Elif Bahat Özdoğan

Could Pyelonephritic Scarring Be Prevented by Anti-Inflammatory Treatment? An Experimental Model of Acute Pyelonephritis

Objectives. This study aimed to demonstrate if the addition of anti-inflammatory treatment to antibiotic therapy shows any superiority to the treatment with antibiotic only. Methods. Forty-nine Wistar rats were divided into 7 groups. Pyelonephritis was performed by E. coli injection to upper pole of kidneys except control group. Group 2 was not treated. Ceftriaxone, ketoprofen, “ceftriaxone + ketoprofen,” methylprednisolone, and “ceftriaxone + methylprednisolone” were given in the groups. The technetium-99m-dimercaptosuccinic acid scintigraphies were performed in 3rd day to detect pyelonephritis and 10th week to detect renal scarring. All kidneys were also histopathologically evaluated. Results. When 3rd day and 10th week scintigraphies were compared, initial 2.00 ± 0.30 point pyelonephritis score resulted in 0.71 ± 0.36 renal scar score in “ceftriaxone + ketoprofen” group (P = 0.039). Initial 2.00 ± 0.43 point pyelonephritis score resulted in 0.86 ± 0.26 renal scar score in “ceftriaxone + methylprednisolone” group (P = 0.041). Renal scar score was declined in “ceftriaxone + ketoprofen” group and “ceftriaxone + methylprednisolone” group compared with no-treatment group on 10th week of the study (P = 0.026, P = 0.044). On histopathological evaluation, it was seen that renal scar prevalence and expansion declined significantly in “ceftriaxone + ketoprofen and ceftriaxone + methylprednisolone” (P = 0.011, P = 0.023). Conclusion. It was evidenced that ceftriaxone treatment in combination with ketoprofen or methylprednisolone declined scar formation in scintigraphic and histopathologic examinations of the kidneys.

An unusual cause of terminal hematuria in a child: Eosinophilic cystitis

Eosinophilic cystitis is a rare inflammatory disease of the bladder; it rarely occurs in children. Patients typically show irritative urination symptoms frequently, with a possible need for urgency, alongside dysuria, gross haematuria, suprapubic pain and painful urination. Sometimes bladder mass accumulation with the possibility of malignancy is also observed. We present an 8-year-old male patient who gained admission for terminal hematuria and discuss the management of eosinophilic cystitis.

Medical Treatment of Hematuria Due to Bladder Hemangioma in a Newborn

To the Editor: Although hemangiomas are the most common benign tumors of infancy, they are extremely rare in urinary bladder and account for 0.6% of bladder tumors [1]. We report a 7-d-old male newborn with multiple bladder capillary hemangiomas successfully treated with propranolol and intravesical corticosteroid. Although routine biochemical analyses, complete blood count, coagulation parameters and acute phase reactants were normal, urinalysis showed abundant red blood cells exhibiting a normal morphology per high-power field. Renal doppler, renal and urinary tract ultrasonography were normal. Urine culture showed no growth. Urine calcium:creatinine and uric acid:creatinine ratio were normal. Cystoscopic examination showed multiple reddish sessile capillary hemangiomas of variable sizes from 0.5 cm to 1.5 cm on the bladder dome. We treated the patient with propranolol beginning dose of 0.5 mg/kg/d in three divided doses for the first 24 h, and then it was gradually increased to 2 mg/kg/d in three divided doses for 5 wk, also 10 mg prednisolone plus 20 ml saline was given into the bladder for irrigation via a Foley catheter, and to catheter was clamped for 20min and thenwas opened everyday for 10 d. No side effects were noted and hematuria was completely resolved at the fifth day of therapy. Control cystoscopic examination was performed after five weeks and it was normal. Hematuria episode has not been detected during the follow-up period of 12 mo. Although bladder hemangioma has been reported in childhood, only one case with a 10-d-old neonate has been reported in the neonatal period [2]. To our knowledge, our case is the youngest and second capillary hemangioma case of the urinary bladder in the neonatal period. Treatment of patients with bladder hemangiomas is controversial. Medical (corticosteroids, propranolol, interferon, and vincristine) or surgical options are available for the treatment of serious hemangiomas [3]. Systemic corticosteroid is the first-line treatment for life-threatening hemangiomas and can be used topical or intralesional [4]. If no contraindications, oral propranolol can be used in patients with infantile hemangioma [5]. Our case was successfully treated with intravesical corticosteroid and propranolol with no side effect and without requiring any surgery.

