Murat Muhtar Yilmazer

Postural Orthostatic Tachycardia Syndrome (POTS) and Vitamin B12 Deficiency in Adolescents

OBJECTIVE: Vitamin B12 is involved in the production of adrenaline from noradrenaline. It is the cofactor involved in catecholamine degradation and plays a role in myelin synthesis. The current study aimed to investigate the association between vitamin B12 levels and postural orthostatic tachycardia syndrome (POTS) during adolescence when accelerated myelin synthesis increases the vitamin B12 need. METHODS: One hundred twenty-five patients (mean age 11.1 ± 2.3 years; 60% female) reporting short-term loss of consciousness and diagnosed with vasovagal syncope based on anamnesis with a normal distribution and 50 control subjects (mean age 10.94 ± 2.5 years, 62% female) were included in this study. Serum vitamin B12, folic acid, and ferritin levels were measured prospectively in addition to other tests. We defined vitamin B12 deficiency as a serum level <300 pg/mL.1–4 RESULTS: Vitamin B12 levels were significantly lower in the patient group compared with the control group (47.2% vs 18%, P < .001). In the patient group, children with the POTS pattern had significantly lower vitamin B12 levels compared with children without the POTS response (P = .03). CONCLUSIONS: Vitamin B12 deficiency in patients with POTS may lead to sympathetic nervous system baroreceptor dysfunction.

Incomplete (atypical) Kawasaki disease in a young infant with remarkable paucity of signs

We read with great interest the case report by Thapa et al. [1] entitled “Atypical Kawasaki disease with remarkable paucity of signs and symptoms” Kawasaki disease (KD) is an acute febrile vasculitis that was seen predominantly in infants and young children. It is the predominant cause of pediatric acquired heart disease in the developing world. The etiology remains unknown, but clinical and epidemiological features strongly suggest an infectious cause or trigger factor plus a genetic predisposition [2, 3]. The conventional diagnostic criteria should be viewed as guidelines that are particularly useful in diagnosis of complete form but may result in failure to recognize incomplete forms of illness. Unlike KD, in cases of incomplete Kawasaki disease (iKD), coronary artery disease was present in children with fever lacking the suYcient number of criteria to fulWll the epidemiologic case deWnition [3]. Thus, iKD diagnosis often depends on echocardiographic Wndings of coronary artery abnormalities (CAA). But according to the Japanese guidelines [4], iKD deWned as the presence of four or fewer of the principal Wndings of KD regardless of the presence or absence of CAA. No matter which diagnostic criteria was preferred, it complications were as severe as KD. In this letter, an 8-month-old infant referred to our pediatric cardiology clinic with high-grade fever for 19 days and lacking associated symptoms was diagnosed as iKD, since she had saccular aneurysm on her echocardiography is described. Her physical examination revealed no speciWc Wndings except fever (39.5°C). There was no history of conjunctivitis, rash, erythema of the lips, extremity changes or cervical lymphadenopathy. Until her reference to our clinic, patient had a history of multiple antibiotic usage with diVerent clinical diagnosis. Laboratory tests revealed the following: hemoglobin, 9.2 gm/dl; leukocyte count, 12,100/mm; (peripheral smear revealed neutrophils, 30%; lymphocytes, 60%; reactive lymphocytes, 8%; eosinophils, 2%); platelets, 988,000/mm. On admission erythrocyte sedimentation rate was 125 mm/h and C-reactive protein level was 22.3 mg/dl (normal range 0–0.5), respectively. Since the patient had persistent fever for 19 days despite antimicrobial therapy, echocardiography was performed. Twodimensional echocardiography revealed saccular aneurysm at left main coronary artery with a diameter of 6 mm (Fig. 1). Intravenous immunoglobulin (IVIG) (2 g/kg per total dose) and high-dose (100 mg/kg per day, divided into 4 doses/day) acetylsalicylic acid was applied to the patient with diagnosis of iKD and her fever recovered on the fourth hour of IVIG administration. Periungual desquamation of the Wnger tips emerged 1 day after the IVIG therapy. He was discharged from the hospital with low-dose acetylsalicylic M. M. Yilmazer (&) · T. Mese · S. Demirpençe · B. Guven · T. Öner Department of Pediatric Cardiology, Behcet Uz Children’s Hospital, Alsancak, 35210 Izmir, Turkey e-mail: drmuratmuhtar@hotmail.com

An observational study on peripheral blood eosinophilia in incomplete Kawasaki disease

OBJECTIVE To investigate the peripheral blood eosinophilia (PBE) in the acute stage of incomplete Kawasaki disease (iKD). METHODS Twenty-four patients with iKD (median age; 31.5 months, range; 7-88 months) and 25 with complete Kawasaki disease (cKD) (median age; 37 months, range; 9-140 months) were evaluated between 2004 and 2010 from İzmir Dr. Behçet Uz Childrens Hospital records retrospectively. We determined the eosinophil counts and rates from the complete blood count in two study groups before the IVIG treatment and 30 febrile age-matched controls and 30 control cases with congenital heart disease (control Group 1 and 2 respectively). Kruskal-Wallis test was performed in detecting the differences of eosinophil rates and counts between four subgroups. RESULTS In iKD group, the mean value of eosinophil rates and median value of eosinophil counts were 4.39±2.5% and 377 cells/mm(3), respectively, which did not significantly different with cKD group (mean eosinophil rates; 5.47±4.8% and median eosinophil counts 525 cells/mm(3)) (p>0.05). The median values of eosinophil cell counts and mean value of eosinophil rates were 220 cell/mm(3) and 2.83±2.65% in the control group 1 and 165 cell/mm(3) and 1.63±1.43% in the control Group 2 respectively, which were statistically significant lower compared to both study groups (p< 0.001). CONCLUSION The rate of PBE was found significantly higher in iKD patients compared to the controls. Since the diagnosis of iKD is difficult, unexplained eosinophilia may be helpful in the presence of suggestive clinical findings of KD.

