Fatih Demircioğlu

Intima-media thickness of carotid artery and susceptibility to atherosclerosis in obese children with nonalcoholic fatty liver disease.

Objective: To test, via prospective case-control study, whether measurements of carotid artery intima-media thickness (cIMT) reflect the susceptibility to atherosclerosis in obese children with nonalcoholic fatty liver disease. Patients and Methods: In all, 80 obese asymptomatic normotensive adolescents (body mass index [BMI], 29.12 ± 5.13; 8.5–17.5 years) and 30 age- and sex-matched nonobese healthy children (BMI 18.55 ± 2.24). Children were analysed in 4 groups: Controls formed group 1, 26 children with obesity without hepatosteatosis formed group 2, 32 children with grade 1 hepatosteatosis formed group 3, and 22 children with grade 2 or 3 hepatosteatosis formed group 4. The key parameters were BMI, liver function tests, lipid profiles, glucose, hepatic ultrasonography, and IMT of common carotid artery (CCA), left carotid bulbus (CB), and left internal carotid artery (ICA). Results: Comparisons of IMT measurements of left CCA, left CB, and left ICA between controls and obesity group revealed statistically significant differences (each segment P < 0.0001). There was an increase in the mean of IMT of each segment with the increase in hepatosteatosis grade (each segment P < 0.0001). The relation between the mean of IMT of left CCA, left CB, and left ICA with BMI (P = 0.001, r = 0.318), alanine aminotransferase (P = 0.007, r = 0.256), and hepatosteatosis (P < 0.0001, r = 0.470) was significant. Multiple regression analysis between left CCA, left CB, and left ICA, and age, sex, relative weight, alanine aminotransferase, total cholesterol, obesity, and hepatosteatosis grade was significant for only hepatosteatosis grade. Conclusions: The cIMT is significantly higher, increasing susceptibility to atherosclerosis, in obese children with hepatosteatosis than in healthy children or obese children without hepatosteatosis.

Evaluation of serum lipids and carotid artery intima media thickness in epileptic children treated with valproic acid

The aim of this study is to evaluate the carotid artery intima media thickness and serum lipids in pediatric patients with epilepsy treated with valproic acid. The study included 44 pediatric epileptic and 40 healthy children. Intima media thickness of left common carotid artery and fasting lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol) were assessed. Although we did not observe any differences regarding serum lipid profiles, intima media thickness of common carotid artery was significantly higher in epileptic patients treated with valproic acid. We suggest that this increase in intima media thickness of common carotid artery may be due to epilepsy and/or valproic acid treatment.

Parvovirus B19: A cause for aplastic crisis and hemophagocytic lymphohistiocytosis†

A 17-year-old female patient with hereditary spherocytosis (HS) presented with fatigue, nausea, headache, and fever for 2 days. On physical examination, she had high fever, pallor, icterus, and mild splenomegaly. Peripheral blood examination demonstrated a Hb level of 8.2 g/dL, WBC 1.9 10/L, platelets 74 10/L,MCV88.9 fL,MCH33.9 pg, MCHC 38.1 g/dL, and reticulocyte 0.7%. The peripheral blood smear revealed 70% neutrophils, 18% lymphocytes, 10% monocytes and 2% band neutrophils, vacuolization in neutrophils andmonocytes;many spherocytes. Bonemarrow aspirate showed hypocellularity with many hemophagocytic histiocytes, giant proerythroblasts, and absence of mature erythroblasts, suggesting a parvovirus infection (Fig. 1). On the second day of hospitalization, her Hb level decreased to 5.6 g/dL. Hepatomegaly developed and splenomegaly progressed. Serum ferritin level was 7,478 ng/mL, triglyceride 1.17 nmol/L and fibrinogen 2.31 g/L. Prothrombin and partial thromboplastin time were within normal limits, but the D-dimer level was very high (3,004 mg/L). The serum folic acid levelwas normal. Parvovirus B19 IgMand IgGwas found to be positive by indirect immunofluoroscent assay. Secondary hemophagocytic lymphohistiocytosis (HLH) and aplastic crisis due to Parvovirus B19 infection was diagnosed. She received red blood cell transfusions and intravenous immunoglobulin was given for the HLH. Shewas discharged from the hospital after a marked clinical and hematological improvement on day 6 with a Hb level of 9.9 g/dL, WBC 4.8 10/L and platelets 198 10/L. Ten days later, her 13-year-old brother, who also had HS, presented with similar clinical features and Parvovirus B19 infection. He improved with red blood cell transfusions and supportive treatment. In patients with hemolytic anemia, with shortened red cell survival time and expanded marrow erythropoiesis, Parvovirus B19 infection can lead to a transient aplastic crisis. Giant proerythroblasts and absence of mature erythroblasts are characteristic findings of parvovirus infection [1–3].

