Özgür Olukman

Epidemic Adenoviral Keratoconjunctivitis Possibly Related to Ophthalmological Procedures in a Neonatal Intensive Care Unit: Lessons from an Outbreak

Purpose: Epidemic adenoviral keratoconjunctivitis can spread rapidly among preterm infants who frequently undergo ophthalmological examination. Here we present our experience on a nosocomial outbreak that affected 8 nursery staff members and 26 premature infants. We focus on the presentation and progress of the outbreak, the diagnosis of the disease and the measures taken for its control. Methods: Data were collected from patients’ files and records of the infection control team. Conjunctival swabs were collected to perform direct fluorescent assay (DFA) and viral culture. Diagnosis was made according to clinical evidence and/or detection of the virus. Statistical analysis was performed using SPSS 15.0 statistical software. Results: Infection was introduced to our unit after a laser photocoagulation procedure of a 28-week gestational infant and circulated rapidly within the unit due to direct transmission through contaminated medical equipment, fomites and hands of nursery staff members. Neither the patients, nor the nursery staff members developed systemic symptoms. While DFA tests were positive in seven infants, culture positivity could be demonstrated in only three infants. Contact and droplet precautions were implemented with the recommendation of the infection control team. No recurrence occurred after definition of the last case on the 32nd day. Conclusion: Ophthalmologic procedures continue to be a potential source of adenovirus outbreaks. However, negligence of contact measures during routine daily nursing care seems to be a more important contributing factor for rapid spread. Strict adherence to appropriate aseptic procedures is required to prevent this potentially hazardous infection in preterm infants.

Genetic Factors that Influence Short-Term Neurodevelopmental Outcome in Term Hypoxic-Ischaemic Encephalopathic Neonates

It is difficult to predict outcome in neonates that experience perinatal hypoxic ischaemia. Morbidity and mortality may be affected by genetic factors that augment inflammatory and coagulative responses. This prospective study analysed the effects of proinflammatory cytokine gene polymorphisms (tumour necrosis factor-α [TNFA] 308G>A and interleukin-6 [IL6] 174G>C) and prothrombotic factor gene mutations (prothrombin G20210A, factor V Leiden G1691A and methylenetetrahydrofolate reductase [MTHFR] C677T) on the early neurological prognosis in 40 term hypoxic ischaemic encephalopathic neonates. There were significant relationships for Sarnat and Sarnat staging with electroencephalographic findings, transfontanelle ultrasound (US) results, early neonatal outcome and neurological morbidity. Genetic mutations in the prothrombotic proteins, the TNFA 308G>A polymorphism and the cerebrospinal fluid levels of TNF-α protein were not related to clinical stage, electroencephalography, transfontanelle US or neurological status at discharge or at postnatal months 6 and 12. The IL6 174GC genotype demonstrated a protective role, being significantly correlated with normal electroencephalography, transfontanelle US and normal neurological findings at discharge. In conclusion, the IL6 174GC gene polymorphism seems to play a role in determining the risk and/or severity of perinatal cerebral injury.

Risk factors for isoniazid hepatotoxicity in children with latent TB and TB: difference from adults.

In an interesting article in CHEST (November 2007), Talmor and colleagues 1 demonstrate that recruitment maneuvers are well tolerated in ARDS, with no major hemodynamic or immunologic evidence of deterioration within the fi rst hour of a recruitment maneuver. However, certain aspects of this study are not clear from the article. In this study, eight out of the 26 patients had intraabdominal pathologic results wherein the pressures applied during the study may not be appropriate, because higher airway pressures are required to generate an equivalent transpulmonary pressure in the patient with increased intraabdominal pressure. 2 The use of bladder pressure measurements may help in determining the intraabdominal pressure and may help in this regard. Furthermore, stratifying the results into abdominal and extraabdominal categories may alter the results. Gattinoni et al 3 showed that patients with extrapulmonary ARDS (ARDSexp) have a greater response rate to recruitment maneuvers than those with pulmonary ARDS (ARDSp). Thus, patients with pneumonia may have a limited amount of recruitable lung tissue, and the higher pressure may overinfl ate normal lung rather than aerating the consolidated tissue. So, further separating the results into ARDSp and ARDSexp may lead to greater insight in the study. A series by Gattinoni et al 4 found that patients with ARDSp had a higher percentage of recruitable lung than patients with ARDSexp when using CT scanning of the whole lung to quantify recruitment. Thus, CT scanning should ideally be performed when evaluating the effects of recruitment maneuvers. Finally, two (7.69%) out of 26 patients in this study did show a hemodynamic compromise and early termination of the recruitment maneuver, which defi nitely puts a question mark on the safety of this maneuver in critically ill patients with ARDS.

