Francy Reis da Silva Patrício

Cow's milk protein intolerance and chronic constipation in children

Cows milk protein (CMP) allergy was investigated in 25 children (age‐range 3 months to 11 years) with chronic constipation. A diagnosis of constipation was made on the basis of a history of painful elimination of hard stools for at least 1 month, whether or not associated with a reduced frequency of stools or soiling. The children were evaluated using clinical parameters and the following laboratory tests: total serum immunoglobulin E (IgE); specific IgE (radioallergosorbent test [RAST]) for whole cows milk, α‐lactoalbumin, β‐lactoglobulin, and a food group; and skin‐prick tests with whole milk, α‐lactoalbumin, β‐lactoglobulin, and casein. Following the evaluation, the children were submitted to a CMP‐free diet for a period of 4 weeks. In seven patients (28%), constipation disappeared during the CMP‐free diet and reappeared within 48–72 h following challenge with cows milk. In two infants a rectal biopsy revealed allergic colitis and they therefore did not undergo the challenge. High serum levels of total IgE were observed in five of the children who showed a clinical improvement (71%), a positive skin‐test in two (29%), and detectable specific IgE in two (29%). These results suggest that CMP allergy or intolerance should be considered as a cause of chronic refractory constipation in children, although the underlying mechanism still require further investigation.

Evaluation of invasive and non-invasive methods for the diagnosis of Helicobacter pylori infection in symptomatic children and adolescents

CONTEXT Multiple diagnostic methods are available for the detection of Helicobacter pylori infection, but at present no single one can be used as the gold standard. OBJECTIVE The aim of this study was to evaluate the diagnostic accuracy of 3 invasive and 2 non-invasive methods for detection of Helicobacter pylori infection in symptomatic children and adolescents. DESIGN Prospective cohort study SETTING Peptic Disease outpatients service, Discipline of Pediatric Gastroenterology, Universidade Federal de São Paulo / Escola Paulista de Medicina. PATIENTS Forty-seven patients who underwent endoscopy because of dyspeptic symptoms. DIAGNOSTIC METHODS Endoscopy with gastric biopsies for 3 invasive (rapid urease test, histology and culture) and 2 non-invasive methods (a commercial ELISA serology and 13carbon urea breath test - isotope ratio mass spectrometry) for detection of Helicobacter pylori infection. MAIN MEASUREMENTS Sensitivity, specificity, positive and negative predictive values of each method and agreement and disagreement rates between the methods. RESULTS Forty-seven patients [mean age, 11y9mo (SD 2y10mo), 27 female and 20 male]; 62% of them were Helicobacter pylori-positive. All methods agreed in 61%, and were negative in 21% and positive in 40%. The greatest concordance between 2 methods occurred between the invasive methods: histology and rapid urease test (89.6%) and histology and culture (87.5%). The greatest sensitivity, considering Helicobacter pylori-positive cases, for any combination of 3 or more tests, was achieved by the rapid urease test (S=100%), followed by histology, serology and 13carbon-urea breath test (S=93.1%) and lastly by culture (S=79.3%). The highest specificity was obtained by histology (100%) and culture (100%), followed by the rapid urease test (84.2%), serology (78.9%) and 13carbon-urea breath test (78.9%). CONCLUSIONS Our results suggest that among invasive methods, an association between the rapid urease test and histology constituted the best choice for the detection of Helicobacter pylori infection. If results of histology and the rapid urease test are different, serology may be recommended.

13C-Urea Breath Test With Infrared Spectroscopy for Diagnosing Helicobacter pylori Infection in Children and Adolescents

Background and Objective Studies support the accuracy of 13C-urea breath test for diagnosing and confirming cure of Helicobacter pylori infection in children. Three methods are used to assess 13CO2 increment in expired air: mass spectrometry, infrared spectroscopy, and laser-assisted ratio analysis. In this study, the 13C-urea breath test performed with infrared spectroscopy in children and adolescents was evaluated. Methods Seventy-five patients (6 months to 18 years old) were included. The gold standard for diagnosis was a positive culture or positive histology and a positive rapid urease test. Tests were performed with 50 mg of 13C-urea diluted in 100 mL orange juice in subjects weighing up to 30 kg, or with 75 mg of 13C-urea diluted in 200 mL commercial orange juice for subjects weighing more than 30 kg. Breath samples were collected just before and at 30 minutes after tracer ingestion. The 13C-urea breath test was considered positive when delta over baseline (DOB) was greater than 4.0%. Results Tests were positive for H. pylori in 31 of 75 patients. Sensitivity was 96.8%, specificity was 93.2%, positive predictive value was 90.9%, negative predictive value was 97.6%, and accuracy was 94.7%. Conclusions 13C-urea breath test performed with infrared spectroscopy is a reliable, accurate, and noninvasive diagnostic tool for detecting H. pylori infection.

