Emanuela A. Laicini

Early exposure to allergens: a new window of opportunity for non-communicable disease prevention in complementary feeding?

Abstract Recent findings suggest that an early exposure to dietary antigens may be more protective towards allergy than a later introduction even in high-risk infants. The consequent earlier introduction of food items such as egg yolk and oily fish, together with breastfeeding continuation through the first year, could contribute to reducing protein and increasing fat supply, respectively. These changes might have a role in the overall prevention of non-communicable disorders of adulthood.

Using a high‐flow nasal cannula provided superior results to low‐flow oxygen delivery in moderate to severe bronchiolitis

An observational study was carried out on infants with moderate to severe bronchiolitis to compare the clinical outcomes following treatment with a high‐flow nasal cannula (HFNC) or standard low‐flow oxygen.

Invasive Aspergillus nidulans infection in a patient with chronic granulomatous disease

The patient was a 21-year-old boy affected by X-linked chronic granulomatous disease (CGD-OMIM number 3064000), with a mutation in the gene encoding gp91 phox (deletion of a single G in position 767, with loss of gp91 phox and no residual NADPH oxidase activity), diagnosed at the age of 2, because of a positive family history for CGD. He had recurrent skin abscesses, lymphadenitis, bacterial pneumonia, and lung aspergillosis with probable brain dissemination. His parents compliance was poor and they had discontinued all therapies for a number of years without notice. The patient was referred to our hospital for the first time at the age of 10 because of a multifocal pneumonia with isolation of Aspergillus fumigatus in multiple sputum cultures. He was successfully treated with intravenous conventional amphotericin B and then a prophylactic regimen with trimethoprim–sulfamethoxazole, itraconazole and interferon gamma was prescribed. At the age of 13, the patient presented another brain focus, which resolved under a treatment with liposomal amphotericin B followed by oral itraconazole. His parents admitted once again their poor compliance with prophylactic treatment. When he was 21, the patient was hospitalised because of a large popliteal abscess in the right leg (Fig. 1) and a large area of parenchymal consolidation in the right lung. Right leg magnetic resonance imaging (MRI) excluded bone damage on multiple scans and a brain MRI did not reveal any new damage, but only traces of the old parenchymal lesions. Aspergillus spp. was isolated from a sputum sample and Aspergillus nidulans was isolated in repeated popliteal abscess cultures. An in vitro antifungal susceptibility test of the A. nidulans isolate was performed with Etest (AB-Biodisk, Solna, Sweden). The minimum inhibitory concentrations resulted in the following: itraconazole 0.12 lg ml, voriconazole 0.094 lg ml, amphotericin B 0.19 lg ml. Histological examination showed granulation tissue with abscesses, a granuloma of giant plurinucleated cells and the presence of septate hyphae compatible with the morphology of the isolated A. nidulans. The presence of precipitating antibodies against somatic and metabolic A. fumigatus antigens (Microgen Bioproducts, Camberley, UK; Bio-Rad, Marnes-la Coquette, France) agreed with the isolation of Aspergillus in culture. On the contrary, no galactomannan antigen was detected using Platelia Aspergillus (Bio-Rad) in repeated serum samples. The level of total serum IgE was 8910 kIU l and anti A. fumigatus IgE Correspondence: Prof. Maria Cristina Pietrogrande, Department of Pediatrics, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Via Commenda 9, Milan 20122, Italy. Tel.: +39 2 5503 2496. Fax: +39 2 5032 0210. E-mail: mariacristina.pietrogrande@unimi.it

Treatment of Severe Hypervolemic Hyponatremia in a Child With Pneumonia.

A 21-month-old boy came to our attention because of pneumonia. His weight increased before presentation, and his blood test results showed hyponatremia (116 mEq/L), low plasma osmolarity (241 mOsm/L), and high urine osmolarity (435 mOsm/L). He was treated with 0.9% sodium chloride solution and intravenous furosemide, and sodium levels rose up to 135 mEq/L in 36 hours. No standard treatment is available for severe hyponatremia in children. The use of vaptans in pediatric patients is described in literature, but it lacks evidence about safety and effectiveness. We suggest that furosemide administration plus salt replacement is effective in restoring normal values of plasma sodium concentration in severe euvolemic and hypervolemic hyponatremia.