Isolated abducens palsy in adolescent girl with Kawasaki disease

Here, we present a case of classic KD with right abducens palsy that developed during the subacute phase of the illness. A 12-year-old Caucasian girl with an unremarkable medical history was referred to our hospital with a 4-day history of fever, weakness and a rash. On the second day of fever, she developed rash in the lower extremities, vomiting, headache and complete blood count revealed leukocytosis (19 000/mm 3 ). Physical

A Valuable Tool in Predicting Poor Outcome due to Sepsis in Pediatric Intensive Care Unit: Tp-e/QT Ratio

OBJECTIVE To assess the feasibility of 12-lead electrocardiographic (ECG) measures such as P wave dispersion (PWd), QT interval, QT dispersion (QTd), Tp-e interval, Tp-e/QT and Tp-e/QTc ratio in predicting poor outcome in patients diagnosed with sepsis in pediatric intensive care unit (PICU). METHODS Ninety-three patients diagnosed with sepsis, severe sepsis or septic shock and 103 age- and sex-matched healthy children were enrolled into the study. PWd, QT interval, QTd, Tp-e interval and Tp-e/QT, Tp-e/QTc ratios were obtained from a 12-lead electrocardiogram. RESULTS PWd, QTd, Tp-e interval and Tp-e/QT, Tp-e/QTc ratios were significantly higher in septic patients compared with the controls. During the study period, 41 patients had died. In multivariate logistic regression analyses, only Tp-e/QT ratio was found to be an independent predictor of mortality. CONCLUSION The ECG measurements can predict the poor outcome in patients with sepsis. The Tp-e/QT ratio may be a valuable tool in predicting mortality for patients with sepsis in the PICU.

Comparison of in vitro activity of ertapenem with other carbapenems against extended-spectrum beta-lactamase-producing Escherichia coli and Kleibsella species isolated in a tertiary children's hospital

Objective: The purpose of this study was to evaluate the susceptibility of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae clinical isolates to ertapenem in a tertiary pediatric care center in Turkey. Design/methods: All isolates of ESBL-producing Enterobacteriaceae were collected from clinical specimens from children, and susceptibility tests were done using the Vitek 2 compact system. Results: Ninety-nine per cent of the ESBL-producing Escherichia coli isolates were found to be susceptible to ertapenem, 99.5% to imipenem and 100% to meropenem. In the Klebsiella species, 91.5% of the isolates were susceptible to ertapenem, 99.3% to imipenem and 100% to meropenem. Conclusion: The results of our data, including isolates from children, showed that ertapenem had high in vitro activity against the majority of the ESBL-producing E. coli and Klebsiella species, as reported in previously published studies. However, additional clinical studies are required to assess the clinical activity of ertapenem and the clinical importance of the resistant isolates.

Red blood cell distribution width: can it be a predictive marker for long-term valvular involvement in children with acute rheumatic carditis?

In this study, we aimed to evaluate Red blood cell distribution width (RDW) in patients with acute rheumatic carditis during the acute phase and after anti‐inflammatory therapy.

Evaluation of left atrial functions in children with chronic renal failure.

OBJECTIVE One-quarter of deaths in children with chronic renal failure is due to cardiovascular complications. Conventional echocardiographic methods are insufficient for evaluating systolic functions in children with chronic renal failure. The aim of the present study was to investigate cardiac functions in children with chronic renal failure by evaluating left atrial volume and functions. METHODS The present cross-sectional observational study included 44 children undergoing dialysis, 16 children with chronic renal failure but not yet on dialysis, and 20 healthy control subjects. Transthoracic echocardiography was performed for all children. Variables regarding to left ventricle and atrium (left atrial systolic force, left atrial systolic force index, left atrial volume, left ventricular mass index, and relative wall thickness) were measured using two-dimensional and M-mode echocardiography. RESULTS Left atrial systolic force index was negatively correlated with systolic blood pressure and left ventricular mass (p=0.01, r=0.266 and p=0.02, r=0.347, respectively). However, it was positively correlated with both early and late diastolic mitral inflow velocity (r=0.518, p=0.001 and r=0.828, p=0.001, respectively). There were no significant difference among the groups in terms of left atrial systolic force index and left atrial volume. However, left atrial systolic force index was higher in children with chronic renal failure but not yet on dialysis. CONCLUSION Left atrial systolic force was negatively correlated with systolic blood pressure and left ventricular mass. These findings suggested that evaluating left atrial systolic force and left atrial volume were useful to determine diastolic dysfunction and the necessity of dialysis in patient with chronic renal failure.

Arterial function and anatomy in obese children with cardiovascular risk factors

Limited data are available related to the effects of cardiovascular risk factors on abdominal arterial stiffness using carotid and brachial artery indices. Therefore, we aimed to determine arterial changes in obese children and investigate any relation with cardiovascular risk factors.

Infracardiac total anomalous pulmonary venous drainage with unusual presentation

Total anomalous pulmonary venous drainage (TAPVD) is a rare entity which forms approximately 0.4 to 2% of all congenital heart disease. The infracardiac type usually involve obstructions on pulmonary venous connections and comprising a quarter of all TAPVD cases. The clinical findings in patients with obstructed infracardiac TAPVD could mimic respiratuary distress of several different etiologies during first hours of life. In this article, we present a case of a neonate with infracardiac type of TAPVD presented with only distinct subcutaneous veins of abdominal and thoracic wall.