Jin-Bok Hwang

Prospective follow-up oral food challenge in food protein-induced enterocolitis syndrome

Objectives: To determine tolerance rates to cow’s milk and soy and to suggest guidelines for follow-up oral food challenges (FU-OFCs) in infantile food protein-induced enterocolitis syndrome (FPIES). Methods: The authors analysed the data of 23 patients with infantile FPIES who underwent two or more FU-OFCs and were followed up until over 2 years of age. The first FU-OFCs were performed at 6 months of age, and patients were randomly allocated to cow’s milk (n = 11) or soy (n = 12) challenge starting groups. Second and third FU-OFCs were performed at 2-month intervals in a crossed and switched-over manner. Results: Tolerance rates to cow’s milk and soy were 27.3% and 75.0% at 6 months of age, 41.7% and 90.9% at 8 months and 63.6% and 91.7% at 10 months, respectively. Patients outgrew cow’s milk and soy intolerance at age 20 and 14 months. Conclusions: In infantile FPIES, the first FU-OFC should be performed with soy at 6–8 months of age and cow’s milk FU-OFC should be conducted at over 12 months of age. Infants with FPIES were observed to outgrow food sensitivities during the first 2 years of life.

The Significance of Gastric Juice Analysis for a Positive Challenge by a Standard Oral Challenge Test in Typical Cow's Milk Protein-Induced Enterocolitis

This study was performed to investigate the significance of gastric juice analysis (GJA) as a diagnostic criterion of a positive challenge in a standard oral cows milk challenge (OCC) to confirm typical cows milk protein-induced enterocolitis (CMPIE). Data from 16 CMPIE patients (aged 14 to 44 days) were analyzed. A standard OCC was openly executed using 0.15 g/kg of protein. Three symptoms (vomiting, lethargy, and bloody or pus-like stool), and four laboratory findings (GJA [3 hr], changes in peripheral blood absolute neutrophil count [ANC] [6 hr], C-reactive protein [6 hr], and stool smear test for occult blood or leukocytes) were observed after OCC. Before OCC, baseline studies were conducted; a stool smear test, blood sampling, and GJA. Positive OCC results were; vomiting (87.5%) (observed 1-3 hr after OCC), lethargy (62.5%) (1-3 hr), bloody or pus-like stool (43.8%) (6-10 hr), abnormal GJA (93.8%), an ANC rise >3,500 cells/µL (93.8%), and an abnormal stool smear test (75.0%). A single GJA test after a standard OCC is a sensitive diagnostic criterion of a positive challenge, and may provide an early confirmatory diagnosis of CMPIE. An investigation of positive OCC outcomes helps to find out a diagnostic algorithm of criteria of a positive challenge in CMPIE.

Clinical features of pathologic childhood aerophagia: early recognition and essential diagnostic criteria.

Objective: This study investigated the early recognition and diagnosis of pathologic childhood aerophagia to avoid unnecessary diagnostic approaches and serious complications. Methods: Between 1995 and 2003, data from 42 consecutive patients with pathologic childhood aerophagia, aged 2 to 16 years, were reviewed. An esophageal air sign was defined as an abnormal air shadow on the proximal esophagus adjacent to the trachea on a full-inflated chest radiograph. Results: Of the 42 patients, the chief complaints were abdominal distention (52.4%), recurrent abdominal pain syndrome (21.4%), chronic diarrhea (11.9%), acute abdominal pain (7.1%) and others (7.2%). Mean symptom duration before diagnosis was 10.6 months (range, 1 to 60 months), and it exceeded 12 months for 16 (38.1%) patients. The clinical features common to all patients were abdominal distention that increased progressively during the day, increased flatus on sleep, increased bowel sound on auscultation and an air-distended stomach with increased gas in the small and large bowel by radiography. Visible or audible air swallowing (26.2%) and repetitive belching (9.5%) were also noted. Esophageal air sign was observed in 76.2% of the patients and in 9.7% of the controls (P = 0.0001). The subgroups of pathologic childhood aerophagia divided by underlying associations were pathologic childhood aerophagia without severe mental retardation (76.2%), which consisted of psychological stresses and uncertain condition, and pathologic childhood aerophagia with severe mental retardation (23.8%). Conclusions: The common manifestations of pathologic childhood aerophagia may be its essential diagnostic criteria, and esophageal air sign may be useful for the early recognition of pathologic childhood aerophagia. Our observations show that the diagnostic clinical profiles suggested by Rome II criteria should be detailed and made clearer if they are to serve as diagnostic criteria for pathologic childhood aerophagia.

PROBIOTIC GASTROINTESTINAL ALLERGIC REACTION CAUSED BY SACCHAROMYCES BOULARDII

ers and that the atopic condition did not influence the effect of tacrolimus ointment therapy in children with AEDS. Furthermore, the lack of changes in T-lymphocyte subsets confirmed that topical tacrolimus therapy did not affect the immune system, in accordance with literature data reporting very low systemic absorption of tacrolimus, 0.03%, ointment, with blood concentrations of the drug ranging from 1 to 2.28 ng/mL.8 Finally we suggest that monitoring of peripheral blood T-lymphocyte subsets during topical tacrolimus therapy did not add useful information in the evaluation of therapeutic success in children with AEDS.

