Hikmet Tekin Nacaroglu

Side Effects of Leukotriene Receptor Antagonists in Asthmatic Children

Background: Leukotriene receptor antagonists (LTRAs) are drugs which have been widely used more than ten years. As the use of LTRAs increases, our knowledge with respect to their side effects increases as well. Objectives: The objective of our study was to evaluat the observed side effects of LTRAs used in patients with astma. Patients and Methods: 1024 patients treated only with LTRAs owing to asthma or early wheezing were included in the study for a five-year period. The observed side effects of LTRAs in these patients were retrospectively investigated. The side effects were divided into two parts as psychiatric and non-psychiatric. Results: Among the 1024 cases included in the study, 67.5% of the patients out of 41 with side effects were male, 32.5% were female and the average age was 6.5 years. The rate of patients with asthma was 63.41% and 36.58% of the patients had early wheezing. It was determined that sex, age and diagnosis (early wheezing or asthma) of the patients were ineffective in the emergence of side effects. The average period for the emergence of side effects was the first month. It was observed that hyperactivity was the most frequently observed psychiatric side effect and that abdominal pain was the non-psychiatric side effect. Conclusions: The side effects of LTRAs were common in children. Therefore, patients must be informed at the beginning of the treatment and they must be evaluated at certain intervals.

The association between urinary tract infection and idiopathic hypercalciuria in children.

Background: Identifying the risk factors is important in prevention of urinary tract infections (UTIs) in children. The aim of this study is to evaluate the association of UTI and idiopathic hypercalciuria (IHC). Methods: Two hundred and twenty-four children aged between 1 month and 16 years and diagnosed to have UTI were evaluated for urinary calcium excretion. The children were diagnosed to have IHC if their urinary calcium/creatinine ratios in at least two different spot urine samples were >0.6 between 0–1 year old and ≥0.21 over 1 year or daily calcium excretion >4 mg/kg. Results: The frequency of IHC was found to be 16.7%. Family history of urolithiasis, parental consanguinity, presentation with abdominal pain, loss of appetite, and discomfort were found to be significantly higher in the IHC group. No association was found between IHC and the recurrence of UTI, presence of vesicoureteral reflux, renal scar formation, and the prognosis. Conclusions: IHC should be considered among the risk factors for UTI and should be investigated particularly in patients with family history of urinary stones and suggestive complaints of IHC.

Tolerance development in food protein-induced allergic proctocolitis: single centre experience

BACKGROUND Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer.

Can neutrophil/lymphocyte ratio be a novel biomarker of inflammation in children with asthma?

Neutrophils are known to play a role in airway inflammation and are activated in inflammatory lung diseases such as asthma. In adult studies the neutrophil/lymphocyte ratio (NLR) was found to be a possible biomarker for both airway and systemic inflammation. However, there is a limited understanding regarding NLR in the pediatric age group. To assess NLR as a biomarker for inflammation in pediatric asthma, 54 children admitted to hospital with exacerbation of asthma between March and October 2013 were enrolled into our study. Complete blood counts were obtained during both exacerbation and an asymptomatic period covering at least 3 months after exacerbation. NLRs of the study group during both exacerbation and the asymptomatic period were compared and these two datasets were then compared with the control group. The study group comprised 27 boys (50%) and 27 girls (50%) with a mean age of 120 ± 36 months. Of the total number of patients, 3.7% had mild, 94.4% had moderate, and 1.9% had severe exacerbation of asthma. The NLRs of the study group were found to be significantly higher during exacerbation compared with both the asymptomatic period and the control group (P = 0.017, P = 0.003). Our study suggests that NLR may be effective and usable measurable biomarker for determining inflammation in cases of pediatric asthma during acute exacerbation period. However, a broad analysis of dependent and independent variables in further prospective studies, is still required. Trial registration: Not applicable.

Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo.

Eosinophilic cellulitis (Wells’ syndrome) is an uncommon condition of unknown etiology. Wells’ syndrome is usually seen in adulthood but very rare in childhood. Although pathogenesis of the disease is not very clear, it is a hypersensitivity reaction developing against a variety of exogenous and endogenous antigenic stimuli. Paraphenylenediamine is a strong allergen frequently used as a temporary henna tattoo, which makes the color darker. Here, a 9-year-old male patient with Wells’ syndrome is presented, which developed following a temporary henna tattoo and shown by the patch test sensitivity to paraphenylenediamine.

