Canan Sule Unsal Karkıner

Tolerance development in food protein-induced allergic proctocolitis: single centre experience

BACKGROUND Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer.

Can neutrophil/lymphocyte ratio be a novel biomarker of inflammation in children with asthma?

Neutrophils are known to play a role in airway inflammation and are activated in inflammatory lung diseases such as asthma. In adult studies the neutrophil/lymphocyte ratio (NLR) was found to be a possible biomarker for both airway and systemic inflammation. However, there is a limited understanding regarding NLR in the pediatric age group. To assess NLR as a biomarker for inflammation in pediatric asthma, 54 children admitted to hospital with exacerbation of asthma between March and October 2013 were enrolled into our study. Complete blood counts were obtained during both exacerbation and an asymptomatic period covering at least 3 months after exacerbation. NLRs of the study group during both exacerbation and the asymptomatic period were compared and these two datasets were then compared with the control group. The study group comprised 27 boys (50%) and 27 girls (50%) with a mean age of 120 ± 36 months. Of the total number of patients, 3.7% had mild, 94.4% had moderate, and 1.9% had severe exacerbation of asthma. The NLRs of the study group were found to be significantly higher during exacerbation compared with both the asymptomatic period and the control group (P = 0.017, P = 0.003). Our study suggests that NLR may be effective and usable measurable biomarker for determining inflammation in cases of pediatric asthma during acute exacerbation period. However, a broad analysis of dependent and independent variables in further prospective studies, is still required. Trial registration: Not applicable.

Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo.

Eosinophilic cellulitis (Wells’ syndrome) is an uncommon condition of unknown etiology. Wells’ syndrome is usually seen in adulthood but very rare in childhood. Although pathogenesis of the disease is not very clear, it is a hypersensitivity reaction developing against a variety of exogenous and endogenous antigenic stimuli. Paraphenylenediamine is a strong allergen frequently used as a temporary henna tattoo, which makes the color darker. Here, a 9-year-old male patient with Wells’ syndrome is presented, which developed following a temporary henna tattoo and shown by the patch test sensitivity to paraphenylenediamine.

Acute generalized exanthematous pustulosis induced by ceftriaxone use

Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous rash characterized by the abrupt onset of a generalized pustular rash often accompanied by fever. There is a history of drug use in 90% of the cases. Here we have reported a 15-year-old male patient with sickle cell anemia who developed AGEP after the use of ceftriaxone. Our patient was hospitalized because of vaso-occlusive crisis and on the third day of ceftriaxone treatment, erythematous pustular lesions accompanied with fever were observed on the body and extremities. Resolution of symptoms followed discontinuation of ceftriaxone. Sensitivity to ceftriaxone was shown with a patch test. The AGEP was considered due to clinical and histopathological findings. This is the first pediatric case of AGEP due to ceftriaxone.

Diagnostic values for egg white specific IgE levels with the skin prick test in Turkish children with egg white allergy

BACKGROUND The diagnostic values for the skin prick test (SPT) diameters and egg white-specific IgE (EW-sIgE) levels that will allow us to predict the result of the oral food challenge test (OFC) in the diagnosis of egg white allergy vary by the community where the study is carried out. OBJECTIVE This study aimed to determine the diagnostic values of SPT and EW-sIgE levels in the diagnosis of egg white allergy. METHODS 59 patients followed with the diagnosis of egg allergy September 2013 to September 2015 were included in our retrospective cross-sectional study. The patients were investigated in terms of egg and anaphylaxis history or the requirement of the OFC positivity. The demographic, clinical and laboratory findings of the cases were recorded, and they were compared with the patients with the suspected egg allergy but negative OFC (n=47). RESULTS In the study, for all age groups, the value of 5mm in SPT was found to be significant at 96.4% positive predictive value (PPV) and 97.8% specificity and the value of 5.27kU/L for EW-sIgE was found to be significant at 76% PPV and 86.6% specificity for egg white. The diagnostic power of the SPT for egg white (AUC: 72.2%) was determined to be significantly higher compared to the diagnostic power of the EW-sIgE (AUC: 52.3%) (p<0.05). CONCLUSION Along with the determination of the diagnostic values of communities, the rapid and accurate diagnosis of the children with a food allergy will be ensured, and the patient follow-up will be made easier.

