Georgios Vaos

The Effects of Apigenin on the Expression of Fas/FasL Apoptotic Pathway in Warm Liver Ischemia-Reperfusion Injury in Rats

Background. The aim of this experimental study was to investigate the role of apigenin in liver apoptosis, in an experimental model of hepatic ischemia-reperfusion in rats. Materials and Methods. Forty-eight Wistar rats (apigenin and control groups), 14 to 16 weeks old and weighing 220 to 350 g, were used. They were all subjected to hepatic ischemia by occlusion of the hepatic artery and portal vein for 45 minutes and reperfusion was followed for 60, 120, and 240 minutes. Apigenin was administrated intraperitoneally. Liver tissues were used for the detection of apoptosis by TUNEL assay and caspase 3 antibodies. Expression analysis of Fas/FasL genes was evaluated by real time PCR. Results. The expression analysis of Fas and FasL genes was increasing during reperfusion (significantly in the group of 240 minutes of reperfusion). It was in the same group that apigenin decreased Fas receptor levels and inhibited apoptosis as confirmed by TUNEL assay and caspase 3 antibodies. Conclusions. The effects of apigenin in the Fas/FasL mediated pathway of apoptosis, in the hepatic ischemia-reperfusion, seem to have a protective result on the hepatic cell.

Serum profiles of M30, M65 and interleukin-17 compared with C-reactive protein in patients with mild and severe acute pancreatitis

Several studies state that a test of severity early in the course of acute pancreatitis is still needed. In this prospective study, an assay of the biomarkers M30 and M65 as well as of interleukin 17 (IL‐17) is investigated.

Technetium-99m scan in the laparoscopic management of a misdiagnosed Meckel's diverticulum: a case report

IntroductionAlthough Meckels diverticulum is the most common congenital abnormality of the gastrointestinal tract and modern imaging techniques are available, its diagnosis remains problematic.Case presentationA technetium-99 scan was performed in an 18-year-old man with abdominal pain, vomiting and rectal bleeding to confirm the presence of a Meckels diverticulum which was not diagnosed laparoscopically elsewhere. The technetium-99 scan was positive and a diagnostic laparoscopy was re-performed which revealed a Meckels diverticulum that was subsequently resected.ConclusionWe suggest that a technetium-99m scan should be performed before laparoscopy in children and adolescents with suspected Meckels diverticulum. A positive technetium-99m scan may significantly contribute to the laparoscopic definitive diagnosis and treatment of a bleeding Meckels diverticulum. However, diagnostic laparoscopy should only be performed by experienced surgeons.

Neonatal scrotal discoloration and swelling (Case Presentation)

The Discussion and Diagnosis can be found on page 888 CASE PRESENTATION A 3300-g male was born after a 37-week gestation to a 33year-old mother after an uneventful pregnancy. A difficult vaginal delivery with cephalic presentation was carried out with instrumental assistance. Apgar scores were 5 and 8 at 1 and 5 min, respectively. Administration of oxygen was required after birth. Forty-eight hours after birth, the newborn developed mild, nonpersistent temperature ranging from 37.2 to 37.8 C and he was noted to have a painless right hemiscrotal swelling associated with scrotal discoloration. Erythrocyte sedimentation rate (5 mm), C-reactive protein (0.45 mg ⁄dL) and procalcitonin (0.5 ng ⁄mL) were within normal limits and there were no clinical signs of sepsis. He was otherwise a well-fed child without jaundice nor episodes of vomiting. A scrotal ultrasound was performed for further investigation, which revealed normal size, echogenicity and blood flow of both testicles and a significantly oedematous scrotum with thickened subcutaneous tissue. A right hydrocele was noted with internal echoes raising the possibility of a haematoma. An abdominal ultrasound was performed (Fig. 1). The patient’s haematological and biochemical examinations were within normal limits: WBC: 12,900 K ⁄lL (Neut 62.5%, Lymph 16.4%, Eos 6.6%), Ht: 33.4%, Hb: 12.1 g ⁄dL, PLT: 272 K ⁄lL, Cre: 1 mg ⁄dL, K: 4.5 mmol ⁄L, Na: 136 mmol ⁄L, total Bil: 11.3 mg ⁄dL, SGOT: 151 U ⁄L and SGPT: 32 U ⁄L. His blood pressure was normal and laboratory tests for urinary catecholamines (homovanillic acid and vanillylmandelic acid) were also within normal limits.

