Budi Setiabudiawan

Age of onset as a risk factor of renal involvement in Henoch-Schönlein purpura

Background Henoch-Schönlein purpura (HSP) is the most common vasculitis in children, characterized by triad of symptoms; palpable purpura without thrombocytopenia, abdominal pain, and arthritis. Renal involvement often occur in children with HSP. No data on the renal involvement of children with HSP in Indonesia, especially West Java. Objective To evaluate renal involvement in children with HSP. Methods Retrospective study was conducted in children with HSP in Department of Child Health, Hasan Sadikin Hospital, from 2006 to 2011. Characteristics and clinical manifestations was reviewed from medical record. HSP was diagnosed by American College of Rheumatology 1990 criteria or European League Against Rheumatism/Pediatric Rheumatology International Trials Organization/Pediatric Rheumatology European Society 2008. Results There were 128 patients, consisting of 82 male (64.9%) and 46 female (35.1%) with ratio 1.8:1. Mean age was 7.9 ± 2.9 years old which range from 6 month to 15 years. Peak morbidity was between 5-10 years old. Prevalence of HSP in Hasan Sadikin Hospital tend to raise from 2.7/100,000 in 2008 to 5.2/100,000 in 2010. In most patients (71%) purpura was the first symptom. Seventy-one patients (44.5%) had arthritis and 89 patients (69.5%) had abdominal pain, while renal involvement was in 28 patients (21.8%). Gastrointestinal manifestations tend to manifest in patients less than 5 years old (p = 0.267), while renal involvement tend to manifest in age group 11-15 years old (p = 0.015) with odds ratio 3.1 (95% confidence interval, 1.2-8.1). Conclusion Renal involvement in children with HSP is more common in age group 11 to 15 years old.

Vogt-Koyanagi-Harada disease in an 8-year-old boy.

Vogt-Koyanagi-Harada (VKH) disease is an autoimmune disease involving pigmented tissue in eyes, auditory system, skin, and central nervous system. The pathogenesis is a result of T cell lymphocyte reaction against melanocyte component, tyrosinase and tyrosinase-related protein. This disease uniquely affected pigmented race in Asia and native America, mostly women aged 20-50. We reported an 8-years-old boy complained for visual disturbance since 6 weeks prior admission. Two years earlier, the parents noted the patient eyes were looked red when photographed (suggesting a dilated pupil) preceded by whitened on the right forehead and nose and whitened hair, eyebrow and eyelashes. The examination showed a vitiligo and skin atrophy on right frontal and right nasal, poliosis on the eyebrows, eyelids and hair. The diameter of right pupil was 8 mm, with a paresis on 3rd, 4th, 6th, and 9th nerves. Fundus examination revealed sunset glow appearance. The visual acuity on the right eye: 2/60, left eye: 1-0. Theres positive serology for antitoxoplasma IgG, anti Rubella IgG, anti CMV IgG. The patient was diagnosed with a VKH disease and then prescribed with methylprednisolone 1 mg/kg/day. The patient also had further follow up with dermatovenerologist and ophthalmologist. The eye examination revealed an improvement on right eye panuveitis, with a remaining keratic precipitate in the endothelium, and minimal flare and cell on the anterior chamber. ENT consultation revealed no ear inflammation or hearing disturbance.

Association between vitamin D levels and left ventricular function and NT-proBNP levels among thalassemia major children with iron overload

Background: Heart disease is the major cause of death in thalassemia patients. Repeated blood transfusions and hemolysis cause iron overload and also disrupts the hydroxylation and synthesis of vitamin D, causing vitamin D deficiency. Vitamin D deficiency is associated with cardiac dysfunction. Objective The purpose of this study was to determine the association between vitamin D levels and left ventricular function and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in thalassemia major children with iron overload. Patients and Methods: A cross-sectional study was conducted in March-April 2015 in the thalassemia clinic, Department of Child Health, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. Thirty-four children with thalassemia were enrolled consecutively. Serum vitamin D and NT-proBNP levels were measured with electrochemiluminescence (ECLIA) method and echocardiography was performed to assess ventricular function. Results: Significant correlations were found between vitamin D levels and left ventricular ejection fraction (LVEF) (r = 0.399, P = 0.019) and fractional shortening (FS) (r = 0.394, P = 0.021). There was also significant correlation between vitamin D and NT-proBNP levels (r = -0.444, P = 0.008). Chi-square analysis also showed a relationship between vitamin D and NT-proBNP (P = 0.019) levels. There was a difference in NT-proBNP levels among thalassemia major children with iron overload (P = 0.020). Post hoc analysis showed that there was a significant difference in NT-proBNP levels between those with vitamin D deficiency and those with normal vitamin D levels (P = 0.012). Conclusion: There is an association between vitamin D and left ventricular function and NT-proBNP levels in children with thalassemia major and iron overload. Vitamin D can be considered in patients with thalassemia having vitamin D deficiency.