Can neonatal hepatitis be more fatal than biliary atresia

Background/Aims: The basic problem in diagnosis of neonatal cholestasis (NC) is to differentiate biliary atresia (BA) from other non-obstructive disorders. Because if bile flow cannot be provided by surgery, BA leads to cirrhosis and death within the first year of life. The aim of the present study is to determine histopathological features that may help to differentiate BA from neonatal hepatitis (NH). Material and Methods: This retrospective study was carried out on 105 liver biopsy specimens of 74 infants with NC who were diagnosed between 2003 and 2012. Results: The mean age was 76.5 ± 40.64 days. The most valuable biopsy findings for the discrimination between NH and BA, in decreasing order of importance, were ductular proliferation (p < 0.001), cholestasis in neoductuli (p < 0.001), fibrosis (p = 0.002), and extramedullar hematopoiesis (p = 0.02). While Kasai operations were performed in 19 cases, liver transplantation was performed in 10 cases. Survival rate among the death cases with BA was longer than the survival time of the death cases with NH (p = 0.023). Currently more children live with a close to normal quality of life with portoenterostomy and/or liver transplantation. On the contrary, NH can be more fatal with associated disorders such as growth retardation, specific infections, respiratory distress, and metabolic or endocrine diseases.

Is there a relationship between maternal periodontitis and pre-term birth? A prospective hospital-based case-control study

Abstract Objective. The aim of this study is to verify the existence of an association between maternal periodontal disease and pre-term delivery in an unselected population of post-partum Turkish women. Materials and methods. This case-control study was conducted on 100 women who gave birth in either a special or a government maternity hospital. The case group consisted of 50 mothers who had delivered an infant before 37 weeks’ gestation and weighed under 2500 g. The control group included 50 mothers who had given birth to an infant with a birth weight of more than 2500 g and a gestational age of ≥37 weeks. Data of mothers and infants were collected using medical registers and questionnaires. Clinical periodontal examinations were carried out in six sites on every tooth in the mother’s mouth. A participant who presented at least four teeth with one or more sites with a PPD ≥4 mm and CAL ≥3 mm at the same site was considered to have periodontal disease. Statistical methods included parametric and non-parametric tests and multiple logistic regression analysis. Results. There were no statistically significant differences between the cases and controls with regard to periodontal disease and pre-term delivery (OR = 1.48; 95% CI = 0.54–4.06). Conclusion. The findings indicated that maternal periodontitis was not a possible risk factor for pre-term delivery. Further studies with additional clinical trials are needed to explore the possible relationship between periodontal disease and pre-term birth.

Effect of unconjugated hyperbilirubinemia on neonatal autonomic functions: evaluation by heart rate variability

Abstract Background: Serum bilirubin levels beyond the physiological limits, may lead to alterations in autonomic regulation in a newborn infant. Heart rate variability (HRV), is a noninvasive and quantitative marker of the activity of the autonomic nervous system (ANS). To date, few studies have demonstrated the undesirable effects of severe unconjugated hyperbilirubinemia (UHB) on autonomic functions, and only one study has used HRV as a marker of the autonomic activity. However, the relationship between altered cardiac autonomic functions and UHB by using the HRV derived from 24-hour Holter electrocardiography (ECG) recording has not been investigated previously. Objective: We aimed to assess whether a relationship exists between severe UHB and cardiac autonomic dysfunction by evaluating HRV via 24-hour Holter ECG recording. Methods: This single-center, prospective, case-control study was conducted on 50 full-term newborn infants with severe UHB requiring phototherapy and 50 healthy infants as controls. HRV assessment was performed by using 24-hour Holter ECG recording. Results: There was no significant difference in terms of mean average heart rate, mean maximum heart rate and mean RR duration between the groups. However, mean minimum heart rate was significantly lower in the study group. When 24-hour time and frequency domain parameters were compared, time and frequency domain parameters rMSDD as well as high frequency (HF), which represent parasymphathetic activity, were significantly higher in the study group. Furthermore, low frequency to high frequency (LF/HF) ratio, that serves as an indicator of sympathovagal balance, was significantly lower in the study group. Conclusion: Severe UHB may cause cardiac autonomic dysfunction in favor of parasympathetic predominance in jaundiced neonates.

Nonketotic Hyperglycinemia in the Neonatal Period: Clinical Features, Diagnosis and Treatment

Nonketotic hyperglycinemia, is a recessively inherited autosomal disorder of the amino acid metabolism caused by a deficiency in the mitochondrial glycine cleavage system. Neonatal type is the most common form. Infants are usually normal at birth and clinical manifestations such as severe hypotonia, poor feeding, seizures, and lethargy progressing rapidly to a deep coma are seen during the first few days of life. Majority of the affected infants die during the first weeks of life. Those who survive develop severe neurological sequelae. The aim of this case series is to evaluate the clinical features, treatment approaches and short term prognosis of the infants diagnosed with neonatal nonketotic hyperglycinemia during the last 5 years in our department. Data were collected retrospectively from patients’ files whose postnatal age at diagnosis varied between 2 to 14 days. All patients were admitted with failure to suck and lethargy, and all had severe hypotonia and decreased newborn reflexes on physical examination. Four patients developed resistant myoclonic seizures and deep apnea requiring mechanical ventilation support. In all patients diagnosis was made based on high plasma and cerebrospinal fluid glycine levels. Genetic study could be performed in only one patient. However enzymatic analysis could not be performed in any patient. All patients demonstrated pathological neuroimaging results, and electroencephalographic abnormalities including multifocal epileptiform abnormalities and “burst supression” patterns in four patients. All patients received low protein diet and drugs reducing plasma glycine levels. Treatment-refractory seizures could only be controlled by levetiracetam in four patients. While two patients died during follow-up, and remaining three patients survived with severe neurological sequels. Physicians should consider nonketotic hyperglycinemia in differential diagnosis in our country where consanguineous marriages are frequent, especially when a newborn healthy for a certain time period develops severe hypotonia, resistant seizures and encephalopathy as detected with routine laboratory tests performed during followup period.