Triple therapy with clarithromycin, amoxicillin and omeprazole for Helicobacter pylori eradication in children and adolescents

BACKGROUND Helicobacter pylori infection presents high prevalence in developing countries, but there are few pediatric assays evaluating antimicrobial treatment. OBJECTIVE The aim of this study was to investigate Helicobacter pylori eradication rate using a short regimen (7 and 10 days) of triple therapy with clarithromycin, amoxicillin and omeprazole. PATIENTS AND METHODS Twenty-five Hp positive patients who presented severe epigastralgia, were submitted to antimicrobial treatment with amoxicillin (50 mg/kg/day--maximum dose 1 g bid), clarithromycin (30 mg/kg/day--maximum dose 500 mg bid) and omeprazole (0.6 mg/kg/day--maximum dose 20 mg bid) during 7 or 10 days. After 2 months, clinical symptoms were evaluated and gastric biopsies were taken to test Hp eradication. RESULTS Overall eradication rate was achieved in 16/25 patients (64%--IC(95% = 45-83%), in 11/15 (73%--IC(95%) = 51-95%) patients who used 10 days therapy course and in 5/10 (50%--IC(95%) = 19-81%) who used 7 days therapy course. Eradication drugs were well accepted and adverse effects were reported in two patients (8%). CONCLUSIONS This triple therapy regimen had moderate efficacy (64%). The data suggests that 10 days therapy course achieves better eradication rate (73%) than 7 days course (50%) to treat Hp infection in our population.

13C-Urea Breath Test to Diagnose Helicobacter pylori Infection in Children Aged up to 6 Years

Background.  13C‐urea breath test (13C‐UBT) is an accurate noninvasive tool for diagnosis of Helicobacter pylori infection. It is considered the best method for epidemiological studies, but there are few studies to evaluate the 13C‐UBT in infants and toddlers.

Validation of a monoclonal stool antigen test for diagnosing Helicobacter pylori infection in young children.

Background and Objective: The monoclonal stool antigen test for diagnosing Helicobacter pylori infection in children has been tested in developed countries, showing sensitivity and specificity higher than 90%. However, its accuracy in young children from developing countries is not well established. The aim of the study was to determine the accuracy of the monoclonal stool antigen test for diagnosing H pylori infection in children up to 7 years old. Patients and Methods: Two hundred seventy-six patients (53.6% female; ages 0.35–6.99 years) were evaluated. Gold standard positive culture or positive histology and rapid urease tests were performed. The test (Amplified IDEIATM Hp StAR) was done according to the manufacturers instructions. Results were expressed as optical density (OD) and an OD more than or equal to 0.190 was considered positive. Additionally, a receiver operating characteristic curve was used to find the best cutoff. Results: The monoclonal stool antigen test for diagnosing H pylori infection showed 100% sensitivity (95% confidence interval [CI] 92.7%–100%) and 76.2% specificity (95% CI 70.1%–81.4%), considering the manufacturers cutoff. After setting a new cutoff with the receiver operating characteristic curve (OD = 0.400), sensitivity remained 100% (95% CI 92.7%–100%), but the specificity improved to 97.7% (95% CI 94.7%–99%). At ages up to 2 years, sensitivity was 100% (95% CI 43.8%–100%) and specificity was 100% (95% CI 92.4%–100%); at ages 2 to 4 years, 100% (95% CI 80.6%–100%) and 97.6% (95% CI 96%–99.2%); at ages older than 4 years, 100% (95% CI 88.6%–100%) and 96.6% (95% CI 94.7%–98%), respectively. Conclusions: The monoclonal stool antigen test is accurate for diagnosing H pylori in children younger than 7 years old, but it must be locally validated in order to find the best cutoff for each population.

