Nuray Uslu

Comparison of short- and long-term treatment protocols and the results of second-line quadruple therapy in children with Helicobacter pylori infection

BackgroundResearch regarding the optimal therapeutic approach to Helicobacter pylori infection in children is ongoing. There is no consensus as to duration of treatment or second-line therapy. The purpose of this study was compare the efficacy of 7-day and 14-day triple therapies and report the results of second-line quadruple therapy in children.MethodsA total of 275 consecutive H. pylori-infected patients were enrolled into two groups. Group 1 (n = 180) received triple therapy with 14 days of amoxicillin and clarithromycin and 21 days of proton pump inhibitor. Group 2 (n = 95) received triple therapy including 7 days of amoxicillin and clarithromycin with 21 days of proton pump inhibitor. Subsequently, 89 patients not responding to the triple therapies received quadruple therapy comprising omeprazole (14 days), bismuth subcitrate (7 days), doxycycline (7 days), and metronidazole (7 days). Eradication was evaluated by 13C-urea breath test.ResultsThe per-protocol eradication rates in groups 1 and 2 were 60.5% and 55.8%, respectively (P = 0.44). In the second interview with 227 patients, severe symptoms were reported to have disappeared in 59% and decreased notably in 34.8%. Helicobacter pylori was eradicated in 66.7% of patients at the end of the quadruple therapy. In the third interview with 75 patients, severe symptoms had decreased in 38.6% and disappeared in 56%.ConclusionsThe different duration of the two treatment regimens had no impact on eradication rates. Furthermore, quadruple therapy was necessary to achieve H. pylori eradication after triple therapy. However, the eradication rate with quadruple therapy was still insuf-ficient. Consequently, a new therapeutic approach to H. pylori infection in children is needed.

Evaluation of lansoprazole as a probe for assessing cytochrome P450 2C19 activity and genotype-phenotype correlation in childhood.

PurposeLansoprazole, a cytochrome P450 2C19 (CYP2C19) substrate, has been widely used in children to manage acid-related diseases. CYP2C19 exhibits marked genetic polymorphisms, and distribution of these polymorphisms varies among different ethnic groups. There is limited data regarding the use of probe drugs for determining CYP2C19 activity in children. The aim of this study was to evaluate lansoprazole as an in vivo phenotyping probe for assessing CYP2C19 activity in children.MethodsThe CYP2C19*2, *3, and *17 variants were determined in 244 children. Three hours after a single oral dose of lansoprazole (n = 94) or omeprazole (n = 19), plasma lansoprazole and 5-hydroxy lansoprazole or omeprazole and 5-hydroxy omeprazole concentrations were analyzed by high-performance liquid chromatography.ResultsThe CYP2C19*17 was the most frequent variant allele (24.4%). The group of patients with CYP2C19*17*17 genotype had a 70% lower (p < 0.05) mean lansoprazole plasma concentration compared with the CYP2C19*1*1 genotype group, whereas the CYP2C19*2*2 group had 6.9-fold higher (p < 0.01) mean lansoprazole plasma concentration. Lansoprazole metabolic ratios (lansoprazole/5-hydroxy-lansoprazole) were found to be significantly lower in the *17*17 [mean ± standard deviation (SD); 2.8 ± 2.1] group and higher in the *2*2 group (63.5 ± 12.2) compared with that of the *1*1 genotype group (6.1 ± 4.5).ConclusionAccording to our results from a Turkish pediatric population, lansoprazole is a suitable probe drug for phenotyping CYP2C19. The CYP2C19*2 and *17 variants should be taken into consideration in predicting the clinical outcome of therapy with lansoprazole in the pediatric population.

Acute tubular injury associated with mesalazine therapy in an adolescent girl with inflammatory bowel disease

Mesalazine is a first-line drug in pediatric inflammatory bowel disease, and is effective as primary treatment and maintenance therapy. It’s usually well tolerated, but various side effects have been described. A 15-year-old female with ulcerative colitis developed polyuria, polydipsia, vomiting, and fatigue. She was receiving mesalazine (500 mg, thrice daily, p.o.) and prednisolone for 4 months. She was detected as acute tubular injury as she had dehydration, acidosis, hypostenuria, hematuria, proteinuria, low levels of potassium, uric acid and bicarbonate. These findings were attributed to interstitial nephritis as a side effect of mesalazine, however as renal biopsy was disapproved by the parents, it was not confirmed. After discontinuation of mesalazine her renal tubular functions improved. Potassium and phosphorus supplements were stopped after 7 months, although she had to continue bicarbonate supplementation. We conclude that regular renal screening is important in patients receiving 5-ASA therapy to prevent rare but serious complications, such as interstitial nephritis sometimes leading to chronic renal failure.

Hemophagocytic syndrome in a child with severe Crohn's disease and familial Mediterranean fever

Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal, severe condition of hyperinflammation caused by the uncontrolled proliferation of activated lymphocytes and histiocytes secreting high amounts of inflammatory cytokines. Here we report a fatal hemophagocytic syndrome in a 11-year-old boy with a diagnosis of both Crohns disease receiving immunosuppressive therapy and familial Mediterranean fever. It is important to evaluate the patients with inflammatory bowel disease receiving immunosuppressive therapy presenting with unexplained fever, cytopenia, progression of organomegaly and biochemical changes for the investigation of HLH for diagnosis and treatment.

