Fuat Gürkan

Central Nervous System Tuberculosis in Children: A Review of 214 Cases

Objective. To study the clinical, laboratory, and treatment features observed in pediatric patients with tuberculous meningitis in Turkey. Study Design. Retrospective case review study. Methods. Review of medical records for demographic data, medical history, clinical manifestations, auxiliary test results, complications, and treatment of 214 children with central nervous system tuberculosis (TB) admitted to Dicle Universitys hospital between August 1988 and February 1996. Results. Of the 214 patients with tuberculous meningitis, 112 (52%) were male. The mean age at presentation was 4.1 years, with 165 patients (77%) younger than 5 years. Twenty-two patients (10%) were in the first stage of the disease, 120 (56%) in the second, and 72 (34%) in the third. Our epidemiologic data showed that 141 (66%) of the patients had a family history of TB, and 64 (30%) had a Mantoux skin test result of >10 mm of induration. Radiographic studies demonstrated abnormal chest findings in 187 patients (87%) (hilar adenopathy, 33%; infiltrates, 33%; miliary pattern, 20%; and pleural effusions, 1%, and 172 (80%) cases with hydrocephalus, 26% with parenchymal disease, 15% with basilar meningitis, and 2% with tuberculomas. Only 22 (13%) of 164 children had a positive acid-fast bacilli smear in cerebrospinal fluid, andMycobacterium tuberculosis was isolated in 49 patients (30%). All the patients were treated with Isoniazid, rifampin, and streptomycin or pyrazinamide for 2 months, followed by 10 months of Isoniazid and rifampin alone. Also, all the patients received adjuvant treatment with steroids early in the course of treatment, and 140 of 172 cases with hydrocephalus had surgical intervention. The overall mortality rate was 23%. Conclusion. One or more of these findings: a family history of TB, positive tuberculin skin test results, abnormal cranial computed tomography, and/or cerebrospinal fluid analysis compatible with TBM were found in all but 3 children in our study. central nervous system, tuberculous meningitis, diagnosis, hydrocephalus, children.

The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis.

In spite of the increasing evidence that passive smoking increases the incidence of respiratory infections and bronchial hyper-responsiveness, the information about whether exposure to sudden heavy smoke enhances the development of acute respiratory infections in children remains inadequate. In this study, to quantitate the level of exposure to environmental tobacco smoke, in 28 children (age ranging 2–18 months) with respiratory syncytial virus (RSV) bronchiolitis and in 30 children (age ranging between 2–15 months) with non-respiratory symptoms, the serum levels of cotinine, the major metabolite of nicotine, were measured at admission to the emergency department. Parents were asked to fill in a questionnaire about the housing conditions and their smoking habits. Serum samples were taken again from the children with RSV bronchiolitis at their second visit at 1 month after discharge from the hospital. The children with RSV bronchiolitis had higher levels of serum cotinine (mean of 10.8 ng/ml) in the acute stage, compared with post-bronchiolitis stage (mean of 7.4 ng/ml). Moreover, patients admitted with non-respiratory symptoms had significantly lower levels of serum cotinine (mean of 3.9 ng/ml) than both phases of patients with RSV bronchiolitis. Children with RSV bronchiolitis were found to have higher levels of cotinine when either the mother or both of the parents smoked, than the children with non-smoker parents. In conclusion, children admitted to the hospital with RSV bronchiolitis were shown to be acutely exposed to more cigarette smoke after 1 month and much more than the children admitted for non-respiratory diseases. These findings may imply that sudden heavy cigarette smoke exposure may predispose to an acute respiratory infection.

Serum leptin levels in asthmatic children treated with an inhaled corticosteroid.

BACKGROUND Recent observations suggest the presence of an interaction between leptin and the inflammatory system; however, there is no adequate knowledge about the role of leptin in atopic states such as asthma. OBJECTIVES To evaluate the potential role of leptin in relation to bronchial asthma and inhaled corticosteroid therapy. METHODS Twenty-three children with mild-to-moderate, newly diagnosed asthma enrolled in this 2-period trial. The control group consisted of 20 age- and sex-matched children. Serum leptin levels were measured in patients at initiation and after 4 weeks of budesonide treatment and were compared with control group measurements. RESULTS Asthmatic children had higher mean +/- SD serum leptin levels at admission (19.3 +/- 5.1 ng/mL) than after budesonide treatment (10.6 +/- 1.6 ng/mL) and vs control group measurements (9.8 +/- 1.6 ng/mL) (P < .001). There was a significant correlation between serum leptin levels before and after budesonide treatment (r = 0.68; P = .007). Mean +/- SD body mass indices in patients and controls were 16.7 +/- 2.1 and 16.9 +/- 2.6 kg/m2, respectively. Serum leptin levels did not correlate with body mass indices before budesonide treatment in the study group (r = -0.13; P = .65) but correlated well after budesonide treatment (r = 0.58; P = .009) and in the control group (r = 0.65; P = .008). CONCLUSIONS The role of leptin elevation in children with asthma might be a regulatory mechanism rather than being etiologic, but a question may be raised whether it is possible that leptin may contribute to poor patient outcomes. Further research, both basic and clinical, is essential to explain the exact mechanism.

