Betul Tavil

Evaluation of Urine Collection Methods for the Diagnosis of Urinary Tract Infection in Children

Objective: To evaluate the accuracy of urine sample collection methods among children suspected of having urinary tract infections. Subjects and Methods: Four methods for urine sample collection were evaluated in 1,067 children aged 0–16 years with suspected urinary tract infections over 2 months at Dr. Sami Ulus Children’s Hospital. Within 30 min of collection, all specimens were sent to the laboratory, refrigerated and processed according to standard hospital microbiological procedures. Urine samples were analyzed using routine culture techniques. Results: At initial sending of the urine culture, 617 (57.8%) had negative culture results, 145 (13.6%) had positive culture results, and 305 (28.6%) had evidence of bacterial contamination. Clean catch specimens showed a contamination rate of 14.3% and urethral catheterization specimens showed a similar contamination rate (14.3%). However, urethral catheterization was preferred in only a small number of cases (n = 7). Suprapubic aspiration was also used in a small number of cases (n: 11) and the contamination rate for suprapubic aspiration was 9.1% (n: 1/11). The contamination rate for sterile urine bag was 43.9%, significantly higher than the other methods (p < 0.001). Conclusion: Suprapubic aspiration showed the lowest contamination rate and sterile urine bag showed the highest contamination rate among 4 methods of urine sample collection. Contaminated specimens, needed to be repeated and this procedure increased the cost of urine culture. In conclusion, measures should be taken to reduce the contamination rate in our center. This is an area where further investigation is required.

Pulmonary thromboembolism in childhood: A single-center experience from Turkey

OBJECTIVEnThis study was designed to evaluate the clinical characteristics, acquired and congenital risk factors, treatment strategies, and long-term outcome in pediatric pulmonary thromboembolism (PTE) cases followed in our center in Turkey.nnnSUBJECTSnOf the total 470 pediatric patients with thrombosis referred to our center, 16 (3.4%) had PTE. The mean age of the children with PTE was 10.3 +/- 6.8 years (range: 1.5-20.0, median: 10.5), and 12 (75.0%) were boys.nnnRESULTSnThe mean follow-up period was 28.9 +/- 21.0 months (range: 3-66, median: 22). During the follow-up period, recurrence was observed in three children (18.8%). The mean time from the appearance of symptoms to accurate diagnosis was 6.4 +/- 4.0 days (range: 2-10). Six patients (37.5%) were initially diagnosed as having pneumonia. After they were hospitalized and showed no clinical improvement with broad-spectrum antibiotic treatment, the accurate diagnosis of PTE was established. Of these 16 patients with PTE, 8 (50%) had associated thrombosis and 6 (37.5%) had congenital heart diseases. Infections including septic arthritis and osteomyelitis (n = 1), cytomegalovirus infection (n = 1), and infective endocarditis (n = 2) were detected in our patient group. In addition, two patients had a central venous line and one patient had obesity associated with malignancy. Other underlying diseases included thalassemia major, Behçet disease, antiphospholipid antibody syndrome, and autoimmune lymphoproliferative disorder in one patient each. Factor V G1691A heterozygous mutation was detected in two children, and methylene tetrahydrofolate reductase C677T homozygous mutation was detected in one child. A high level of factor VIII was the most common (8/16, 50%) laboratory risk factor in our patient group, and 12 children (75.0%) had a high D-dimer level. Among 16 children with PTE, one child had one, three children had two, five children had three, three children had four, and four children had five laboratory and/or clinical risk factors. Therefore, all children with PTE had at least one laboratory and/or clinical risk factor that facilitated development of thrombosis. In addition, according to the risk assessment for persistence or recurrence of venous thrombosis in children conducted by Manco-Johnson, 12 children (75%) with PTE in the present study had high-risk criteria.nnnCONCLUSIONnWhen a child with thrombosis at any site of the body develops unexpected respiratory symptoms or pneumonia unresponsive to antibiotic treatment, imaging studies should be performed for diagnosis of PTE. Furthermore, thrombotic children with high-risk criteria should be followed closely for the development of PTE.

ACUTE RENAL FAILURE DURING ATRA TREATMENT

All-trans-retinoic acid (ATRA), which is used in acute promyelocytic leukemia, is usually well tolerated, but some side effects can be observed. Retinoic acid syndrome is the most severe side effect. Triazole derivatives such as fluconazole inhibit the NADPH-dependent cytochrome P-450-mediated catabolism of ATRA and are increased plasma levels of ATRA. Here, the authors report a case of APL who developed acute renal failure during ATRA and concurrent use of fluconazole.

Evaluation of shigellosis in a Turkish children’s hospital

Background: The aim of the present study was to evaluate cases of Shigella and determine the pattern of antimicrobial resistance of shigella species in central Turkey.

