Hwa Jin Cho

Clinical significance of pleural effusion in the new influenza A (H1N1) viral pneumonia in children and adolescent

Parapneumonic effusion has been reported to develop either in typical bacterial infection or in viral pneumonia with bacterial co‐infection and to cause death. Swine‐origin influenza A (H1N1) virus infection can be accompanied with pleural effusion; however, there are no reports about the significance of pleural effusion in H1N1 pneumonia. We retrospectively analyzed both the clinical characteristics and the significance of pleural effusion associated with H1N1 pneumonia in children and adolescent.

Mosaic Ring Chromosome 6 in an Infant with Significant Patent Ductus Arteriosus and Multiple Congenital Anomalies

The clinical features of ring chromosome 6 include central nervous system anomalies, growth retardation, facial dysmorphism and other congenital anomalies. Ring chromosome 6 occurs rarely and manifests as various phenotypes. We report the case of mosaic ring chromosome 6 by conventional karyotyping in a 7-day-old male infant diagnosed with a large patent ductus arteriosus (PDA) with hypoplasia of aortic valve and aortic arch. These have not been previously reported with ring chromosome 6. He recovered from heart failure symptoms after ligation of the PDA. He showed infantile failure to thrive and delayed milestone in a follow-up evaluation. To the best of our knowledge, this is the first report of a Korean individual with ring chromosome 6 and hemodynamically significant PDA.

Anticoagulation Therapy during Extracorporeal Membrane Oxygenator Support in Pediatric Patients

Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for critically ill patients. Although ECMO is becoming more common, hemorrhagic and thromboembolic complications remain the major causes of death in patients undergoing ECMO treatments. These complications commence upon blood contact with artificial surfaces of the circuit, blood pump, and oxygenator system. Therefore, anticoagulation therapy is required in most cases to prevent these problems. Anticoagulation is more complicated in pediatric patients than in adults, and the foreign surface of ECMO only increases the complexity of systemic anticoagulation. In this review, we discuss the pathophysiology of coagulation, anticoagulants, and monitoring tools in pediatric patients receiving ECMO.

Recurrent Plastic Bronchitis in a Child with 2009 Influenza A (H1N1) and Influenza B Virus Infection

Plastic bronchitis is an uncommon disorder characterized by the formation of bronchial casts. It is associated with congenital heart disease or pulmonary disease. In children with underlying conditions such as allergy or asthma, influenza can cause severe plastic bronchitis resulting in respiratory failure. A review of the literature showed nine cases of plastic bronchitis with H1N1 including this case. We report a case of a child with recurrent plastic bronchitis with eosinophilic cast associated with influenza B infection, who had recovered from plastic bronchitis associated with an influenza A (H1N1) virus infection 5 months previously. To the best of our knowledge, this is the first case of recurrent plastic bronchitis related to influenza viral infection. If patients with influenza virus infection manifest acute respiratory distress with total lung atelectasis, clinicians should consider plastic bronchitis and early bronchoscopy should be intervened. In addition, management for underlying disease may prevent from recurrence of plastic bronchitis.

Radiodensity on serial chest X-rays for the diagnosis of foreign body aspiration in children

ObjectivesTo evaluate the utility of measuring lung radiodensity from chest X-ray for the diagnosis of foreign body aspirationMethodsRecords of 59 children with foreign body aspiration were retrospectively reviewed. Lung radiodensity and radiodensity ratio (right/left lung radio density) before and after foreign body removal were measured. Radiodensity was calculated as the relative score compared with the tenth thoracic vertebra body (100 points) and the background (0 point). The change of radiodensity ratio (difference in radiodensity ratio of the second X-ray from that of first X-ray) was compared between 22 patients (foreign body group) and 22 normal subjects (control group).ResultsIn the group of foreign body in the left bronchus, the mean (SD) radiodensity of the left lung [53.5 (12.8)] was lower than that of the right lung [60.8 (7.7), P<0.01] and it increased after foreign body removal [60.0 (6.9), P=0.02]. The radiodensity ratio decreased from 1.20 (0.30) to 0.96 (0.09) (P<0.01) after foreign body removal. In the group with a foreign body in the right bronchus, the radiodensity of the right lung [51.8 (12.8)] was lower than that of left lung [62.0 (11.7), P=0.03], and it also increased after foreign body removal [58.4 (9.6), P=0.03]. The change of radiodensity ratio in the foreign body group [15.7 (17.8)%] was higher than the control group [5.4 (4.3)%, P=0.01] and the cutoff value was 7.5%.ConclusionRadiodensity from chest X-ray could be a useful tool for diagnosing foreign body aspiration in children.

Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure

OBJECTIVE Children with ventricular septal defects (VSD) can have chronic volume overload, which can result in changes of left heart echocardiographic parameters. To evaluate the changes before and after surgical closure, the children were divided into three groups according to the degree of mitral regurgitation (MR), and their echocardiographic characteristics were reviewed at serial follow-up after surgical closure. METHODS The preoperative, and one-, three-, and 12-month postoperative echocardiographic data of 40 children who underwent surgical closure of VSD were retrospectively reviewed. Left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), mitral valvular characteristics, including degree of MR and mitral valve annulus, and left atrial (LA) characteristics, including volume and dimensions, were observed. RESULTS Preoperative LVEDV, LVEDD, LVESD, mitral valvular annulus, LA volume, and LA dimensions were significantly larger in children with MR. Additionally, there were significant decreases in LVEDV, LVEDD, LA volume, and LA dimensions at one, three, and 12 months postoperatively. The degree of MR also improved to a lower grade after surgical closure of the VSD without additional mitral valve repair. CONCLUSION The echocardiographic parameters of left heart dilation and MR in children with VSD improved within the first year after surgical closure without additional mitral valve repair. Furthermore, in all of the patients with VSD, regardless of MR, LA dilation was reduced within three months after surgical closure of the VSD; however, LV and mitral valve annular dilatation decreased within 12 months.

Transvenous proximal closure of large congenital coronary arteriovenous fistula using the single Amplatzer vascular plug in a 3-year-old girl

Congenital coronary arteriovenous fistulas (CCAFs) are rare coronary artery abnormalities in which blood is shunted into a cardiac chamber or great vessel. If the fistula itself is large and tortuous, it is generally recommended to occlude the fistula to prevent several complications. In approaches of transcatheter occlusion, the transvenous approach is preferred over the transarterial approach. The transvenous approach would enable the cannulation of a relatively larger catheter or sheath without potential damage to the femoral vessels or normal coronary arteries, which can occur in the transarterial approach. The transvenous approach may also minimize the blind pouch after releasing the devices. Herein, we report the success of transvenous proximal closure of a CCAF using an Amplatzer vascular plug (AVP) in a 3-year-old patient with cardiomegaly. Complete occlusion was achieved by a single AVP and thrombus formation of the distal aneurysmal portion of the fistula. We suggest that this strategy of closing the proximal end with a dilated fistula using a single AVP by the transvenous approach may be a good option in treating CCAFs in a young child.

Procalcitonin Levels in Patients with Complete and Incomplete Kawasaki Disease

Incomplete Kawasaki disease (iKD) is considered to be a less complete form of Kawasaki disease (cKD), and several differences in the laboratory presentations of iKD and cKD have been noted. We investigated serum procalcitonin levels in patients with iKD, cKD, and other febrile diseases (a control group). Seventy-seven patients with cKD, 24 with iKD, and 41 controls admitted to our hospital from November 2009 to November 2011 were enrolled in the present study. We obtained four measurements of serum procalcitonin levels and those of other inflammatory markers from each patient. Samples were taken for analysis on the day of diagnosis (thus before treatment commenced; D0) and 2 (D2), 14 (D14), and 56 days (D56) after intravenous immunoglobulin infusion. We obtained control group data at D0. The mean D0 serum procalcitonin levels of cKD patients (0.71 ± 1.36 ng/mL) and controls (0.67 ± 1.06 ng/mL) were significantly higher than those of iKD patients (0.26 ± 0.26 ng/mL) (P = 0.014 and P = 0.041, resp.). No significant difference in mean procalcitonin level was evident among groups at any subsequent time. In conclusion, the serum procalcitonin level of patients with acute-stage cKD was significantly higher than that of iKD patients.