Comparison of the Performance of Urinary Mycobacterium tuberculosis Antigens Cocktail (ESAT6, CFP10, and MPT64) with Culture and Microscopy in Pulmonary Tuberculosis Patients

Pulmonary tuberculosis (TB) is a major global health problem and is one of the top 10 causes of death worldwide. Our study aimed to evaluate the performance of urinary Mycobacterium tuberculosis (Mtb) antigens cocktail (ESAT6, CFP10, and MPT64) compared with culture and microscopy. This descriptive cross-sectional study was conducted in Dr. Hasan Sadikin General Hospital, Bandung, from January 2014 to October 2016. A total of 141 pulmonary tuberculosis patients were included. Sputum samples were examined for acid-fast bacilli (ZN stain) and mycobacterial culture (LJ); the Mtb antigens cocktail was examined in the urine sample. The positivity rate of TB detection from the three methods was as follows: AFB 52/141 (36.9%), culture 50/141 (35.5%), and urinary Mtb antigens cocktail 95/141 (67.4%). Sensitivity, specificity, PPV, and NPV of urinary Mtb antigens cocktail were 68.2%, 33%, 31.6%, and 69.6%, respectively. Validity of combination of both methods with culture as a gold standard yielded sensitivity, specificity, PPV, and NPV of 90%, 28.6%, 40.9%, and 83.8%, respectively. Combination of urinary Mtb antigens cocktail with AFB as a screening test gives a good sensitivity, although the specificity is reduced. Urinary Mtb antigens cocktail can be used as screening test for pulmonary tuberculosis.

Peran Terapi Adjuvan Vitamin D3 Terhadap Kadar T Regulator dan Gejala Klinis Penderita Rinitis Alergi Yang Mendapat Imunoterapi Subkutaneus Initial Build Up Dose

Imunoterapi spesifik (ITS) merupakan pilihan terapi pada rinitis alergi yang tidak memberikan respons perbaikan klinis dengan medikamentosa. Peran zat adjuvan diduga dapat meningkatkan efektivitas dan efikasi ITS. Penelitian ini bertujuan menganalisis peran adjuvan vitamin D3 pada ITS terhadap percepatan timbulnya respons imun toleran. Penelitian analitik komparatif numerik dua kelompok tidak berpasangan dengan rancangan uji klinis acak terkontrol ganda ini dilakukan di Klinik Rinologi-Alergi THT-KL RSUP dr. Hasan Sadikin Bandung sejak Mei 2016–April 2017. Sampel terdiri atas 18 pasien menerima ITS+kalsitriol dan 18 pasien menerima ITS+plasebo yang memenuhi kriteria penelitian diambil secara consecutive sampling . Dilakukan pemeriksaan jumlah sel Tregulator dengan flowcitometry pada baseline , minggu ke-8 dan 15 dan skor gejala hidung. Analisis dengan Uji Mann-Whitney, uji Friedman, uji T berpasangan dan analisis Post hoc. Perbandingan kenaikan rerata median jumlah sel Treg kelompok intervensi dengan kontrol pada minggu ke 8 menunjukkan nilai p=0,04, rerata MFI Treg pada kelompok intervensi dengan kontrol nilai p=0,002. Analisis post hoc terhadap MFI Treg menunjukkan peningkatan pada kelompok intervensi dengan p=0,001 pada minggu ke-8. Disimpulkan perubahan di tingkat imunologi mulai terjadi pada minggu ke-8, tetapi perbaikan gejala klinis terlihat setara. Kata kunci: Imunoterapi spesifik, rinitis alergi, sel t-toleran perifer, sel T-regulator, vitamin D3 Role of Adjuvant Therapy with Vitamin D3 on T-Regulator in Allergic Rhinitis Patient with Subcutaneus Immunotherapy Allergen-specific immunotherapy (AIT) is a potentially disease-modifying therapy that is useful for the treatment of allergic rhinitis, especially in those who do not response to pharmacotherapy. Currently, the role of adjuvant is expected to increase the clinical efficacy in AIT. The aim of this study was to analyze the role of vitamin D3 adjuvant in AIT to induce immune tolerance. This was an unpaired comparative analytic research with a randomized controlled trial dstudy conducted at the Rhinology-Allergy Clinic ORL-HNS of Dr. Hasan Sadikin General Hospital Bandung from May 2016 to April 2017. Eighteen subjects with AIT+ calcitriol treatment and 18 subjects with AIT+placebo treatment who met the study criteria were selected through consecutive sampling. All subjects were evaluated for Treg cells using flow citometry at baseline, week 8, and week 15. Nasal symptom score was also evaluated. Statistical analysis performed in this study included Mann-Whitney test, Friedman test, T-Paired test,and Post hoc analysis. There was a significant different of Treg cells average results between the intervention group and control at week 8 with a p-value of 0.04. The mean delta value on MFI Treg reflected significant differences within intervention group (p=0.002). Post hoc analysis results presented a significant increase in MFI Treg in the intervention group at week 8 (p=0,001). Therefore, immunological changes start in week eight but the improvement of clinical symptoms looks similar. Key words: Allergic rhinitis, peripheral t-cell tolerance, regulatory t(treg) cell allergen specific immunotherapy, vitamin D3