FLUDARABINE, CYTARABINE, GRANULOCYTE COLONY-STIMULATING FACTOR, AND IDARUBICIN (FLAG-IDA) FOR THE TREATMENT OF CHILDREN WITH POOR-PROGNOSIS ACUTE LEUKEMIA: The Hacettepe Experience

Fludarabine, cytarabine, granulocyte colony-stimulating factor (G-CSF), and idarubicin (FLAG-IDA) regimen has been proven to be a potentially useful chemotherapy regimen for relapsed or poor-prognosis childhood leukemia. The aim of the study was to evaluate complete remission (CR) rate, toxicity, and overall survival of children with poor-prognosis acute leukemia who received the FLAG-IDA regimen. Furthermore, the authors investigated the children who achieved CR following FLAG-IDA treatment regarding their eligibility for allogeneic hematopoietic stem cell transplantation (HSCT). Between January 2002 and April 2007, 25 children with poor-prognosis acute leukemia were treated with FLAG-IDA regimen in our center. Of the 25 children (16 AML, 9 ALL) with poor-prognosis acute leukemia, 7 (28.0%) received 1 cycle, 17 (68.0%) received 2 cycles, and 1 (4%) received 3 cycles of FLAG or FLAG-IDA regimen. After 44 cycles of FLAG-IDA or FLAG regimen, 10/25 (40%) children were nonresponders, 15/25 (60.0%) showed CR. Five (20%) of these patients in CR who underwent allogeneic HSCT are still in remission. The remaining 20 (80.0%) children were lost due to infection or relapse of the primary diseases. The overall survival of patients who are still alive and underwent allogeneic HSCT (mean: 40.6 ± 4.7, median: 40, range: 34–46 months) was longer than that of patients (mean: 5.5 ± 4.3, median: 4, range: 1–15 months) who did not undergo allogeneic HSCT. The CR rate was quite high in the present study using the FLAG-IDA regimen, and the authors believe this regimen is a possible option prior to allogeneic HSCT in children with poor-prognosis acute leukemia.

THE EFFECTS OF ACUTE INFECTION ON HEMATOLOGICAL PARAMETERS

This study was undertaken to investigate the effects of acute infections (e.g., upper respiratory tract infection, acute gastroenteritis, urinary tract infection) on total blood count, the relation of these effects with acute phase reactants, and the level of improvement in the total blood count after the resolution of acute infection. A total of 113 previously healthy children between the ages of 6 months and 12 years were enrolled in the study. The control group consisted of 43 healthy children with proper age and gender distribution. A total of 55.7% of the patients had a decrease of 0.10–2.40 g/dL in Hb values on the 3rd day of acute infections. The comparisons of the 1st, 3rd, and 15th day Htc, RBC, MCV, MCHC, RDW values of the study and control groups revealed no significant differences. The 1st day SI, SIBC, and TS values of the study group were low in majority of the patients. Then they gradually increased, finally reaching at their normal levels on the 15th day. There was no significant difference between the sTfR and sTfR/log ferritin values of the study and control groups.

Effect of Twice Weekly Versus Daily Iron Treatment in Turkish Children with Iron Deficiency Anemia

This study was designed to propose a more practical, effective, safer, inexpensive, and manageable alternative treatment of iron deficiency anemia (IDA) for the developing countries. The study involves 94 children between the ages of 5 months and 6 years who had been seen in the authors hospital and diagnosed as having iron deficiency anemia. Ninety-four children with IDA were randomly divided into two groups: 48 children comprised the first group, which was administered conventional treatment, and 46 children comprised the second group, which was administered intermittent treatment involving iron administration 2 days a week. Twenty-three children whose age and gender distribution were compatible with the other groups were included in the study as the control group. Both groups were reevaluated for their initial hematologic parameters at the end of the treatment. When the parameters of both groups were compared with the parameters of the control group after the treatment, there were no differences between hemoglobin, hematocrit, red blood cell, mean corpuscular volume, mean corpuscular hemoglobin concentration, serum iron, and ferritin levels of conventional and intermittent treatment groups. With respect to certain parameters, such as red cell distribution, serum iron binding capacity, transferrin saturation, transferrin receptor, and transferrin receptor/log ferritin, however, intermittent treatment was superior to the conventional treatment method (p < .05). In IDA, when a conventional treatment method or an intermittent treatment method is used, there are no differences between the hematological parameters. In fact, the intermittent treatment method has been found to be superior in many parameters.