Neonatal scrotal discoloration and swelling (Discussion and Diagnosis)

The Case Presentation can be found page 799 DISCUSSION AND DIAGNOSIS Abdominal ultrasound revealed a rather well-defined heterogeneous, space-occupying lesion in the anatomic region of the right adrenal. This lesion retained the triangular shape of the adrenal exhibiting intermingled anechoic, hypoechoic and hyperechoic areas surrounded by a hypoechoic halo (Fig. 1). No blood flow was detected within the lesion, and normal parenchyma of the right adrenal was not seen. Left adrenal, kidneys, liver and pancreas were within normal limits. Adrenal haemorrhage and extension to the scrotum via the retroperitoneal space were considered as the most probable diagnosis, and the possibilities of abscess and tumour were considered less likely. An abdominal MRI was performed to exclude possible underlying pathology of the right adrenal. MRI revealed a heterogeneous lesion retaining the triangular shape of the adrenal gland, with predominantly high signal intensity on T1-weighted images and significant blooming artefact in gradient-echo images confirming the diagnosis of adrenal haemorrhage (Fig. 2). Extension of haemorrhage along the retroperitoneal space was noticed. No underlying mass was seen. The patient was managed conservatively and was discharged after 1 week. Monitoring of the adrenal hematoma with ultrasonography revealed a gradual decrease in size with the residual hematoma measuring only 0.66 · 0.67 cm in size on the 6-week follow-up US examination. Scrotal hematoma as a consequence of adrenal haemorrhage has been very scarcely described in the literature and – to the best of our knowledge – this is the first report of this rare association documented by both ultrasound and MRI evaluation. In cases of abundant adrenal haemorrhage – where the blood cannot be contained into an intact adrenal capsule – it may dissect along the retroperitoneum into the scrotum through an open processus vaginalis. The latter is reported to be open in 90% of neonates (1). Clinical manifestations include discoloration of the scrotum and ⁄ or inguinal and perineal areas, scrotal hematoma and painful or painless acute swelling of the hemiscrotum and groin (2). Differential diagnosis of scrotal discoloration and swelling includes traumatic hematoma, hydrocele, torsion of the testes, orchitis, scrotal or testicular oedema, inguinal hernia, meconium peritonitis, hematocele and testicular tumour (1,3). US of the scrotum could assist clinical differential diagnosis; it readily shows scrotal effusions and confirms the viability and vascularity of the testicles excluding the possibility of testicular torsion (1). Neonatal adrenal haemorrhage is an uncommon entity with a reported incidence of 0.05–1.4% (1). It is assumed that the adrenal gland of the neonate is vulnerable to vascular damage and haemorrhage because of its relatively large size (4). It usually occurs at the right adrenal – as in our case – probably due to the direct drainage of the right adrenal vein to the inferior vena cava, while in 10% of the cases, it occurs bilaterally (4). Predisposing factors are difficult delivery, preterm gestation, increased birth weight, perinatal hypoxia, asphyxia and renal vein thrombosis (5). Clinical manifestations may vary from completely asymptomatic to rarely severe intraabdominal life-threatening haemorrhage. Acta Pædiatrica ISSN 0803–5253

Acute abdomen: always a puzzle (Discussion and Diagnosis)

childhood, so there may be an overlap between these two disorders. Legrain and colleagues (8) reviewed 10 cases of AHEI. They concluded that although the majority of the cases presented with cockade-patterned lesions and oedema of the limbs and face, there were also cases in which extracutaneous symptoms were present with joint and abdominal pain. Recently, Obeid and colleagues (9) published a case of AHEI in which there was visceral involvement. Therefore, AHEI and HSP should be considered as separate disorders with their own distinctive features, which are part of the same spectrum of immune-mediated vasculitis (8–10). Although a skin biopsy is not really necessary for the diagnosis, the biopsy obtained in this case showed a leucocytoclastic vasculitis. The direct immunofluorescence lacked IgA, IgG, IgM and C3 deposition. AHEI is selflimiting and a complete resolution can be expected in 1–3 weeks. As expected, on follow up, the patient had recovered completely (11). In conclusion, knowledge of the classical clinical presentation of this relatively unknown form of leucocytoclastic vasculitis will not only assist in making the right diagnosis, but will also prevent unnecessary concern and extensive investigations.

Acute abdomen: always a puzzle (Case presentation).

The Discussion and Diagnosis can be found on page 1538. CASE A 13-year-old boy presented at the emergency casualty department of our hospital with acute abdominal pain and vomiting. During the previous 3 days, he had suffered mild diffuse abdominal pain, low-grade fever (37.5 C) and two episodes of diarrhoea. The child’s past history included hypospadias repair at the age of 2 years and mild asthma that had not troubled him for the last previous several years. The boy had a younger sibling who was fit and healthy. His father had several health problems, including end-stage chronic renal failure and angina, for which he had undergone a cardiac by-pass 3 years previously. His mother suffered from thrombotic thrombopenic purpura and diabetes mellitus. Physical examination revealed tenderness at the right-lower quadrant of the abdomen and a positive rebound sign. His temperature was 37.4 C. Laboratory investigations revealed normal biochemistry and urinalysis as well as the following parameters results: WBC 14,220 K ⁄ lL (neutrophils 82% and lymphocytes 17%), Ht 39.5%, Hb 13.9 g ⁄ dL, platelet count 237,000 K ⁄ lL, CRP 3.1 mg ⁄ dL and ESR 25 mm ⁄ h. An abdominal X-ray revealed distended loops of bowel with air–liquid levels in the right abdomen. An ultrasound (US) examination of the abdomen revealed free peritoneal fluid, particularly in the right-lower quadrant. The appendix was not identified, probably because of the presence of enteric gaseous distension. A mild dilatation of the right renal pelvis was found. These clinical and radiological findings were suggestive of acute appendicitis. A hyperaemic appendicitis, oedematous and inflamed terminal ileum, serous ascetic fluid (200 mL) and a Meckel’s diverticulum were found during the operation. An appendicectomy was performed and Meckel’s resection was avoided because of the child’s age and the inflamed adjacent bowel. The post-operative course was uneventful and the child was discharged on the fourth post-operative day in good health. The patient was followed closely because the histological findings following surgery were negative for acute appendicitis, the ascetic fluid was exudate and its culture and cytological examination were negative. These latter findings presented a puzzle as to the underlying cause of this patient’s initial presenting symptoms. At 15-day follow-up, the child complained of diffuse abdominal pain. A subsequent US examination revealed ascetic fluid in the peritoneal cavity. The child was admitted to the paediatric department for further investigation. The diagnostic issue of this child with a negative history was recurrent abdominal pain with exudative ascites. Vaos et al. Acute abdomen