A Newborn Case of “c” Subgroup Mismatch Presenting with Severe Hemolysis and Anemia

249 ©Copyright 2017 by Ege University Faculty of Medicine, Department of Pediatrics and Ege Children’s Foundation The Journal of Pediatric Research, published by Galenos Yayınevi. Ad dress for Cor res pon den ce/Ya z›fl ma Ad re si Ezgi Yangın Ergon MD, University of Health Sciences, Dr. Behçet Uz Children’s Diseases and Surgery Training and Research Hospital, Department of Neonatology, İzmir, Turkey Phone: +90 533 348 56 45 E-mail: yanginezgi@yahoo.com ORCID ID: orcid.org/0000-0003-0836-7379 Re cei ved/Ge liş ta ri hi: 02.06.2016 Ac cep ted/Ka bul ta ri hi:10.09.2016 Ağır Hemoliz ve Anemiyle Başvuran “c” Subgrup Uyuşmazlıklı Bir Yenidoğan Olgusu

A Histologically Diagnosed Case with Infantile Osteopetrosis Complicated by Hypopituitarism

Malignant infantile osteopetrosis is a rarely seen severe disorder which appears early in life with general sclerosis of the skeleton. It is caused by functionally defective osteoclasts which fail to resorb bone. Affected infants can exhibit a wide spectrum of clinical manifestations including impaired hematopoiesis, hepatosplenomegaly, visual impairment, and hypocalcemia. With the exception of secondary hyperparathyroidism, involvement of the endocrine system seems to be quite rare. Hypopituitarism is defined as underproduction of the growth hormone in combination with deficiencies of other pituitary hormones. Any lesion that damages hypothalamus, pituitary stalk, or anterior pituitary can cause secondary hypopituitarism. In this report, we presented a rare combination of malignant infantile osteopetrosis and secondary hypopituitarism in a newborn who presented predominantly with endocrinological symptoms. This is the first case report of malignant infantile osteopetrosis accompanied by hypopituitarism secondary to sclerosis of the sella turcica. On the other hand, this is a very interesting case which was diagnosed based on histological examination of bone marrow biopsy specimens despite lack of any clinical suspicion.

İndirekt hiperbilirübinemili olgularda minör eritrosit antijenlerinin alloimmünizasyondaki rolü

Sum mary Aim: ABO/Rh incompatibilities are common causes of blood group incompatibility in newborns. On rare occasions, alloimmunization due to minor erythrocyte antigens may cause severe hemolytic disease requiring exchange transfusion. Most common minor erythrocyte antigens include non-D Rh antigens (c, C, e, E), Kell, Duffy, Kidd and MNS. In this study, we aimed to investigate minor erythrocyte antigens and their possible effects in newborns who were hospitalized for indirect hyperbilirubinemia and did not have any other detectable cause for neonatal jaundice. Material and Method: : Between July 1st 2009 and September 31st 2009, 107 newborns were enrolled to investigate the relationship between minor erythrocyte antigens and neonatal jaundice. Patients with common causes of hyperbilirubinemia such as ABO/Rh incompatibility, hypothyroidism, glucose-6-phosphate dehydrogenase deficiency, inborn errors of metabolism and sepsis were excluded. The study was approved by the ethics commite ((25.06.2006/35-2009). Minor erythrocyte antigens were studied by performing gel centrifugation method using human monoclonal antibodies. Antibodies were detected in mothers with positive antibody screening. Antigens which countered the antibodies present in the mother and which were found to be positive in the infant were considered as a cause of incompatibility. Kell, C, E,c, e antigens were investigated in all newborns regardless of their antibody screening results. Results: Minor erythrocyte incompatibility was detected in 7 out of 107 newborns (6.5%). Assessment among 230 newborns hospitalized for indirect hyperbilirubinemia revealed a rate of 3% for minor erythrocyte antigen positivity. The most common incompatibility was related to “s” antigen which was detected in 4 patients. Other antigens detected included C, Jka, S, Lub and N. Only 1 patient was found to carry Kell antigen. However his mother displayed negative antibody screening. Direct coombs positivity or severe hemolysis could not be detected in any of the patients with minor erythrocyte antigen incompatibility. Although the clinical course was similar, jaundice was realized much later in these infants when compared to other infants with indirect hyperbilirubinemia. Conclusions: Currently minor erythrocyte antigens are not being investigated routinely in neonatal jaundice. However, clinicians should keep in mind that minor erythrocyte antigens can cause indirect hyperbilirubinemia and sometimes severe hemolytic disease. Therefore they should remember to study these antigens in newborns with pathologic jaundice. (Turk Arch Ped 2013; 48: 23-29)