Scorpion Sting Envenomation in Children in Southeast Turkey

Abstract Background.—Scorpion sting envenomation is a life-threatening emergency and a common public health problem in many regions of the world, particularly in children. Children are at greater risk of developing severe cardiac, respiratory, and neurological complications. Objectives.—The aims of this study were to evaluate demographic, clinical, laboratory, treatment, and outcome characteristics for pediatric patients with scorpion sting envenomation in southeast Turkey and to describe features that may be predictive of the need for pediatric intensive care unit (PICU) care. Methods.—A total of 52 charts of children (mean age: 7.7 ± 2.8 years; age range: 1.5–15 years) presenting with scorpion sting envenomation to a single hospital in southeastern Turkey were investigated. General characteristics of the children, species of the scorpions, anatomic site of the sting, clinical and laboratory findings, treatment approaches, complications, and outcomes were recorded. Results.—Twenty-four stings (46.2%) were inflicted by Androctonus crassicauda, 1 (1.9%) by Leiurus quinquestriatus, and the sources of the other stings were not known. Thirty-one patients (59.6%) were admitted from rural areas. Admission from a rural area was a significant risk factor for severe envenomation. Foot-leg was the most frequently stung part of the body (48%). The greatest number of stings occurred in the summer (78.8%). Cold extremities and tachycardia were the most frequently seen clinical findings (38.4% for both). Twenty patients (38.5%) had signs of serious envenomation and required admission to the PICU. Hemoglobin, white blood cell count, activated prothrombin time, aspartate aminotransferase, alanine aminotransferase, and creatine phosphokinase levels were higher in severely envenomed children compared to levels in those with mild-moderate stings. Antivenom was given at a primary or secondary health center before arrival to our hospital in 44 (84.6%) patients, without any apparent difference in the number of patients presenting with mild-moderate and severe envenomed stings. All patients recovered after treatment except for 1 child who died with severe pulmonary edema. Conclusions.—We found no clinically useful demographic or epidemiological data to guide decision making regarding the need for PICU admission for pediatric victims of scorpion sting in our area. Decisions on transfer and admission to a PICU should be based on the development of systemic findings of envenomation.

Oxidative stress, inflammation and early cardiovascular damage in children with chronic renal failure

The relationship between inflammation, oxidant stress and cardiovascular damage in children with chronic renal failure (CRF) has not previously been investigated. The aim of this study was to investigate markers of oxidative stress, inflammation and early cardiovascular abnormalities. Therefore, erythrocyte superoxide dismutase (SOD) and catalase (CAT) activities; blood glutathione (GSH) and serum malondialdehyde (MDA) levels; C-reactive protein (CRP) and proinflammatory cytokines (IL-6, TNF-α,); and left ventricular masses (LVM) and intima media thicknesses (IMT) were measured in children with CRF. A total of 29 children with CRF (19 nondialysis, 10 peritoneal dialysis) were included. The control group consisted of 25 healthy subjects. CRF children had significantly increased IL-6, TNF-α, CRP and MDA concentrations and decreased SOD, CAT and GSH levels compared with controls (P<0.05). Nondialysis and peritoneal dialysis subgroups had similar oxidative stress and inflammation biomarkers (P>0.05). Erythrocyte CAT was positively correlated with CRP, TNF-α, and IL2-R in the study group. Positive correlations were found between cytokine concentrations, CRP and urea/creatinine levels. Significantly increased LVM and IMT values were found in CRF children (P<0.05). In conclusion, increased oxidant stress and inflammation together with early cardiovascular damage were found in CRF children. Further studies with more patients are needed to verify these results.

Tuberculosis of the metacarpals and phalanges of the hand

Skeletal tuberculosis (TB) is less common than the pulmonary form. Involvements of the metacarpals and phalanges of the hand are infrequent. The authors report their experience with treatment and outcome of TB of the metacarpals and phalanges of the hand in 7 patients. There were 4 women and 3 men in the study who ranged in age from 3 to 60 years (average age, 22.7 years). The duration of complaints at presentation ranged from 4 to 17 months (average, 9 months). The most common presentation was pain and swelling. The presumptive preoperative diagnoses were bone tumor in 4 patients, spina ventosa in 2, and chronic pyogenic osteomyelitis in 1 patients. The results of the laboratory examination showed a mild increase in the erythrocyte sedimentation rate. No patient had an active tubercular lesion or history of pulmonary disease. The diagnosis was based on the clinical picture and radiographic features, and was confirmed by open biopsy. No patient had bony debridement or arthrodesis to control the infection. The treatment of all patients began with a 4-drug regimen for 2 months, followed by a 2-drug regimen for 10 months. The mean follow-up was 30.28 months (range, 16–52 months). At the time of the last follow-up, all lesions had healed with no recurrence. The functional results were satisfactory in all patients. One patient with thumb metacarpophalangeal TB had joint irregularity and thumb metacarpal shortening. Arthrodesis was not needed in any patient. TB of the metacarpals and phalanges of the hand can be difficult to diagnose during the early stages. TB should be suspected in cases of long-standing pain and swelling in the metacarpals and phalanges. It is necessary to keep TB in mind when making the differential diagnosis of several osseous pathologies.