Urinary tract infections in neonates with unexplained pathological indirect hyperbilirubinemia: Prevalence and significance

BACKGROUND It is controversial to test for urinary tract infection (UTI) in patients with unexplained indirect hyperbilirubinemia in the first 2 weeks of life. We aimed to study the prevalence and significance of UTIs in such neonates who were requiring phototherapy. METHODS Subjects were 2- to 14-day-old neonates with indirect bilirubin levels above phototherapy limit with no other abnormality in their bilirubinaemia-related etiologic workup. UTI was diagnosed by 2 consecutive positive cultures obtained by catheterisation, documenting growth of >10,000 colonies of the same microorganism with consistent antibiograms. The UTI (+) patients were evaluated by renal ultrasonography (US), and some were followed up for possible recurrent UTI. RESULTS 262 neonates were included in the study. UTI prevalence was 12.2%, and bacteraemia was 6.2% among UTI (+) patients. The two most common pathogens (81.2%) were Escherichiacoli and Klebsiella. pneumonia. All UTI (+) patients had undergone US, revealing 12.5% pelvicaliectasis, other 12.5% increased renal parenchymal echogenicity, 3.1% concurrent pelvicaliectasis and increased renal parenchymal echogenicity. 53.1% of UTI (+) patients had undergone follow-up, after which 23.5% recurrent UTI were found at the end of a mean of 52 months. CONCLUSION We suggest that the neonates with unexplained pathological jaundice should be tested for possible UTI. Consequently, all newborns with UTI shall be evaluated by the urinary US and followed up for recurrent UTI.

Neurological Involvement in Pediatric Hemolytic Uremic Syndrome: A Symptom-Oriented Analysis

Background Neurological involvement is common in hemolytic uremic syndrome (HUS), but each neurological symptom may be due to a variety of factors. Objective We aimed to evaluate predisposing factors to the neurological symptoms in HUS. Materials and Methods The 10‐year follow‐up data on HUS patients were retrospectively analyzed. Statistical comparisons were made across subgroups based on age and neurological symptoms. Results The neurological involvement rate was 37.5%. The female‐to‐male ratio increased in patients with neurological involvement (3.8 vs. 1.37). Regarding all HUS patients, hemoglobin levels were higher in patients with paresis. The rate of paresis was twofold higher in patients with a hemoglobin level above 11 g/dL (p < 0.05). In diarrhea‐associated HUS patients, D‐dimer and C‐reactive protein levels were higher in patients with paresis, and leukocyte counts were higher in patients with seizures. Patients with altered consciousness had higher creatinine levels. The survival rate was significantly lower in patients with a reticulocyte percentage of less than 2% (50 vs. 100%). Conclusion Results of our study indicate that neurological involvement depends on overall findings in HUS. A symptom‐oriented approach, which is different from that employed in previous studies, reveals some clues to the pathogenesis and management of these patients.

Reference Ranges of Serum Blood Urea Nitrogen, Creatinine Concentration and Ultrasonographic Measurement of the Kidneys in Term Healthy Newborns in the Neonatal Period

Objective: Acute kidney injury is an important problem in neonates. We conducted a cross-sectional prospective study to determine normal serum blood urea nitrogen, creatinine reference ranges and ranges of ultrasonographic measurement of kidneys in healthy term newborns. Study Design: Blood samples were collected from total 357 healthy newborns at birth (n=45), 1st (n=30), 3rd (n=61), 7th (n=34), 10th (n=132), 14th (n=36), and 28th (n=19) days of life. Renal ultrasonographic was performed by the same two radiologists on 81 newborns aged 10 days. Results: Serum blood urea nitrogen and creatinine concentrations have reached to the highest level at the first day of life and have returned to cord level at the third day of life. There were gradually decrease in serum blood urea nitrogen and creatinine levels after the first day of life. There were significant difference in both right and left renal length, width, and volumes in terms of gender and these parameters were statistically higher in boys than girls (p<0.05). Birth weight of the boys (3548±539g) was statistically higher than girls (3307±405 g) (p=0.028). There was a positive correlation between birth weight and right (r=0.38, p=0.000) and left kidney volumes (r=0.44, p=0.000). Conclusion: Our findings showed that measured blood urea nitrogen and creatinine levels changed in accordance with postnatal days and there was a positive correlation between kidney volume and birth weight of newborns. We concluded that these findings are important for evaluation of acute kidney injury and for screening of for urinary tract anomalies in neonates

Molecular analysis of the AGXT gene in patients suspected with hyperoxaluria type 1 and three novel mutations from Turkey