The changing face of celiac disease: a girl with obesity and celiac disease.

The widespread use of serological tests has changed the clinical spectrum of recently diagnosed celiac patients. In this paper, we present an obese patient with Hashimoto’s thyroiditis who was investigated for hypochromic microcytic anaemia that is unresponsive to iron replacement therapy and finally had the diagnosis of celiac disease. A 7-year-old girl was admitted to our hospital with the complaint of being overweight for 3 years. Her medical history was unremarkable except for consuming high energy-containing foods and sedentary life-style. Her mother was taking treatment for Hashimoto’s disease. On physical examination, her weight was 42.5 kg (>95 percentile), height 126.8 cm (75–90 percentile), weight for height 167%. She had an obese appearance but no signs of stria, hepatomegaly or acanthosis nigricans. Laboratory results showed: haemoglobin: 11.2 g/dL, hematocrit: 34.8%, MCV: Mean corpuscular volume 69 fL, RDW: Red cell distribution width 18, leukocyte: 9800/mm, thrombocyte: 361 000/ mm, fasting blood glucose: 85 mg/dL, aspartate aminotransferase: 18 U/L, alanine aminotransferase: 30 U/L, triglyceride: 150 mg/ dL, total cholesterol: 233 mg/dL, LDL-cholesterol: Low density lipoprotein 158 mg/dL, free T3: 4.11 (2–4.1 pg/mL), free T4: 0.91 (0.8–2.2 ng/dL), thyroid stimulating hormone: 56.3 (0.6– 5.5 U/mL), anti-T: 621 IU/mL, anti-G: 92.9 IU/mL, in abdominal ultrasonography there was no sign of fatty liver. Thyroid ultrasonography revealed fibrous septa in both thyroid glands consistent with autoimmune thyroiditis. She was started thyroid replacement therapy for Hashimoto’s disease and also diet and exercise for obesity. At the first year of follow-up, her weight for height was 152%. She was found to have a persistent iron-deficiency anaemia that is not responsive to iron supplements (Table 1). She did not have bleeding history and stool examination was negative for occult blood. Haemoglobin electrophoresis was normal. An antibody screening test resulted positive for anti-endomysium IgA and anti-gliadin IgG and IgA antibodies. Serum IgA level was within the normal ranges (212 mg/dL (N: 33–226)). Her parent’s screening tests for celiac disease were negative. Endoscopic duodenal biopsy showed villous atrophy, crypt hyperplasia and lymphocyte proliferation consistent with the celiac disease. She was started a gluten-free diet and encouraged to consume iron-rich foods. After 4 months of treatment with gluten-free diet, all her haematological parameters returned to normal values. There are few published data in the literature about the co-existence of obesity and celiac disease. Classically in a disease where there is a disorder of absorption, the expected clinical condition is malnutrition rather than obesity. Co-existence of obesity and celiac disease is explained with a compensation theory. According to this theory, nutrients that cannot be absorbed because of villous atrophy in proximal small bowel is taken into body with increased absorption in distal small bowel and as a result, these patients do not lose weight. The patients reported with obesity and celiac disease presented with different clinical signs in the literature. Franzese et al. determined hepatosteatosis in an obese patient. This patient was evaluated for persistent liver disease despite the hypocaloric-diet and celiac disease was diagnosed. Oso and Fraser detected celiac disease in an obese adolescent patient who had recurrent diarrhoea attacks especially after eating spaghetti. Another published obese celiac case is a 5-year-old girl with short stature and recurrent abdominal pain. Our patient was presented with obesity and refractory irondeficiency anaemia. Anaemia can be seen in obese patients. Bekri et al. reported that 24% of morbid obese patients presented with anaemia. Similarly, in childhood series, anaemia frequency was found to be higher in obese children than normal children. The possible causes of this situation are early menarche in girls and on the contrary of assumed; the fact that obese patients consume inadequate iron in their diet. Our patient was taking adequate iron through her diet and supplementation. In celiac disease patients who have obesity, anaemia is a frequent finding. Four adult morbid obese patients who had the diagnosis of celiac disease were reported. Two of these patients had diarrhoea and one of them had gastroesophageal reflux complaints. At admission, iron deficiency was determined in two patients while vitamin B12 deficiency was determined in one. The prevalence of celiac disease in adults with Hashimoto’s disease was 5%. Similarly, the frequency of autoimmune thyroiditis is increased in celiac patients compared with normal population. But in childhood period, this togetherness of two diseases was reported very rarely. Our patient was admitted to our clinic for obesity and found to have autoimmune thyroiditis after investigations. She was screened for celiac disease in the follow-up period because of iron-deficiency anaemia. In conclusion, patients who have symptoms and signs suggesting celiac disease should be screened for celiac disease without considering their body weight.