Change in Blood Pressure and Pulse Pressure in Preterm Infants After Treatment of Patent Ductus Arteriosus With Indomethacin

Background and Objectives Patent ductus arteriosus (PDA) is associated with increased morbidity and mortality in premature infants. Therefore, an early diagnosis and treatment of a hemodynamically significant PDA are very important. A widened pulse pressure is considered to be a well known clinical sign of a PDA in older infants and children; however, whether this is also applicable in the case of preterm infants remains to be confirmed. The aims of this study were to investigate the change in blood pressure (BP) before and after medical treatment of a PDA with indomethacin and to evaluate if the change in the pulse pressure in preterm infants with a medically treated PDA could be used as a reliable clinical predictor of a hemodynamically significant PDA. Subjects and Methods Between January 2005 and June 2009, a retrospective analysis was performed in preterm infants with a hemodynamically significant PDA (PDA group, n=72) and preterm infants without a PDA (control group, n=72) at the Chonnam National University Hospital Neonatal Intensive Care Unit. The PDA was closed by treatment with indomethacin. The BP was compared between the two groups over the seven days after the first dose of indomethacin. Results In preterm infants with a hemodynamically significant PDA, the mean systolic (55.1±6.0 mmHg) and diastolic BPs (31.4±6.2 mmHg) were lower than those in the controls (mean systolic BP 58.0±6.4 mmHg, mean diastolic BP 34.7±6.0 mmHg) before indomethacin treatment. When the ductus arteriosus was successfully closed by indomethacin treatment, there was a gradual increase in both the systolic and diastolic BPs without any change in the pulse pressure. Conclusion The results of this study show that a widened pulse pressure is not a useful clinical sign of a hemodynamically significant PDA in preterm infants. However, low systolic and diastolic BPs may be useful clinical signs of a hemodynamically significant PDA in preterm infants. If the systolic and diastolic BP is low, a PDA should be considered and echocardiography should be performed for early diagnosis and treatment.

Predictive Value of Procalcitonin for Infection and Survival in Adult Cardiogenic Shock Patients Treated with Extracorporeal Membrane Oxygenation

Procalcitonin (PCT) is a predictive marker for the occurrence of bacterial infection and the decision to terminate antibiotic treatment in critically ill patients. An unusual increase in PCT, regardless of infection, has been observed during extracorporeal membrane oxygenation (ECMO) support. We evaluated trends and the predictive value of PCT levels in adult cardiogenic shock during treatment with ECMO. We reviewed the clinical records of 38 adult cardiogenic shock patients undergoing veno-arterial ECMO support between January 2014 and December 2016. The exclusion criteria were age <18 years, pre-ECMO infection, and less than 48 hours of support. The mean patient age was 56.7±14.7 years and 12 (31.6%) patients were female. The mean duration of ECMO support was 9.0±7.6 days. The rates of successful ECMO weaning and survival to discharge were 55.3% (n=21) and 52.6% (n=20), respectively. There were 17 nosocomial infections in 16 (42.1%) patients. Peak PCT levels (mean 25.6±9.4 ng/mL) were reached within 48 hours after initiation of ECMO support and decreased to ≤5 ng/mL within one week. The change in PCT levels was not useful in predicting the occurrence of new nosocomial infections during the ECMO run. However, a PCT level >10 ng/mL during the first week of ECMO support was significantly associated with mortality (p<0.01). The change in PCT level was not useful in predicting new infection during ECMO support. However, higher PCT levels within the first week of the ECMO run are associated with significantly higher mortality.