Severe and isolated headache associated with hypertension as unique clinical presentation of posterior reversible encephalopathy syndrome

BackgroundPosterior reversible encephalopathy syndrome is a potentially reversible clinicoradiologic syndrome characterized by headache, mental confusion, visual disturbances and seizures associated with posterior cerebral lesions on radiological imaging. Prompt treatment of this condition is mandatory to avoid severe irreversible complications.Case presentationWe report a 9-year-old boy with arterial hypertension and headache as unique clinical presentation of posterior reversible encephalopathy syndrome.ConclusionsSevere and isolated headache associated with arterial hypertension can be the unique clinical presentation of posterior reversible encephalopathy syndrome. This syndrome must be considered even in absence of all typical symptoms to prevent the progression of a potentially life threatening condition.

Nutcracker phenomenon and idiopathic IgA nephropathy

Sir, Entrapment of the left renal vein between the aorta and the superior mesenteric artery is a documented cause of both postural proteinuria as well as intermittent gross haematuria associated with left flank pain. Idiopathic IgA nephropathy typically presents with recurrent episodes of gross haematuria, usually following an acute febrile illness. Rarely, the disease presents as microscopic haematuria and usually mild proteinuria. We present the first case of postural proteinuria caused by left renal vein entrapment and recurrent gross haematuria caused by an IgA nephropathy. In an 11-year-old boy with postural proteinuria, renal ultrasonic Doppler disclosed left renal vein entrapment: the anteroposterior diameter at the hilar portion divided by that at the aortomesenteric portion was 13.3 (reference ≤ 4.0) and the peak flow velocity at the aortomesenteric portion divided by that at the hilar portion 15.1 (reference ≤ 4.0). Two years later, three episodes of acute febrile diarrhoea were followed by gross haematuria that was not associated with flank pain. The kidney biopsy showed mild diffuse mesangial proliferation and matrix expansion. The diagnosis of IgA nephropathy was made on immunofluorescence microscopy, which demonstrated isolated prominent globular deposits of IgA, C3 and IgG in the mesangium. The link between left renal vein entrapment and postural proteinuria is well documented. Furthermore, both left renal vein entrapment and IgA nephropathy are recognized causes of recurrent gross haematuria. There are five reported patients affected with both left renal vein entrapment and idiopathic IgA nephropathy [1–4]. A 12-year-old German girl with microscopic haematuria was found to have left renal vein entrapment and mesangial deposits of IgA [1]. Similarly, left renal vein entrapment and mesangial deposits of IgA were reported in a 9-year-old Korean girl with isolated microscopic haematuria and recurrent gross haematuria [2] and in a 25-year old Taiwanese woman with recurrent gross haematuria and left flank pain [3]. Left renal vein entrapment and IgA nephropathy were also disclosed in a 20-year-old woman and in a 22-year-old Japanese man, who, in the context of a pharyngitis, developed gross haematuria and a tendency to microscopic haematuria with persisting proteinuria [4]. In addition, left renal vein entrapment was disclosed in two Korean children a 13-year-old Korean girl with Henoch–Schonlein syndrome and IgA nephropathy [5]. Finally, a 10-year-old Korean boy with a clinically characteristic and rapidly resolving form of Henoch–Schonlein syndrome followed by microscopic haematuria persisting for 26 months was found to have left renal vein entrapment; haematuria subsided in accordance with radiological improvement of renal vein entrapment [6]. Our patient is the first case with concurrent existence of postural proteinuria caused by left renal vein entrapment and recurrent gross haematuria caused by an idiopathic IgA nephropathy. Renal venous congestion may induce both proteinuria and haematuria, which have been implicated as a cause of renal damage. So, a causal relationship between left renal vein entrapment and IgA nephropathy cannot be ruled out. Further investigations are necessary to detect this correlation.