Primary hyperoxaluria type 1 (PH1) is a rare, autosomal recessive disease, caused by the defect of AGXT gene encoding hepatic peroxisomal alanine glyoxylateaminotransferase (AGT). This enzyme is responsible for the conversion of glyoxylate to glycine. The diagnosis of PH1 should be suspected in infants and children with nephrocalcinosis or nephrolithiasis. Early diagnosis and treatment is crucial in preventing disease progression to end stage kidney disease (ESKD). In this study, AGXT gene sequence analyses were performed in 82 patients who were clinically suspected (hyperoxaluria and nephrolithiasis or nephrocalcinosis with or without renal impairment) to have PH1. Disease causing mutations have been found in fifteen patients from thirteen families (18%). Novel mutations have been found (c.458T>A (p.L153X), c.733_734delAA (p.Lys245Valfs*11), c.52 C>T (p.L18F)) in three of 13 families. There were 3-year lag time between initial symptoms and the time of PH1 is suspected; additionally, 5.5-year lag time between initial symptoms and definitive diagnosis. Consanguinity was detected in 77% of the patients with mutation. After genetic diagnosis, one patient received combined kidney and liver transplantation. AGXT gene sequencing is now the choice of diagnosis of PH1 due to its non-invasive nature compared to liver enzyme assay. Early diagnosis and accurate treatment in PH1 is important for better patient outcomes.

Carbapenem-resistant Leuconostoc Septicemia in an Immunocompetent Infant.

To the Editor: Leuconostoc species are catalase (−), alpha or non-hemolytic gram (+) cocci, present commonly in nature, but are absent in human flora [1]. L. mesenteroides is the most frequently isolated type in human infections [2]. The first Leuconostoc infection in humans was reported in two immune deficient patients in the year 1985 [2, 3]. Immunosuppression, intravascular catheter or previous vancomycin use are risk factors for Leuconostoc infection [4]. We hereby present an immunocompetent infant who developed L. mesenteroides septicemia. A 17-mo-old boy was admitted with seizure. He had fever, tachycardia and tachypnea, and was confused without meningeal irritation. White blood cell was 14.400/mm, C-reactive protein 10.09 mg/dl (<0.5), procalcitonin 2.52 μg/l (N < 0.5) with toxic granulation in the peripheral blood smear. Ceftriaxone and amikasin were started. In blood culture, alpha hemolytic gram (+) cocci grown were detected and the strain was identified as L. mesenteroides (Fig. 1). Minimum inhibitor concentration (MIC) were ≥256 μg/ml for ceftriaxone, 0.25 for penicillin, 1 for amikacin, 4 for imipenem and 0.75 for linezolid. He had diarrhea on the second day of hospitalization. Stool analysis was negative for parasites, rotavirus and adenovirus. He had no fever and no growth on blood culture after 48 h of treatment. Immune system examination revealed normal serum immunoglobulins, positive antiHbs and Bacillus Calmette-Guerin (BCG) vaccination scar. We could not perform lumbar puncture because the family did not accept the procedure. Electroencephalography and cranial magnetic resonance imaging were normal. The patient was discharged in good health, without any additional problems. Gastrointestinal system can both be a colonization source and an entrance route for infections [2]. Gastrointestinal system was a possible entry route as the source of infection was diarrhea. Treatment of leuconostoc infections rely on antimicrobial sensitivity test results. Penicillin G and ampicillinMIC values are higher than those observed in other streptococci. Carbapanems, erythromycin, clindamycin, tetracyclin, minocycline, chloramphenicol, linezolid, gentamycin and daptomycin are amongst other possible antibiotic choices.

Is Sinusitis Innocent?– Unilateral Subdural Empyema in an Immunocompetent Child

Subdural empyema related to Streptococcus constellatus is extremely rare in an immunocompetent child, and also there is no reported case along with Staphylococcus lugdunensis infection. Although Streptococcus constellatus has been determined as a co-pathogen with anerobic bacteria in many infections, it has not been reported in combination with Staphylococcus lugdunensis. The authors describe a case of previously healthy 16-y-old child with unilateral subdural empyema due to these bacteria. Sinusitis was the only predisposing factor in the index case. The authors propose that some cases of culture-negative intracranial infections may be due to these infectious agents. Therefore, these agents should be considered as causes of intracranial infection in persistent complaints such as fever and headache after sinusitis in children. It is important to treat them with effective antibiotics and early surgical intervention for favorable outcome, because fatal cases were reported due to Streptococcus constellatus infections.

Compartment syndrome, disseminated intravascular coagulation, pneumonia, and acute renal failure due to varicella in a previously healthy child.

Abstract Varicella infections are usually considered to be benign. Although very rare, infection of an immunocompetent patient by this virus may result in a severe illness. We describe a case of varicella infection in a previously healthy, immunocompetent 5-y-old boy, complicated with compartment syndrome, disseminated intravascular coagulation (DIC), pneumonia, and acute renal failure. He was treated successfully with aciclovir and intravenous immunoglobulins for the varicella infection, a fasciotomy for compartment syndrome, and fresh frozen plasma for DIC.