Association of Osteoprotegerin with Obesity, Insulin Resistance and Non-Alcoholic Fatty Liver Disease in Children

Background Osteoprotegerin (OPG) is a member of the tumor necrosis factor superfamily. Reduced OPG levels are related to obesity, insulin resistance, and non-alcoholic fatty liver disease (NAFLD). Objectives The aim of this study was to evaluate the relationship between OPG levels, obesity, insulin resistance, and NAFLD in pediatric patients. Methods This was a prospective, cross-sectional, controlled study that was conducted in the department of pediatrics at Bagcilar training and research hospital in Istanbul, Turkey, between April and August 2015. The study was performed on 107 children with obesity and 37 controls aged 5 - 17 years. In the obese subset, 62 patients had NAFLD. Homeostatic model assessment-insulin resistance (HOMA-IR) was used to calculate insulin resistance. Insulin resistance was defined as a HOMA-IR value greater than 2.5. Plasma OPG levels were measured using enzyme-linked immunosorbent assays. NAFLD was diagnosed by hepatic ultrasound. Results The mean age was 11.25 ± 3.38 years in the patient group and 10.41 ± 3.15 years in the control group. The OPG level in the obese group with the mean of 55.20 ± 24.55 pg/mL (median = 48.81 pg/mL) was significantly lower than that in the control group with the mean of 70.78 ± 33.41 pg/mL (median = 64.57 pg/mL) (P = 0.0001). The optimal cut-off point (sensitivity, specificity) of the OPG level for the diagnosis of obesity was ≤ 46, 19 pg/mL. According to logistic regression analysis, fasting insulin (P = 0.036) and OPG (P = 0.01) levels were most affected by obesity. In the obese patients, who had HOMA-IR < 2.5, the mean level of OPG was 58.91 ± 6.88729 pg/mL (median = 49.55). In the obese patients, who had HOMA-IR ≥ 2.5, the mean level of OPG was 54.19 ± 22.21 pg/mL (median = 48.47). No significant correlations were found between OPG and HOMA-IR (P = 0.791). No statistically significant difference was observed in the mean OPG between patients with hepatosteatosis (mean = 54.55 ± 25.01 pg/mL) (median = 49.46) and those without the disease (56.30 ± 24.02 pg/mL) (mean = 48.34) (P = 0.089). Conclusions We confirmed that serum OPG concentrations reduce in obese children. However, no correlation was identified between OPG and insulin resistance. OPG levels are not meaningful in the diagnosis of NAFLD in children with obesity.

DRESS syndrome associated with type 2 diabetes in a child

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an uncommon, life-threatening drug reaction. The basic findings are skin rash, multiorgan involvement, and eosinophilia. Most of the aromatic anticonvulsants, such as phenytoin, phenobarbital and carbamazepine can induce DRESS. Herein we report a 14-year-old patient with DRESS syndrome related to carbamazepine use. The patient presented with signs of involvement of the skin, lungs, liver, and microscopic hematuria. Carbamazepine treatment was discontinued; antihistamines and steroids were started. Hyperglycemia, commencing on the first dose of the steroid given, persisted even after the discontinuation of steroids and improvement of other signs. There were no signs of pancreatitis or type 1 diabetes clinically in laboratory tests. Her blood glucose levels were regulated at first with insulin and later with metformin. Within 1 year of follow-up, still regulated with oral antidiabetics, she has been diagnosed with type 2 diabetes. Formerly, long-term sequelae related to “drug rash with eosinophilia and systemic symptoms syndrome” such as hepatic and renal failure, type 1 diabetes mellitus, Graves disease, autoimmune hemolytic anemia, and lupus have also been reported. However, up to date, no cases with type 2 diabetes have been reported as long-term sequelae. To our knowledge, this is the first case in the literature presenting with type 2 diabetes as long-term sequelae.

