Gokhan Kalkan

Does age affect presenting symptoms in children with carbon monoxide poisoning

Objective Previous studies have reported on a link between carboxyhemoglobin (COHb) levels and the severity of presenting findings. However, studies on pediatric populations evaluating the effect of age on presenting symptoms are severely lacking. The aim of this study was to investigate the presence of any link between age and presenting symptoms in children with carbon monoxide (CO) poisoning. Methods This retrospective study was undertaken in Ankara Children’s Hematology and Oncology Hospital, a tertiary care center, between January 2007 and March 2010. The medical records of patients aged between 0 and 16 years with a confirmed diagnosis of CO poisoning, defined as the presence of a COHb level of more than 5%, were evaluated. Relevant information such as age, sex, source of CO, coaffected family members, month of presentation, time of presentation and presenting symptoms, duration of oxygen treatment in the emergency department, need for admission to an inpatient ward or intensive care unit, Glasgow Coma Scale scores, and administered treatments during follow-up was recorded for each patient on preprepared forms. For the purpose of comparison, patients were divided into 2 groups based on COHb levels (group 1, 5%–25%; group 2, >25%). Comparisons were also made after dividing patients into 3 age groups: infants (0–3 years), preschool and early-school children (4–8 years), and adolescents (9–16 years). Results The records of 261 patients were deemed sufficient for inclusion in the final analysis, 149 (57.1%) of which were female, and 112 (42.9%) were male, with a median age of 7.0 years (range, 1 month to 16 years) and a mean COHb level 16.9% (SD, 7.8%). Two hundred eighteen patients (83.5%) had a COHb between 5% and 25% on presentation, whereas the remaining 43 patients (16.5%) had a presenting COHb of greater than 25%. Neurologic symptoms such as headache, syncope, seizures, and confusion were encountered more frequently in the COHb greater than 25% group compared with the group with 5% to 25% COHb levels, with adolescents having more severe symptoms than do younger patients. Conclusions In this study, we managed to demonstrate the presence of more severe symptoms in patients with a COHb level of 25% or greater. Further analysis revealed that severe symptoms were more pronounced in adolescents and that the severity of symptoms increased with age.

Hydrogen peroxide solution ingestion caused brain death of a 3-year-old girl

Hydrogen peroxide solutions are often used in daily life as a household disinfectant and in cosmetic products and are therefore a common source of intentional poisonings, especially for children. When ingested in small amounts, it may cause severe central nervous system damage as a result of arterial emboli like our case. The benefit of hyperbaric oxygen treatment in this situation is known, but the neurologic deficits of our case did not improve with this method and finally brain death occurred. This is may be related by the timing of treatment after the event. We would like to emphasize that every clinician must be aware of the dangers of hydrogen peroxide ingestion and hyperbaric oxygen treatment may be of benefit if it is performed immediately.

Alteration of thiol-disulphide homeostasis in acute tonsillopharyngitis.

Objective: Thiol-disulphide homeostasis (TDH) has a critical role in various clinical disorders. We aimed to assess the association of TDH with acute tonsillopharyngitis (AT) in children. Methods: This study included 94 (73 viral and 21 bacterial) tonsillopharyngitis patients and 88 control children. Their native thiol, total thiol, and disulphide levels were measured. Results: Viral and bacterial tonsillopharyngitis patients had lower native thiol levels compared with healthy children (P < 0.001 and P = 0.008, respectively). Both groups had lower total thiol levels compared with control children (P = 0.002 for viral, P = 0.011 for bacterial). The disulphide levels were lower in bacterial than in viral tonsillopharyngitis patients (P = 0.04), and there was a significant difference between viral tonsillopharyngitis patients and the control group (P < 0.001). The native/total thiol ratio in each patient group was lower than in the control group (P < 0.001 for viral, P = 0.017 for bacterial). The disulphide/native thiol and disulphide/total thiol ratios were significantly higher in viral (P < 0.001 for both) and bacterial tonsillopharyngitis patients (P = 0.017 for both) than in healthy children. In all patients, a correlation was found between the levels of C-reactive protein (CRP) and native thiol (r = −0.211, P = 0.04), CRP and total thiol (r = −0.217, P = 0.036), white blood cell (WBC) and native thiol (r = −0.228, P = 0.002), WBC and total thiol (r = −0.191, P = 0.01), and WBC and disulphide (r = 0.160, P = 0.03). Discussion: TDH is altered in AT in children. The alteration is more prominent in viral than in bacterial tonsillopharyngitis.