Does raising awareness in families reduce environmental tobacco smoke exposure in wheezy children

Introduction Environmental tobacco smoke (ETS) is thought to increase the severity and number of attacks in wheezy children. Objective assessments are needed to change the behavior of families to reduce the exposure of wheezy children to ETS. Aim To determine whether informing families about their children’s urinary cotinine levels curtailed the exposure of children to ETS. Material and methods A survey was used to determine the ETS exposure level, and the urinary cotinine level of each patient was tested. Children with positive urinary cotinine levels were included in the second part of the study. The families were randomly divided into two groups: an intervention group that was advised about urinary cotinine levels by telephone and a non-intervention group that was not so advised. The groups were followed-up 2 months later, and urinary cotinine levels were measured once again. Results The intervention group contained 65 children of average age of 24.4 ±8.9 months, of whom 46 (70.8%) were male. The non-intervention group contained 69 children of average age of 25.3 ±9.8 months (p > 0.05), of whom 52 (75.4%) were male. The urinary cotinine levels at the time of the second interview were lower in both groups. The number of cigarettes that fathers smoked at home decreased in the intervention group (p = 0.037). Conclusions Presenting objective evidence on ETS exposure to families draws attention to their smoking habits. Measurement of cotinine levels is cheap, practical, and noninvasive. Combined with education, creating awareness by measuring cotinine levels may be beneficial.

Risk of systemic allergic reactions to allergen immunotherapy in a pediatric allergy clinic in Turkey

OBJECTIVES Even though allergen immunotherapy is an effective treatment method that has been used on rhinitis, asthma and venom anaphylaxis for over 100 years, systemic reactions (SRs) limit the use of this treatment method. We classified SRs associated with subcutaneous immunotherapy (SCIT) according to the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System. Risk factors for the SRs were assessed. METHODS In this study 67,758 injections to 1350 children with allergic rhinitis and/or asthma were analyzed throughout January 1999-December 2014. RESULTS A total of 51 systemic reactions were observed in 39 patients (0.075% per injection, %3 per patient). Mean age of SRs observed patients was 13±2.6 years (range 9.5-16 years) and 64.1% were male, 35.9% were female. 51.3% of SRs were grade 1, 38.5% grade 2, 7.7% grade 3 and 2.6% grade 4. SRs were early onset in 41% of the patients and delayed onset in 59%. 76.9% of SRs were seen during maintenance therapy and 56.4% during peak pollen season. In 28.2% of cases previous local reactions and in 30.8% previous grade 1 reactions were determined. There was no fatal outcome from any of the SRs. CONCLUSION SCIT related SRs are generally of mild severity. Although only 10% of the SRs were grade 3 or 4, there is a still a small risk of severe reactions. 76.9% of SRs were observed during maintenance therapy. Delayed-onset SRs rate in our study is 59%. So both clinicians and parents should be alert about the delayed reactions after SCIT.

Seizures as a rare but serious adverse effect of leukotriene receptor

Leukotriene receptor antagonists (LTRAs) are used widely in the treatment of allergic rhinitis and asthma in children.1,2 LTRAs are safe in combination with antihistamines in patients with chronic urticaria who respond inadequately to antihistamines alone.3 Several clinical trials have emphasized that LTRAs can be considered safe. Nevertheless, many adverse effects associatedwith LTRAs have been reported. Most of the adverse events aremild (headache, gastrointestinal disorders, pharyngitis, fatigue, upper respiratory tract infection, cutaneous rash, and reversible changes in the serum transaminase levels). Although adverse events, such as seizures, are probable, no case reports of LTRAs leading to or triggering convulsions have been reported.1,2 We describe 3 patients who had convulsions after beginning treatment with LTRAs. Patient 1 was a 15-year-old girl with atopic asthma who was monitored for 2 years. She started using valproic acid for epilepsy 1 year ago. No seizures were observed while she was taking inhaled corticosteroids and valproic acid. Three days after adding an LTRA to her asthma treatment, she started having seizures during sleep. Initially, her physicians and family did not associate the convulsions with the LTRA. While she was hospitalized for her convulsions, the LTRA could not be given because the family left it at home. No seizures were observed during the hospitalization, and the patient was discharged. When she returned home and started using the LTRA again, the seizures during sleep returned. Consequently, the LTRA was blamed for triggering the seizures and was stopped. seizure further seizures were observed. Patient 2 was a 6-year-old girl who had been followed up with a diagnosis of epilepsy for 1.5 years. She was using antiepileptic medication but had not had any seizures in the last year. When she had attacks of wheezing, an LTRAwas added to treat mild persistent asthma. With resumption of use of the LTRA, she started having seizures again. The family suspected the LTRA and discontinued its use. The seizures disappeared. A few weeks later, when the patient’s asthmatic symptoms increased, the patient started using the LTRA again, and the seizures returned. We recommended discontinuing use of the LTRA, and the seizures were controlled. Patient 3was a 21⁄2-year-old boywith an episode of urticaria that lasted for 1.5 months and was treated with antihistamines. His pediatrician added an LTRA to the treatment when the antihistamines failed to control the urticaria. Three days after adding the LTRA to his treatment, the patient had an afebrile convulsion for the first time in his life. At that time, the antihistamines were held responsible for the seizure. All medications were cut for 1 week, and the patient’s seizures disappeared. Three days after starting use of only an LTRA for the ongoing urticaria, the patient had another