Association of Colecalciferol, Ferritin, and Anemia among Pregnant Women: Result from Cohort Study on Vitamin D Status and Its Impact during Pregnancy and Childhood in Indonesia

Studies had shown that iron-cycling was disturbed by inflammatory process through the role of hepcidin. Pregnancy is characterized by shifts of interleukin. Our objective was to determine if 25(OH) vitamin D (colecalciferol) status was associated with ferritin, anemia, and its changes during pregnancy. Method. A cohort study was done in 4 cities in West Java, Indonesia, beginning in July 2016. Subjects were followed up until third trimester. Examinations included were maternal ferritin, colecalciferol, and haemoglobin level. Result. 191 (95.5%) subjects had low colecalciferol, and 151 (75.5%) among them were at deficient state. Anemia is found in 15 (7.5%) subjects, much lower than previous report. Proportion of anemia increased by trimester among women with colecalciferol deficiency. Ferritin status and prepregnancy body mass index in the first trimester were correlated with anemia (r = 0.147, p = 0.038 and r = −0.56, p = 0.03). Anemia in the second trimester was strongly correlated with anemia in the third trimester (r = 0.676, p < 0.01). Conclusion. Our study showed that the state of colecalciferol was not associated with either ferritin state or anemia, but proportion of anemia tends to increase by trimester in the colecalciferol deficient subjects.

Updates on the Status of Vitamin D as a Risk Factor for Respiratory Distress Syndrome

To update the guidelines regarding vitamin D status in respiratory distress syndrome, we reviewed recent human and animal studies on the benefits of vitamin D in respiratory distress. We searched PubMed and ProQuest for studies on the use of vitamin D from 2009 to 2017. The common parameters in these studies included the use of lung tissue, phospholipids, blood, and plasma to assess the effects of vitamin D on respiratory syndrome. The metabolized form of vitamin D used in these studies was 1,25(OH)2D3 in animal studies and 25(OH)D in human studies. Vitamin D supplementation decreases the risk of respiratory distress syndrome, improves the quality of life, and is relatively effective and safe for preterm neonates as well as during lung maturation. However, although vitamin D supplementation may offer benefits for respiratory distress syndrome, the optimal dosing strategies for specific types of risk factors in the lungs must be clarified to confirm the therapeutic efficacy.

Peran Defisiensi Vitamin D dan Polimorfisme Fokl, Bsml, Apal serta Taql Gen Reseptor Vitamin D Terhadap Tuberkulosis Pada Anak

Latar belakang. Tuberkulosis (TB) adalah penyakit menular yang disebabkan oleh infeksi Mycobacterium tuberculosis. Kuman bukan merupakan faktor tunggal dalam kejadian TB, tetapi harus disertai dengan faktor lain. Defisiensi vitamin D dan polimorfisme FokI, BsmI, ApaI, serta TaqI gen reseptor vitamin D (RVD) berperan penting dalam kerentanan seseorang terhadap TB. Tujuan. Mengetahui peran defisiensi vitamin D dan polimorfisme FokI, BsmI, ApaI, serta TaqI gen RVD terhadap TB anak. Metode. Penelitian observasional dengan rancangan kasus kontrol, di RSUP Dr. Hasan Sadikin Bandung dan RSU Cibabat Cimahi, Mei 2008 - Maret 2009. Sampel diambil secara consecutive sampling, masingmasing 42 anak. Dilakukan pemeriksaan kadar vitamin D [25-(OH)D dan 1,25-(OH)2D] serum, serta polimorfisme FokI, BsmI, ApaI, dan TaqI gen RVD. Analisis dengan uji Chi-kuadrat, Mann-Whitney, uji t, menghitung OR dan 95% CI, serta regresi logistik ganda. Hasil. Angka kejadian defisiensi kadar 1,25(OH)2D serum pada kelompok kasus TB 28,6% dan kontrol 9,5% (p=0,026), OR (95% CI): 3,80 (1,11-12,98). Kejadian polimorfisme FokI gen RVD pada kelompok kasus TB 66,7% dan kontrol 40,5%, (p=0,016), OR (95% CI): 2,94 (1,21-7,16), sedangkan ApaI, BsmI, dan TaqI pada TB tidak bermakna (p>0,05). Variabel yang berpengaruh terhadap kejadian TB adalah jenis kelamin OR (95% CI): 2,276 (0,841-6,161); polimorfisme FokI OR (95% CI): 2,346 (1,053-5,225); polimorfisme ApaI OR (95% CI): 0,81 (0,912-3,593) dan defisiensi vitamin D OR (95% CI): 5,645 (1,441- 22,113). Peluang terjadinya TB pada anak perempuan dengan defisiensi vitamin D serta polimorfisme FokI (genotipe FF) dan ApaI homozigot (genotipe aa) 0,98 pada laki-laki 0,955. Kesimpulan. Defisiensi vitamin D (1,25(OH)2D) dan polimorfisme FokI gen RVD merupakan faktor risiko terjadi TB anak. Perempuan dengan defisiensi vitamin D serta polimorfisme FokI dan ApaI homozigot memiliki peluang lebih besar untuk terjadinya TB anak dibandingkan laki-laki.