Clonazepam Treatment of Pathologic Childhood Aerophagia with Psychological Stresses

The treatment of pathologic aerophagia has rarely been discussed in the literature. In this retrospective study, the authors investigated the effects of clonazepam on the management of pathologic childhood aerophagia (PCA) with psychological stresses (PS), but not with mental retardation. Data from 22 consecutive PCA patients with PS (aged 2 to 10 yr), who had been followed up for over 1 yr, were reviewed. On the basis of videolaryngoscopic views, the authors observed that the pathologyof aerophagia was the result of reflex-induced swallowing with paroxysmal openings of the upper esophageal sphincter due to unknown factors and also observed that these reflex-induced openings were subsided after intravenous low dose benzodiazepine administration. Hence, clonazepam was administered to treat paroxysmal openings in these PCA patients with PS. Remission positivity was defined as symptom-free for a consecutive 1 month within 6 months of treatment. The results of treatment in 22 PCA patients with PS were analyzed. A remission positive state was documented in 14.3% of PCA patients managed by reassurance, and in 66.7% of PCA patients treated with clonazepam (p=0.032). Thus, clonazepam may produce positive results in PCA with PS. Future studies by randomized and placebo-controlled trials are needed to confirm the favorable effect of clonazepam in PCA.

Epstein-Barr Virus Infection with Acute Pancreatitis Associated with Cholestatic Hepatitis

Infection-induced acute hepatitis complicated with acute pancreatitis is associated with hepatitis A virus, hepatitis B virus or hepatitis E virus. Although rare, Epstein-Barr virus (EBV) infection should be considered also in the differential diagnosis if the patient has acute hepatitis combined with pancreatitis. We report a case of EBV infection with cholestatic hepatitis and pancreatitis with review of literature. An 11-year-old female was admitted due to 1-day history of abdominal pain and vomiting without any clinical symptoms of infectious mononucleosis. Diagnosis of reactivated EBV infection was made by the positive result of viral capsid antigen (VCA) IgM, VCA IgG, Epstein-Barr nuclear antigen and heterophile antibody test. We performed serologic tests and magnetic resonance cholangiopancreatography to exclude other viral or bacterial infection, autoimmune disorder, and structural problems. The patients symptoms recovered rapidly and blood chemistry returned to normal with conservative treatment similar to previously reported cases.

Acute Pancreatitis Induced by Azathioprine and 6-mercaptopurine Proven by Single and Low Dose Challenge Testing in a Child with Crohn Disease

We report here a case of drug-induced acute pancreatitis proved by elimination and single, low dose challenge test in a child with Crohn disease. A 14-year-old boy with moderate/severe Crohn disease was admitted due to high fever and severe epigastric pain during administration of mesalazine and azathioprine. Blood test and abdominal ultrasonography revealed acute pancreatitis. After discontinuance of the medication and supportive care, the symptoms and laboratory findings improved. A single, low dose challenge test was done to confirm the relationship of the adverse drug reaction and acute pancreatitis, and to discriminate the responsible drug. Azathioprine and 6-mercaptopurine showed positive responses, and mesalazine showed a negative response. We introduce the method of single, low dose challenge test and its interpretation for drug-induced pancreatitis.

Cytomegalovirus-associated esophageal ulcer in an immunocompetent infant: When should ganciclovir be administered?

Cytomegalovirus (CMV)-associated esophageal ulcer is rare in immunocompetent infants. The presence of inclusion bodies and immunohistochemical staining for CMV in biopsy specimens obtained during esophagogastroduodenoscopy (EGD) indicate that such ulcers occur because of CMV infection. A 7-week-old female infant who experienced frequent vomiting and feeding intolerance was diagnosed with a massive CMV-associated ulcer in the distal esophagus. The ulcer improved after conservative treatment using proton-pump inhibitors; however, ganciclovir was not administered. In a follow-up EGD biopsy specimen, no CMV inclusion bodies were present, and immunohistochemical staining results for this virus were negative. The presence of CMV inclusion bodies indicates active viral replication. If persistent inclusion bodies or positive immunohistochemical staining for CMV is observed in follow-up biopsy specimens, ganciclovir may be used to treat CMV-associated esophageal ulcers.

Successful endoscopic submucosal dissection of a giant polyp in a 21-month-old female

Endoscopic submucosal dissection (ESD) is now recognized as the preferred treatment modality for gastrointestinal epithelial lesions. A 21-month-old female was admitted with a giant hyperplastic polyp causing a gastric outlet obstruction. Successful ESD was performed with caution. The post-procedural course was uneventful without a bleeding episode. Although further study of the feasibility of ESD in early children is necessary, ESD could be applied to avoid laparotomy even in young children.

Diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia in an infant with obscure massive lower gastrointestinal bleeding: a diagnostic challenge.

The authors report a rare case of diffuse microscopic angiodysplasia and nodular lymphoid hyperplasia involving the distal ileum and total colon in a 13-month-old girl who had recurrent episodes of massive lower gastrointestinal bleeding of obscure origin. Colonoscopy showed multiple nodular hyperplasia and mucosal erosions, and all other diagnostic studies were negative. At laparotomy, intraoperative transluminal endoscopic transillumination was of benefit in identifying the bleeding foci but could not detect every angiodysplastic lesion.