT were identified from 28 retrospective studies. The majority were boys. Osteomyelitis was the most frequent MSI (69/74, 93%). Staphylococcus aureus was the predominant pathogen (83/93, 89%); 61% of these isolates were methicillin-resistant S. aureus (MRSA). Pulmonary involvement, presumably due to septic emboli, was observed in 65% of the included children. Four children died due to multiple organ failure and two due to respiratory distress. In two of the three studies providing comparative data, MRSA infections were observed significantly more frequently in children who developed DVT compared to those who did not. Yet, the respective differences observed for methicillin-susceptible S. aureus (MSSA) infections were non-significant in these three studies. CONCLUSIONS Despite the inclusion of many case reports and the retrospective design of the evaluated studies, our findings suggest that boys seem to be more frequently affected by MSIs complicated by DVT. Moreover, MRSA seems to be more frequently associated with DVT compared to MSSA. Pulmonary involvement appears to be a frequent complication. Prospective studies are needed in order to further clarify this issue.

A case of immune thrombocytopenic purpura after influenza vaccination: consequence or coincidence?

The researchers describe the case of a earlier healthy 3-year-old boy, who developed immune thrombocytopenic purpura (ITP) 26 days after immunization with the second dose of seasonal influenza vaccine. He recovered quickly and uneventfully within 2 days after receiving a single dose of intravenous immunoglobulin. Review of the medical literature showed that symptomatic thrombocytopenia occurs in a substantial number of children and adults who require hospitalization for complicated natural influenza infection, particularly avian influenza. In contrast, it is exceptionally rare after influenza immunization, as only few case reports describe such an association in adults but not in children. As the risk of thrombocytopenia after natural influenza seems to be much higher than after immunization, annual influenza vaccination is advised for patients with personal history of ITP who at risk of influenza-related complications owing to underlying medical problems.

Involution of a Large Parotid Hemangioma with Oral Propranolol: An Illustrative Report and Review of the Literature

Propranolol has emerged as a new treatment option for infantile hemangiomas. We describe a 20-month-old boy with a large right parotid hemangioma diagnosed at the age of 37 days. Starting at the age of 2.5 months, he received oral propranolol for 6.5 months. Although the mass regressed, it recurred when propranolol was discontinued. He was successfully retreated at the age of 11 months with propranolol for another 5.5 months without further recurrences. Treatment was tolerated well. Our paper and a review of the literature demonstrate that propranolol appears to be safe and effective for symptomatic infantile parotid gland hemangiomas.

X‐linked thrombocytopenia in three males with normal sized platelets due to novel WAS gene mutations

The authors describe two young brothers and a 12‐year‐old male with long‐standing thrombocytopenia with normal sized platelets, in whom novel mutations of the WAS gene were identified. Their clinical picture and the in vitro assessment of the T‐cell function were consistent with X‐linked thrombocytopenia (XLT). A high index of suspicion for XLT is required, even in the setting of normal sized platelets for males with affected maternally‐related male family members, and males with moderately severe chronic thrombocytopenia that have failed to respond to treatments that are usually effective for immune thrombocytopenia. Pediatr Blood Cancer 2014;61:2305–2306.

Seizures as initial manifestation of vitamin D-deficiency rickets in a 5-month-old exclusively breastfed infant.

Despite the fact that sunlight-dependent skin synthesis is the major mechanism for vitamin D synthesis in vivo, vitamin D-deficiency rickets continues to occur in exclusively breastfed infants in Greece. We present such a case in a 5-month-old infant who presented with afebrile seizures and whose mother was underexposed to sunlight due to veiling for religious reasons. Additionally, we briefly but thoroughly review the relevant medical literature. A high index of suspicion is required for nutritional rickets, when seizures occur in exclusively breastfed infants whose mothers have inadequate exposure to sunlight.

Spinal epidural abscess in a young girl without risk factors

Spinal epidural abscess (SEA) is a rare infection associated with well-established risk factors mainly in adults. We describe an 11-year-old girl without any known risk factors who presented with fever and localized spinal tenderness in the lumbar area and was diagnosed with spinal MRI as suffering from a posterior SEA extending between T11 and L4. She was successfully managed with sequential intravenous and oral antibiotics along with minimally invasive surgery without laminectomy. Methicillin-sensitive Staphylococcus aureus was the responsible pathogen isolated at surgery. Immediate institution of antibiotics, spinal MRI, and well-timed neurosurgical consultation are mandatory for a favorable outcome in cases of SEA in children.

Intravenous iron sucrose for children with iron deficiency anemia: a single institution study

BackgroundIntravenous iron sucrose is not recommended by its manufacturers for use in children despite extensive safety and efficacy data in adults.MethodsWe reviewed the experience of our department between January, 2011 and February, 2014 with the use of intravenous iron sucrose in children ≤14 years of age who failed in oral iron therapy for iron deficiency anemia (IDA).ResultsTwelve children (6 females) aged 1.2-14 years (median age 8.9 years) received at least one dose of intravenous iron sucrose. Ten patients had IDA inadequately treated or non-responsive to oral iron therapy. One patient received therapy for blood transfusion avoidance and one for presumed iron refractory iron deficiency anemia (IRIDA). Iron sucrose infusions were given on alternate days up to three times per week. The number of infusions per patient ranged from 2 to 6 (median, 3), the individual doses from 100 mg to 200 mg (median, 200 mg), and the total doses from 200 mg to 1200 mg (median, 400 mg). Iron sucrose was effective in raising the hemoglobin concentration to normal in all patients with IDA, i.e., from 7.6±2.38 g/dL to 12.4±0.64 g/dL, within 31-42 days after the first infusion. The single patient with IRIDA demonstrated a 1.8 g/dL rise. Injection site disorders in three cases and transient taste perversion in one case were the only side effects.ConclusionIntravenous iron sucrose appears to be safe and very effective in children with IDA who do not respond or cannot tolerate oral iron therapy.

Recurrence of paroxysmal cold hemoglobinuria in a boy after physical cooling for fever.

Hemolysis and hemoglobinuria after direct exposure to cold has rarely been reported in paroxysmal cold hemoglobinuria (PCH). The authors describe a 2.5-year-old boy with PCH (Donath-Landsteiner autoimmune hemolytic anemia), in whom 16 days after presentation, the hemoglobinuria and hemolysis recurred, when he was subjected to physical cooling, as a means to control fever associated with hospital-acquired croup. The hemolysis resolved with warmth, and administration of dexamethasone. PCH should be suspected in children with hemolytic anemia and positive direct antiglobulin test for complement. Avoidance of cold in the recovery period is imperative to prevent recurrences, whereas a short course of corticosteroids may be of benefit in suppressing the antibody production.