533 Viral Respiratory Infections and the Development of Atopy and Asthma.

Background There is an association between severe RSV bronchiolitis in early childhood, recurrent wheezing, asthma, and allergy in later childhood. And also becomes increasingly evident that other viruses such as RV, also showed association with the development of asthma. The objective of this study is to know the relationship between viral respiratory infections in the first 5 years of age and the development of atopy and asthma. Methods This study is a prospective follow-up study in 2 communities, 9 years after a respiratory infection study was performed. Assessment included questionnaires, physical examination, skin prick tests (SPT), pulmonary function test (PFT), and reversibility testing. Results Three hundred thirty-two children, age 7 to 14 years, including 182 (54.8%) boys, were enrolled in the study. In 86 children, histories of viral respiratory infections (RSV, RV, and hMPV) were detected. The rate of positive SPT was high (81.6%), and 15 (4.5%) children showed dermatographism. The percentage of positive SPT among children with and without viral respiratory infections was almost similar (83.4% vs 85.4%). The positive SPT > 1 in children with history of viral respiratory infections was 65.9%; 5.9% with 1 positive, 27.1% with 2 to 3 positive, 20% with 4 to 5 positive and 18.8% with > 5 positive; while the positive SPT > 1 in the non viral respiratory infections was 75,3%; 9.3%, 23.9%, 30.4%, and 21.1%, respectively. The difference between those 2 groups of children was not significant (P = 0.076). History of asthma in the children with history of respiratory infections was higher compared with the non infections group (19.7% vs 8.1%). However, the spirometry results show no difference (P > 0.05) of FEV1 < 80%, FVC < 80%, FEV1/FVC < 80% and bronchodilator response > 12%, between those 2 groups. Conclusions The positive rate of SPT in the children is high, but no difference is found between history of viral respiratory infections in early life in relation to the later development of atopy and asthma. The spirometry test results show no difference between the 2 groups.

474 Relationship Between Total Serum IgE, Atopy, and Obesity in Children With or Without Family History of Atopic Disease.

Background Prevalence of obesity and atopy had been increased simultanoeuosly. The relationship between obesity, atopy, and total serum IgE had been estimated. The aim of this study is to find out the relationship between total serum Ig E, atopy, and obese children with or without family history of atopic disease. Methods This was a cross sectional study. There were 160 children aged 6 to 11 years which were divided into 4 groups: obese children with and without family history of atopic disease and normal weight children with and without family history of atopic disease. Atopic was defined by positive result of one of allergens skin prick test and ECLIA method were done for total serum IgE. Significancy for categorical data used Chi-Square test. Logistic regression model were used to examine the relationship between obesity, total serum IgE, and atopy. Results We measured the total serum IgE of 155 children. The number of obese and normal weight children with family history of atopic disease who had high level of total serum IgE were 30 and 25 respectively, whereas these children who had normal level of total serum IgE were 6 and 15 respectively [OR = 1.9 (95% CI 0.9-3.9)]. On the other hand, obese and normal weight children without family history of atopic disease who had high level of total serum IgE were 21 and 11 respectively, whereas these children who had normal level of total serum IgE were 18 and 29 respectively [OR = 1.7 (95% CI 1.1-2.7)]. The number of obese and normal weight children without family history of atopic disease who had atopy were 38 and 9 respectively, whereas these children who had non-atopy were 2 and 31 respectively [OR = 13.3 (95% CI 3.5-52)], but there was no relationship between atopy and obesity in group with family history of atopic disease (P = 0.314). Conclusions There were relationship between high level of total serum IgE and obesity in group with and without family history of atopic disease and also relationship between atopy and obesity in group without family history of atopic disease.