Mercury poisoning: a diagnostic challenge

Clinical features of mercury poisoning are nonspecific, and a detailed history is very valuable. The silvery, shiny appearance of mercury makes it very exciting and attractive for children. The overall half-life of elemental mercury in the body averages approximately 2 months. Chelation therapy with dimercaptosuccinic acid is the treatment of choice if the urine or blood level of mercury is high or the symptoms are profound. Here, we describe a 14-year-old boy with fever, respiratory distress, and body rash. Investigation leading to a diagnosis of mercury poisoning was made only after his mother presented with the similar symptoms a few days later.

An adolescent boy with acute kidney injury and fever: Questions

A 17-year-old and otherwise healthy adolescent boy was admitted to our hospital with complaints of nausea, vomiting, headache, and fever lasting for 5 days. His first complaints started 1 week prior to admission when he began to suffer from generalized myalgia and abdominal and back pain. He lived in a rural area. His past and family histories were unremarkable. On presentation, he looked acutely ill, and physical examination revealed conjunctival hemorrhage, pharyngeal injection together with facial flushing, diffuse abdominal tenderness, and excoriee lesions on his feet and soles. His heart rate was 112/min, blood pressure 80/60 mmHg, respiratory rate 32/min, and temperature was 39 °C. Initial laboratory values were as follows: hemoglobin 12 g/dl, white blood cell count 9,000/ mm, platelets 10,000/ mm, C-reactive protein 233 mg/L, erythrocyte sedimentation rate 63 mm/h, serum creatinine (sCr) level 4.6 mg/dl, and blood urea nitrogen (BUN) 88 mg/dl. There was no hemolysis on blood smear examination. Prothrombin, partial thromboplastin time, and fibrinogen levels were normal. Aspartate aminotransferase (71 U/L), alanine aminotransferase (66 U/L), and lactic acid dehydrogenase (466 U/L) were elevated. Urinalysis showed microscopic hematuria, pyuria, hyposthenuria, and mild proteinuria. The initial chest radiograph was normal. There was increased echogenicity in the parenchyma of both kidneys on renal ultrasonography. In the follow-up his fever subsided and then he developed epistaxis and petechiae on his soft palate and entire body, as well as hypotension (65/40 mmHg), bradycardia, and clinical shock. Urine output decreased to <0.5 ml/kg per hour. Leukocytosis with a left shift (27,000/mm, 90 % neutrophil), hypoalbuminemia (2.5 g/dl), striking elevations in BUN/sCr levels (108/6.6 mg/dl), electrolyte imbalance, and metabolic acidosis developed. He was treated with supportive care (fluid and inotropic agents) and continuous venovenous hemofiltration with dialysis. On the 5th day of admission to the pediatric intensive care unit (PICU), his general condition was good, blood pressure returned to normal, urine output increased to 5 ml/kg per hour, sCr improved to 0.6 mg/dl, and platelet count increased to 358,000/mm. The patient was discharged from PICU after 8 days.

An adolescent boy with acute kidney injury and fever: Answers

1. Hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, systemic inflammatory response syndrome, leptospirosis, Crimean Congo hemorrhagic fever, and hemorrhagic fever with renal syndrome should be considered for the differential diagnosis. 2. Hemorrhagic fever with renal syndrome. hantavirus immunoglobulin (Ig)M and IgG antibodies were positivewith the titer of ≥1:100 using an indirect immunofluorescence test (Hantavirus Mosaic-1, Euroimmun, Germany), and results were confirmed by immunoblot test (Hantavirus Profile 1 EUROLINE IgG and IgM, Euroimmun, Germany). In this case, a 17-year-old adolescent boy was admitted to our hospital with fever, nausea, vomiting, headache, abdominal pain, and generalized myalgia. His clinical course progressed through clinical shock with hypotension, followed by oliguric, polyuric, and recovery phases. In the patient’s laboratory examination, we observed thrombocytopenia, a left shift in leukocyte differential count, elevated levels of hepatic transaminases and lactate dehydrogenase, hypoalbuminemia, microscopic hematuria, pyuria, hyposthenuria, and mild proteinuria. He was living in a rural and endemic area for hantavirus infection, and when we repeated the history regarding possible rodent exposure, his family stated that he walked barefoot in the forested area infested with rodent feces and he had excoriee lesions on his feet and soles. These findings led us to the consideration of hemorrhagic fever with renal syndrome, and on the 6th day of hospitalization, hantavirus infection was proven serologically. Due to the presence of fever, thrombocytopenia, and renal failure without laboratory findings of any bacterial or viral infection, in the differential diagnosis, we also considered leptospirosis and Crimean Congo hemorrhagic fever, which are both endemic in our country. The results of serological and reverse transcriptase real-time polymerase chain reaction (PCR) tests were negative for both infections.

Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey

Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children.