ASSESSMENT OF FEBRILE NEUTROPENIA EPISODES IN CHILDREN WITH ACUTE LEUKEMIA TREATED WITH BFM PROTOCOLS

The authors overviewed 239 febrile neutropenia (FN) episodes in 82 pediatric leukemia cases treated with BFM treatment protocols. FN was observed mostly during consolidation therapy. Mucositis was the most identified focus; gram-negative microorganisms were the most identified pathogens. Five patients developed invasive fungal infections. Fever resolved after mean 5.3 days and mean antibiotic administration time was 12.7 days. Addition of G-CSF to antimicrobial therapy shortened the duration of neutropenia, but it did not affect duration of fever resolution and antibiotic administration. The duration of neutropenia, fever resolution, and antibiotic administration was significantly longer in children with acute myeloid leukemia. The authors conclude that children with acute leukemia have severe prolonged neutropenia and are in high risk. In these patients, prediction of the risk of bacteremia based on clinical and laboratory features is important for immediate empiric broad-spectrum antimicrobial therapy and for higher survival rate.

CLINICAL FEATURES, TREATMENT RESPONSES, AND OUTCOME OF CHILDREN WITH IDIOPATHIC THROMBOCYTOPENIC PURPURA

The authors investigated demographics, clinical and laboratory features, treatment responses, and outcomes of 93 children (median age 5 years) admitted for idiopathic thrombocytopenic purpura (ITP). The therapy responses of high-dose methylprednisolone (HDMP) (n = 77) and intravenous immunoglobulin (IVIG) (n = 10) treatments were similar. None of the patients with hemorrhage died. Fifteen patients (16.1%) had progressed into chronic ITP. Seven infants had a probable relationship with vaccination; none of these infants progressed into chronic ITP. In conclusion, the overall prognosis in childhood ITP is good. The therapy responses of HDMP and IVIG treatments are similar. Also, ITP cases who havw vaccination history have a benign course.

Assessment of atherosclerosis in obese adolescents: Positive correlation of mean platelet volume and carotid intima media thickness

This study aims to assess the correlation of mean platelet volume (MPV) and common carotid artery (CCA) thickness in a population of obese adolescents.

Subscapular abscess after blunt trauma.

Infection around the shoulder girdle is an infrequent and difficult diagnosis requiring a high index of suspicion and early evaluation by the physician. An infection within the area of the subscapularis muscle and the chest wall is extremely rare. To the best of our knowledge, only 4 cases of subscapular abscess have been reported. In this article, we present a 7-year-old boy with a subscapular abscess after blunt trauma.

Hepatic Artery Resistance in Children with Obesity and Fatty Liver

ObjectiveThe present study assessed whether there is a correlation between hepatic artery resistive index (HARI) and increase of body mass index and hepatosteatosis grading in children with non-alcoholic fatty liver disease (NAFLD) reflecting hemodynamic effects of hepatosteatosis.MethodsThirty three healthy children [body mass index(BMI): mean± standart deviation(SD), min-max: 20.1±1.14(18.5–23.7), 33 overweight [BMI:25.1±2.2 (18.5–23.7)] and 66 obese [BMI:31.1±2(25.6–40)] adolescents were enrolled into the study. To search the relation of HARI with fatty liver degree, study subjects subdivided into groups according to their degree of fatty liver at ultrasonography(US).ResultsIncrease of HARI was correlated with increase in BMI (p<0.0001, r=0.533). Increase of HARI was well correlated with increase in degree of fatty liver (p<0.0001, r=0.630).ConclusionThe present study results suggest that there are positive correlations of HARI with BMI and hepatoseatosis grade in obese children with NAFLD. HARI may be a candidate parameter to determine early alarming hemodynamic changes in hepatic tissue of obese children with fatty liver before development of severe stages NAFLD.

RHABDOMYOLYSIS DUE TO Escherichia coli SEPSIS IN THREE PEDIATRIC PATIENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA

Rhabdomyolysis with myoglobinuria is an uncommon complication of bacterial sepsis. The authors describe three pediatric acute lymphoblastic leukemia patients who developed rhabdomyolysis during a neutropenic sepsis episode due to Escherichia coli. All of the patients needed hemodynamic supportive treatment because of septic shock. Broad-spectrum antibiotics, alkalinization, and intravenous fluid therapy was given. One patient with renal insufficiency died, despite aggressive treatment. Muscle pain and dark urine color should alert physicians to the possibility of rhabdomyolysis in immunocompromised patients with sepsis. Early and appropriate treatment is critical in these patients to prevent renal failure and shock, and for a better outcome.