Acute generalized exanthematous pustulosis induced by ceftriaxone use

Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous rash characterized by the abrupt onset of a generalized pustular rash often accompanied by fever. There is a history of drug use in 90% of the cases. Here we have reported a 15-year-old male patient with sickle cell anemia who developed AGEP after the use of ceftriaxone. Our patient was hospitalized because of vaso-occlusive crisis and on the third day of ceftriaxone treatment, erythematous pustular lesions accompanied with fever were observed on the body and extremities. Resolution of symptoms followed discontinuation of ceftriaxone. Sensitivity to ceftriaxone was shown with a patch test. The AGEP was considered due to clinical and histopathological findings. This is the first pediatric case of AGEP due to ceftriaxone.

Diagnostic values for egg white specific IgE levels with the skin prick test in Turkish children with egg white allergy

BACKGROUND The diagnostic values for the skin prick test (SPT) diameters and egg white-specific IgE (EW-sIgE) levels that will allow us to predict the result of the oral food challenge test (OFC) in the diagnosis of egg white allergy vary by the community where the study is carried out. OBJECTIVE This study aimed to determine the diagnostic values of SPT and EW-sIgE levels in the diagnosis of egg white allergy. METHODS 59 patients followed with the diagnosis of egg allergy September 2013 to September 2015 were included in our retrospective cross-sectional study. The patients were investigated in terms of egg and anaphylaxis history or the requirement of the OFC positivity. The demographic, clinical and laboratory findings of the cases were recorded, and they were compared with the patients with the suspected egg allergy but negative OFC (n=47). RESULTS In the study, for all age groups, the value of 5mm in SPT was found to be significant at 96.4% positive predictive value (PPV) and 97.8% specificity and the value of 5.27kU/L for EW-sIgE was found to be significant at 76% PPV and 86.6% specificity for egg white. The diagnostic power of the SPT for egg white (AUC: 72.2%) was determined to be significantly higher compared to the diagnostic power of the EW-sIgE (AUC: 52.3%) (p<0.05). CONCLUSION Along with the determination of the diagnostic values of communities, the rapid and accurate diagnosis of the children with a food allergy will be ensured, and the patient follow-up will be made easier.

Increased mean platelet volume in children with sepsis as a predictor of mortality

Our aim is to investigate the correlation between the mean platelet volume (MPV) levels and platelet counts of the septic children with 28-day mortality risk. MPV at admission (MPV < sub > adm < /sub > ), MPV at 72 < sup > nd < /sup > hour (MPV < sub > 72h < /sub > ) and the difference between these two parameters (ΔMPV < sub > 72h-adm < /sub > ) and platelet counts were recorded retrospectively. The control group consisted of 100 healthy children matched for age, gender, and ethnicity. One hundred eighty six children were enrolled into the study. The study group had significant higher MPV values than those of control group. There were 156 survivors and 32 nonsurvivors in study group with a mortality rate of 17%. Nonsurvivors had significantly higher MPV < sub > adm < /sub > (p: 0.001), MPV < sub > 72h < /sub > (p: 0.001), ΔMPV < sub > 72h-adm < /sub > (p < 0.001) and lower platelet count (p: 0.002) than survivors. MPVadm (OR 2.39), MPV < sub > 72h < /sub > (OR 4.23), ΔMPV < sub > 72h-adm < /sub > (OR 6.4), platelet count (OR 7.3), and need for mechanical ventilation support (OR 9.76) had significant effect on 28-day mortality risk at logistic regression analysis. At the receiver operating characteristic analysis (ROC) the cutoff values for MPV < sub > adm < /sub > , MPV < sub > 72h < /sub > , and ΔMPV < sub > 72h-adm < /sub > were found to be 9 fL, 9.86 fL, and 0.79, respectively. Kaplan-Meier analysis and log-rank test proved that these cutoff values were significantly associated with the time of survival. Septic children who had high MPV levels at admission and whose MPV levels increased during follow up had higher risk of mortality. With the results of further researches targetting large groups of pediatric patients, MPV < sub > adm < /sub > , MPV < sub > 72h < /sub > , and ΔMPV < sub > 72h-adm < /sub > values can be fast and reliable markers for early diagnosis of sepsis and mortality prediction.