Case 2: Painful red plagues in a 6-year-old child (Discussion and Diagnosis)

DISCUSSION Histology in this case revealed a malignant Ewing’s sarcoma with rhabdoid signs. A computed tomography (CT) scan of the thorax showed multiple pulmonary metastases. Curative treatment was not possible and the child died at the age of 1 year. The most common cause of an extracranial tumour in infants is cephalic haematoma, whereas in older children, dermoid cysts are most frequently found. Both are benign lesions. Less common diagnoses are also mostly benign (1). Therefore, a screening US may be sufficient in most cases. However, a small risk of malignancy always has to be taken into consideration, especially when the tumour continues to grow and certainly when there are neurological signs that indicate intracranial extension or pressure. Parents’ as well as doctors’ delay in the diagnosis of a malignant tumour is a well-known caveat, especially in slowly growing tumours (2). Even when a lesion appears to be benign at first, it is wise to remain vigilant and to instruct the parents to report continuous growth, combined with close clinical follow-up. Repeated radiological examinations may then reveal signs of malignant growth, such as an irregular aspect of the tabula externa and blood flow within the tumour, and enable timely treatment. Malignant extracranial tumours in children may be osteosarcoma, small round cell tumours, such as neuroblastoma, cutaneous malignant lymphoma or Ewing’s sarcoma, but also extracranial localization of a primary brain tumour. Ewing’s sarcoma, as was found here, may present with localized swelling, but rarely in the head or neck (<10%). Constitutional signs are present in only 10%–20%. Subclinical metastatic disease, mainly in the lungs and bones, is presumed to be present in nearly all cases (3,4). The proper use of available imaging tools is important for the management of a child with an extracranial tumour. The reliable, noninvasive nature and high resolution of US make it an excellent initial investigation for a wide range of clinical referrals (5). Accordingly, US has been recommended as the appropriate investigation whenever possible. However, extension of the lesion and involvement of underlying structures cannot always be fully excluded (6). Plain skull radiography is useful to rule out osseous involvement and is also relatively easy to perform. Growth of the tumour, osseous involvement, visible blood flow by power Doppler US or irregular borders of the lesion are reasons to suspect malignancy. In these cases, CT or MRI is indicated. Both CT and MRI are able to demonstrate intracranial extension. CT is the method of choice to show osseous involvement. MRI gives more information about intracranial lesions and, therefore, helps to predict the histological diagnosis (6,7). But, as mentioned before, vigilance remains important, and a histological diagnosis should always be pursued when in doubt. Here, we discuss a regrettable misdiagnosis in an infant who initially presented with ‘only’ a small lump on the head. The tumour was interpreted to be benign. Ultimately, however, histology showed a very malignant tumour, by then with multiple metastases. The importance of remaining alert to changing symptoms is underlined by the course in this patient. Parents should be very well instructed when to return to a physician, who should then reconsider the initial diagnosis, leading to further radiological examinations. When there is any doubt about the nature of a lesion, histological diagnosis should be obtained.

Case 2: Painful red plagues in a 6‐year‐old child (Case Presentation)

CASE PRESENTATION At the age of 8 months, a boy was referred to our paediatric clinic presenting with a large extracranial protuberance. At 1 month of age, his parents had first discovered a small lump on his head. Three months later, they visited their general practitioner since the lump was slowly growing. After referral to a surgeon, ultrasound (US) was performed at the age of 5 months. This showed a hypoechogenic subcutaneous structure of 2 × 0.5 cm with small internal reflections and distinct margins (Fig. 1). No blood flow could be detected with power Doppler US, rendering a haemangioma unlikely. The tabula externa was intact, but minimally depressed. A dermoid cyst was suspected and the surgeon advised the parents to postpone surgical removal until the age of 1 year. At the age of 6 months, a second small protuberance alongside the first became visible. Both showed continuous growth and eventually fused.