Barbara Kaplan

Risk of capsule endoscope retention in pediatric patients: a large single-center experience and review of the literature.

Objectives: Capsule retention is a potential complication of capsule endoscopy (CE). The aims of our study were to determine the incidence of capsule retention in pediatric patients undergoing CE and to identify potential risk factors for capsule retention. Materials and Methods: We performed an institutional review board–approved retrospective chart review of pediatric patients undergoing CE studies at a single center. Data collected included patient age, sex, prior diagnosis of inflammatory bowel disease (IBD), CE indication, prior small bowel series results, study result, and complications. Results: Two hundred seven CE procedures were performed in pediatric patients during the study period. Capsule retention occurred in 3 (1.4%) of the 207 studies. All 3 patients had known Crohn disease (CD). The risk of capsule retention in pediatric patients with known IBD was 5.2% (3/58). The risk of capsule retention for patients with suspected IBD and all other indications was 0%. If small bowel disease was identified on upper gastrointestinal series in patients with known CD, then the risk of capsule retention was 37.5% (3/8). Only 7 patients with known IBD had a body mass index (BMI) below the 5th percentile. Of these 7 patients, 3 (43%) had capsule retention. Conclusions: Red flags for potential CE retention identified in our study include known IBD (5.2% retention risk), previous small bowel follow-through demonstrating small bowel CD (37.5% retention risk), and BMI <5th percentile with known IBD (43% retention risk). Caution is advised in these pediatric patients before capsule ingestion.

Low-dose naltrexone for treatment of duodenal Crohn's disease in a pediatric patient.

To the Editor: Naltrexone is an opioid receptor antagonist used as an opiate antidote. It acts as a competitive antagonist at several opioid receptor sites, showing the highest affinity for mu receptors. Studies have shown that opioids have immunomodulatory activity, including modulation of the inflammatory response and healing and repair of tissues. Short-term blockade of opioid receptors has been shown to lead to increased endogenous levels of opioids, which is the basis for naltrexone use in Crohn’s disease (CD). The presumption is that high levels of opioid receptor antagonism would lead to a complete block of the receptors and prohibit the effect of the endogenous opioids. Hence, low-dose naltrexone (LDN) therapy has been used in a study of adult patients with CD. This study demonstrated the effectiveness and safety of LDN therapy in subjects with moderate to severe CD. We describe the first case of treating CD with LDN in a pediatric patient.

Stool-withholding activity mimicking epilepsy

Nonepileptic paroxysmal events account for 30% of admissions to pediatric epilepsy monitoring units,1 present with a broad semiologic spectrum,2 and are frequently manifestations of other, treatable conditions.3 We report a patient with stool withholding owing to constipation and painful defecation that was misdiagnosed as epilepsy prior to admission, leading to unnecessary exposure to antiepileptic drugs (AED) and expensive investigations.nnA 5-year-old right-handed boy was admitted to our pediatric epilepsy monitoring unit for evaluation of spells that started 7 months previously. Episodes were characterized by brief bilateral leg stiffening, staring, moaning, a blank facial expression, and decreased responsiveness. Afterwards he complained about “tummy ache.” These occurred up to 15 times per day and were refractory to AED. His teachers noted inattentiveness, staring spells, and a declining school performance. Upon further questioning, the parents reported that sometimes during the episodes the boy had leakage of stool into his pants.nnPrevious evaluations included normal CT and MRI scans of the head. An EEG showed epileptiform discharges, which led to a diagnosis of epilepsy and treatment with AED.nnMedical …

Low Indeterminate Rates Associated With Use of the QuantiFERON-TB Gold In-Tube Test in Children With Inflammatory Bowel Disease on Long-term Infliximab

BackgroundnTumor necrosis factor alpha (TNF-α) inhibitors are linked with increased risk of reactivation of active tuberculosis. The QuantiFERON-TB Gold In-Tube test is approved for screening latent tuberculosis infection in children and adults. There are limited data on the test performance in children on long-term treatment with TNF-α inhibitors. The objective of this study was to assess the proportion of indeterminate results for the QuantiFERON-TB Gold In-Tube in children with inflammatory bowel disease (IBD) on long-term infliximab treatment and to evaluate the range of interferon-γ responses to mitogen.nnnMethodsnA single-center prospective study of children 5 to 19 years of age with IBD on long-term infliximab treatment (>3 months). Each child was assessed for tuberculosis exposure risk and had blood drawn for the QuantiFERON-TB Gold In-Tube. Data on the range of interferon-γ responses and final QuantiFERON-TB Gold In-Tube test results were collected.nnnResultsnNinety-three children were included, with a median age of 16 years. The median total duration of infliximab therapy was 34 months (range, 3-119 months). The QuantiFERON-TB Gold In-Tube was indeterminate in 1 patient (1.1%), positive in 2 patients, and negative in 90 patients. The maximum interferon-γ response to mitogen (10 IU/mL) was observed in 82 patients (88%), with only 1 patient having an inadequate response. The proportion of indeterminate results was significantly lower than the prospectively hypothesized rate of 8%, based on prior studies in nonimmunosuppressed patients (P = 0.004).nnnConclusionsnPediatric patients with IBD on long-term treatment with infliximab had an adequate interferon-γ response to mitogen and a low indeterminate rate when assessed with the QuantiFERON-TB Gold In-Tube test. This study demonstrates a robust interferon gamma response to phytohemagglutinin stimulation in a pediatric population on long-term therapy with infliximab. The QuantiFERON-TB Gold In-Tube test may therefore be useful as a periodic screening tactic for latent TB in children on long-term infliximab therapy.

Successful pregnancies after pediatric liver transplantation with tacrolimus immunosuppression: two case reports

Successful pregnancies after pediatric liver transplantation with tacrolimus immunosuppression: two case reports