Fetal-onset IPEX: Report of two families and review of literature

Early-life autoimmunity is an IPEX characteristic, however intrauterine forms had not yet been described. Here, two unrelated families with clear evidence of fetal-onset IPEX are reported. One had 5 miscarriages of males in two generations, and a newborn presenting type-1 diabetes mellitus immediately after birth, diarrhea, thrombocytopenia, eczematous dermatitis, eosinophilia, high IgE levels and autoantibodies to pancreatic islet antigens at 4-days-old. Maternal serology was negative. He presented a FOXP3 mutation, c.1189C>T, p.Arg397Trp, previously described only in another family with IPEX at birth. The second family had several miscarriages of males in three consecutive generations and a novel FOXP3 c.319_320delTC mutation was observed in two miscarried monochorionic twin male fetuses. These twins died at 21weeks of gestation due to hydrops, and CD3+ infiltrating lymphocytes were found in their pancreas. We demonstrate that: i) IPEX may develop in fetal life; and ii) c.1189C>T and c.319_320delTC mutations are associated with early-onset phenotype.

Nitric Oxide Levels in the Intestines of Mice Submitted to Ischemia and Reperfusion: l-Arginine Effects

OBJECTIVE Usually an experimental necrotizing enterocolitis experimental model, we Investigated nitric oxide levels in intestinal tissues of newborn mice with or without l-arginine therapy during sessions of ischemia and reoxygenation. METHODS Twenty-six newborn mice from the Wistar EPM-1 lineage, weighing from 4.5 to 6.2 g, were randomly assigned to three groups: G-I/R, hypoxia and reoxygenation; G-Arg, l-arginine treatment I/R; and G-CTL, controls. G-I/R and G-Arg mice underwent twice a day during their first 3 days of life exposure to gas chambers with 100% CO(2) for 5 minutes at 22 degrees C before reoxygenation with 100% O(2) for another 5 minutes. After 12 hours, all animals were sedated, laparotomized, and had samples of ileum and colon taken and- either formalin fixed histopathologic examinations or frozen to -80 degrees C for estimation of tissue nitric oxide levels. Intestinal injuries were classified according to the criteria of Chiu et al. RESULTS The G-I/R and G-Arg groups showed injuries characteristic of necrotizing enterocolitis (NEC) with an improved structural preservation rate in G-Arg. The concentration of nitric oxide in the Ileum was much higher with G-Arg (16.5 +/- 4.9; P = 0.0019) G-I/R (7.3 +/- 2.0). This effect was not observed in the colon: G-I/R = 10.7 +/- 4.6 versus G-Arg = 15.5 +/- 8.7 (P = .2480). CONCLUSION Supply of L-arginine increased tissue levels of nitricoxide and reduced morphologic intestinal injury among mice undergoing I/R.

High Helicobacter pylori resistance to metronidazole and clarithromycin in Brazilian children and adolescents.

Objective: The aim of the present study was to assess the primary and secondary resistance of Helicobacter pylori strains to clarithromycin, amoxicillin, furazolidone, tetracycline, and metronidazole, the conventional antibiotics presently used in Brazilian children and adolescents. Methods: Seventy-seven consecutive H pylori strains, 71 of 77 strains obtained from patients without previous eradication treatment for H pylori infection, and 6 strains from patients in whom previous eradication treatment had failed. Results: Global rate of resistance was 49.3% (38/77): 40% of strains were resistant to metronidazole, 19.5% to clarithromycin, and 10.4% to amoxicillin. All of the tested H pylori strains were susceptible to furazolidone and tetracycline. Multiple resistance were detected in 18.2% (14/77 patients) of the strains: 6 of 14 (43%) simultaneously resistant to clarithromycin and metronidazole; 5 of 14 (36%) to amoxicillin and metronidazole; 2 of 14 (14%) to amoxicillin, clarithromycin, and metronidazole; and 1 of 14 (7%) to clarithromycin and amoxicillin. Conclusions: The high resistance rate to metronidazole and clarithromycin observed in clinical H pylori isolates can exclude these antimicrobials in empirical eradication treatment in Brazil. Otherwise, furazolidone and tetracycline presented no resistance. Properly assessing the risks and benefits, these 2 antimicrobials and their derivatives could be used in empirical eradication schedules, both associated with amoxicillin, which showed a low resistance rate despite its wide use in pediatric patients.

Imaging Trypanosoma cruzi within tissues from chagasic patients using confocal microscopy with monoclonal antibodies.

Abstract Confocal fluorescence microscopy combined with differential interference contrast imaging of tissues from chagasic patients enabled the unequivocal identification of the parasite Trypanosoma cruzi. Using different monoclonal antibodies that indicate the parasite form and replication stage in conjunction with DNA labelling, specimens derived from distinct clinical forms of the disease were examined. Intracellular amastigote forms of the parasite were clearly detected in heart, brain, skin, lung, and kidney. Dividing amastigotes as well as trypomastigote forms were recognized in samples obtained from patients undergoing either acute-phase or some form of reactivation caused by immunosuppression.