LINEZOLID-INDUCED REVERSIBLE BICYTOPENIA IN A 4-YEAR-OLD BOY WITH METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA

The authors report on a 4-year-old child with the diagnosis of tetralogy of Fallot (TOF) and infective endocarditis. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from the blood culture of the patient. While receiving imipenem, amikacin, and linezolid therapies, the boys general condition improved, acute phase reactants decreased, and his blood culture became negative for MRSA. On his follow-up echocardiography, the vegetation had also disappeared. However, he developed progressive bicytopenia following linezolid therapy for 5 weeks. During linezolid therapy, his hemoglobin level decreased from 12.1 to 5.3 g/dL and his platelet count from 242 × 109 to 14 × 109/L. His white blood cell count (WBC) did not decrease during linezolid therapy. Six days following termination of linezolid therapy, his hemoglobin had increased to 8.2 g/dL and platelet count to 192 × 109/L. Thus, it should be kept in mind that linezolid may induce cytopenias in children. If these side effects of linezolid are known, unnecessary laboratory investigations may be prevented and cessation of the drug may be sufficient for reversal of the cytopenias.

Cerebral sinovenous thrombosis in a child with steroid sensitive nephrotic syndrome.

Dear Editor, Fluss et al. [1] reported 21 pediatric patients with the nephrotic syndrome (NS) and sinovenous thrombosis (SVT). In most of these patients, SVT presented during the first flare or within 6 months of the onset of the NS. Among those 21 patients, only one had SVT at the initial presentation of the NS. Furthermore, only one patient of that series had FV Leiden (heterozygous for a mutation) and presented within 3 weeks of the onset of the NS. We would like to report a 5-year-old boy with FV-Leiden heterozygous for G1691A mutation, who presented with cerebral SVT followed by the NS. To the best of our knowledge this is the first patient with NS, FV-Leiden and NS presenting with cerebral SVT as the initial symptomatology. The patient presented with 2 days of headache and vomiting, followed by swelling of the eyelids and legs. There was neither neurological deficit nor neck stiffness. In the laboratory screening, proteinuria was detected. Other laboratory results were as follows: normal blood count serum total protein 4.7 g/dL (N 6–8.7), albumin 2.2 g/dL (N 3.2–4.8), cholesterol 406 mg/dL (N<200), and triglyceride 209 mg/dL (N<200). Protein C, S, antithrombin III, homocysteine, lipoprotein a, and factor II, V, VII, VIII, IX, XI, XII levels were within normal range. Lupus anticoagulant, antiphospholipid, and anticardiolipin antibodies were negative. Prothrombin G20210A and methylenetetrahydrofolate reductase (MTHFR) gene mutations were not found, while FV Leiden heterozygous mutation was positive. Cranial magnetic resonance imaging (MRI) angiography revealed a thrombosis in the superior sagittal sinus and right transverse sinus. A treatment for NS and thrombosis comprising prednisolone (2 mg/kg/day) and unfractionated heparin (20 U/kg/ hour) was started. One week after the prednisolon treatment, full remission of NS occurred. After the patient had received unfractionated heparin for 10 days as an initial anticoagulant therapy, low molecular weight heparin (LMWH) was administered for 2 months. At the end of the 2nd month of diagnosis, cranial MRI angiography did not show any thrombi in dural sinuses. He is currently well and still on low dose prednisolon and LMWH treatments. Nephrotic syndrome (NS) is a common renal childhood disease. Its relation with hypercoagulability and thromboembolic complications is well-known [3]. Hypercoagulation in NS has been accounted for by the loss of anticoagulant factors with urine, increased platelet aggregation with higher plasma fibrinogen concentration, and insufficient intravascular volume. In children, the incidence of NS associated with thromboembolic complications vary between 1.8 and 5.3% [2]. However, cerebral SVT accompanied by NS is extremely rare with few reported cases in the literature. In our patient, thrombosis was the initial finding and was followed by NS diagnosis, which suggests that thrombosis may develop even before the full blown clinical picture of NS develops. Furthermore, hereditary thrombotic risk factors, especially FV Leiden mutation, should also be investigated in patients with NS associated with thrombosis because NS patients with FV Leiden heterozygous mutation may be at increased risk for developing SVT at early phases of the disease. Eur J Pediatr (2007) 166:757–758 DOI 10.1007/s00431-007-0488-x

Acute iron ingestion

Objective : Intoxication is one of the most common causes of admissions to emergency department in pediatric age group. Incidence of iron poisoning gradually increased because of wide spread use of iron containing drugs.Method : In this report, we present five cases of iron ingestion who were admitted to our emergency department within a year.Result : Whole bowel irrigation in addition to gastric lavage with an iron dose of over 50mg/kg as well as deferoxamine treatment for patients in whom clinical and laboratory indications are present.Conclusion : The prompt recognition and treatment of children with acute iron poisoning is the single and the most critical point for decreasing the morbidity and mortality associated with iron containing products.