MRCP diagnosis of Mirizzi syndrome in a paediatric patient: importance of T1-weighted gradient echo images for diagnosis

We report a 15-year-old boy with Mirizzi syndrome diagnosed by MR cholangiopancreatography (MRCP). Respiratory-triggered 3D MRCP was performed during free breathing. An impacted gallstone was noted in the infundibulum; this was not visible on T2-weighted images, but was hyperintense on T1-weighted gradient-echo images. This case illustrates the utility of 3D MRCP with parallel imaging in paediatric patients and the importance of T1-weighted gradient-echo images for the diagnosis of impacted gallstones.

Bone mineral density in children with cirrhosis

BackgroundDespite the clinical importance of osteoporosis in individuals with cirrhosis, little is known about it, especially in children. We evaluated the bone mineral density (BMD) and bone mineral content (BMC) of children with cirrhosis.MethodsForty children with cirrhosis (mean age, 10.4 ± 3.9 years) were involved. BMD and BMC were measured by dual energy X-ray absorptiometry at lumbar vertebrae 1–4, and the results were compared with those of 62 healthy age- and sex-matched children.ResultsThe mean lumbar spine BMD of patients with cirrhosis was 0.482 ± 0.107 g/cm2 and that of the controls was 0.687 ± 0.172 g/cm2 (P < 0.0001). The mean lumbar spine BMC of patients with cirrhosis was 20.008 ± 8.409 g and that of controls was 32.859 ± 14.665 g (P < 0.0001). After the confounding variables (weight, height, and pubertal stage) were controlled for, the difference in BMD and BMC values between patients with cirrhosis and healthy controls was significant (0.535 ± 0.061 g/cm2 vs 0.653 ± 0.048 g/cm2, and 24.515 ± 5.052 g vs 29.952 ± 3.971 g, respectively).ConclusionsBecause of the significant difference in BMD and BMC values between our patients with cirrhosis and healthy controls, patients with cirrhosis should be evaluated for osteopenia.

Echocardiographic assessment in children with Gaucher disease receiving enzyme replacement therapy.

hypersensitivity and anaphylactic or anaphylactoid reactions constitutes the Kounis syndrome (1). Two variants of Kounis syndrome have been described (2). The type I variant includes patients with normal coronary arteries without predisposing factors for coronary artery disease. The type II variant includes patients with active or quiescent preexisting atheromatous disease. The type III variant has been proposed recently (3). A number of conditions, several drugs, foods and venom and toxins have been reported as capable of inducing Kounis syndrome (1, 2). Activation of mast cells and the systemic release of histamine are common side effects of morphine. In addition to other side effects, cutaneous changes may occur as manifested by peripheral vasodilatation and flushing of the skin with urticaria, a response to the histamine releasing properties of the morphine. This case calls attention to the Kounis syndrome which was induced by two other β-lactam antibiotics and aggravated by morphine.

Safety of ribavirin in adolescent thalassemic patients with chronic hepatitis C virus infection

Hepatitis C virus (HCV) infection is still a common and imporant problem in thalassemic patients.1 There have been important mprovements in the treatment of chronic HCV infection especially n the last decade. Combination of pegylated interferon (peg-IFN) lfa-2 and ribavirin seems to improve the success of treatment esponse and currently is the recommended therapy for adults.2,3 owever, studies about the treatment of adolescents with thaassemia and HCV infection are limited and are concerned with the dverse effects of the treatment.1,4 We herein present two adoescents with -thalassemia major and chronic HCV infection who ere treated with peg-IFN and ribavirin and discuss the safety of he treatment.

Ineffectiveness of infliximab therapy in severe infantile Crohn's disease

Crohns disease is extremely rare in infancy and can be present in severe forms. Infants with Crohns disease might require intensive immunosuppressive therapy. Infliximab is a chimeric mouse/human monoclonal IgG1 antibody against tumor necrosis factor-α, and completely neutralizes its biologic activity. Though widely used in the treatment of pediatric Crohns disease, there are few data regarding its applicability in infancy. We therefore report herein our experiences with infliximab therapy in two infantile patients with Crohns disease who were resistant to conventional therapies; one patient showed a partial response while there was no response in the second. We were unable to achieve satisfactory results from infliximab therapy. It remains to be determined whether inflammatory bowel disease starting in infancy represents a separate pathogenetic subgroup and whether the inflammatory bowel disease diagnosis should follow the exclusion of an immunodeficiency state. Studies in larger series are needed to further clarify the efficacy, safety and timing of infliximab therapy for infantile Crohns disease patients.

A rare cause of carpal tunnel syndrome in childhood: Benign recurrent intrahepatic cholestasis

Carpal tunnel syndrome and benign recurrent intrahepatic cholestasis are rare conditions in childhood. Benign intrahepatic cholestasis is characterized by repeated self-limited attacks of cholestasis that can start at any age and last from weeks to months. The patients are asymptomatic between these attacks. We report a 16 year-old male patient with benign recurrent intrahepatic cholestasis who developed carpal tunnel syndrome during a cholestatic attack. He was admitted with complaints of jaundice, pruritus and pain, tingling and muscle weakness in both hands for 15 days. Nerve conduction studies revealed findings compatible with carpal tunnel syndrome. He was started on ursodeoxycholic acid, fat soluble vitamins and cholestyramine and cholestasis regressed after four weeks of therapy. With the improvement of cholestasis, the symptoms of carpal tunnel syndrome also disappeared. In conclusion, benign recurrent intrahepatic cholestasis can be a rare cause of carpal tunnel syndrome in childhood. We also advocate treating the underlying disease as an appropriate conservative treatment before surgery.