Clinical review of tuberculous peritonitis in 39 patients in Diyarbakir, Turkey

Abstract  Abdominal tuberculosis (TB) is a rare manifestation, which can be overlooked on long‐lasting and non‐specific findings unless a high index of suspicion is maintained. The purpose of the present study was to investigate the diagnostic features of 39 patients hospitalized with tuberculous peritonitis (TBP) in Dicle University Hospital, Turkey between January 1994 and August 2003. Twenty‐two patients were male; patient age ranged between 1 and 59 years (mean: 16.2 ± 14.4 years). There were 21 patients (54%) under 15 years of age. Thirteen children had a history of familial TB and seven adults had prior history of TB. Six (29%) of 21 pediatric cases had bacille Calmette‐Guerin (BCG) scars and results of 5‐tuberculin units (TU) tuberculin test were positive in seven children (18%). Of all cases, the most common presenting findings were abdominal pain (95%), ascites (92%) and abdominal distention (82%). Five of the patients had accompanying pulmonary TB, and six patients (15%) had intestinal TB who were admitted to emergency service with acute abdomen, of whom three (8%) had perforation and three (8%) had ileus. Histopathologically 20 cases (51%) were proven on abdominal ultrasonography, and computed tomography revealed most commonly ascites and thickening of peritoneum. No microbiologic evidence was obtained except three positive culture results for Mycobacterium tuberculosis. As a result, TBP should be considered for diagnosis, in patients with non‐specific symptoms of abdominal pain, wasting, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen, because early diagnosis and effective treatment will decrease morbidity and mortality.

Fatal falls from heights in and around Diyarbakir, Turkey

Falls from high places, such as from a building, are frequently encountered in suicides, in some accidents, and sometimes in homicides. In this study, we evaluated the demographic data, mortality rates, fall causes, and post-mortem findings of individuals who fell from heights. Our cases were collected retrospectively from the files of the Branch of the Council of Forensic Medicine in Diyarbakir between 1996 and 2001. There were 431 accidental and 53 suicidal deaths due to blunt injury resulting from falls. Of the victims, 188 were female and 296 were male. The average age of the 484 victims was 27.05 years (range: 4 months-100 years). For buildings, the height ranged from 3 to 8 stories for suicides and from 1 to 8 stories for accidents. We proceeded to analyse the characteristics of accidental falls as follows. The majority of falls were from balconies or rooftops due to the tendency of people to sit and sleep on these places during the hotter months of the year. Some 54.5% of all falls occurred in May-August. The 53 suicidal jumps all occurred off buildings. The victims ranged in age from 15 to 70 years, and comprised 29 women and 24 men. One of the deceased jumped from the roof of a school in which he was boarding, and another from the seventh story of a hospital in which he was receiving treatment. The remaining 51 jumped from heights ranging from 3 to 8 stories. Psychiatric illness was reported in 18 (33.9%) of the suicide deaths, while 10 (18.8%) of the 53 suicides were single women. The results of this study were at variance with literature data with respect to the following: falls from heights were most common in the 0-5 year age group, females had a higher suicide rate than males, and the majority of accidental falls occurred at home rather than in the workplace.

Characteristics of pediatric urolithiasis in south‐east Anatolia

Abstract Background : Urolithiasis is endemic in Turkey and characteristics of urolithiasis vary in different regions of the world. The aim of the present study was to evaluate the etiological and clinical characteristics and course of pediatric urolithiasis in south‐east Turkey.

Suicide in children and adolescents at a province in Turkey.

Despite the well-documented increases in the rate of completed suicide among children, accurate knowledge of the characteristics of these suicides is limited. We examined all suicides by children and adolescents in Diyarbakir during 1999 and 2001. All of the cases were analyzed regarding the age, sex, method and location of suicide, time of year, and predictive factors. There were 56 children aged 11 through 19 years. Adolescents between 15 and 19 years of age constituted the overwhelming number (87%) of all the childhood suicides. Female children and adolescents predominated among the suicide victims (71%). The most frequent means of suicide were firearms (43%), hanging (28%), and jumping (16%), respectively. The majority of suicides occurred at the decedent’s home (88%). Reasons identified were mainly psychiatric disorders, followed by troubles within the family. A prior suicide attempt or a note that was left by the decedent and elucidated the reason for the suicide was rare. There was no seasonal difference in rates of suicides.