Özlem Kayabey

Effect of cholecalciferol on local arterial stiffness and endothelial dysfunction in children with chronic kidney disease

BackgroundAs cardiovascular factors are the leading cause of mortality in chronic kidney disease (CKD) and as vitamin D deficiency is prevalent in this population, we aimed to examine the effect of oral cholecalciferol on cardiac parameters and biomarkers for endothelial cell activation in children with CKD.MethodsForty-one children with CKD and 24 healthy subjects free of any underlying cardiac or renal disease with low 25-hydroxyvitamin D3 (25OHD) levels were evaluated using echocardiography basally and following Stoss vitamin D supplementation. The local vascular stiffness and endothelial dysfunction markers were compared among the groups.ResultsInitial flow-mediated dilatation (FMD) measurements were lower and local arterial stiffness was significantly higher in patients. After vitamin D supplementation, these improved significantly in patients, while no significant change was observed for the healthy group. Homocysteine showed inverse correlation with baseline vitamin D level in CKD children and von Willebrand factor emerged as an independent risk factor for FMD impairment.ConclusionsOur interventional study revealed the favorable effects of high-dose cholecalciferol on cardiovascular and endothelial parameters, implying the importance of vitamin D supplementation in children with CKD.

Left ventricular mechanics are affected in children with celiac disease: A study based on two‐dimensional speckle tracking echocardiography

An association between cardiomyopathy and celiac disease has been reported, but not frequently. We examined the effects on cardiac mechanics in children with celiac disease (CD) by two‐dimensional speckle tracking echocardiography (2DSTE).

A rare cause of early repolarisation in an adolescent boy with chest pain: myocardial bridging

Summary Early repolarisation is a common electrocardiographic (ECG) finding characterised by J-point and ST segment elevation ≥ 0.1 mV in two or more adjacent leads. The ECG pattern of early repolarisation is relatively common in asymptomatic subjects. Early repolarisation pattern may be seen in secondary conditions such as hypothermia, autonomic nervous system disturbances, cocaine abuse, hypercalcaemia and myocardial ischaemia. We present a case of an adolescent boy with chest pain and concurrent ST-segment elevation. Early repolarisation pattern was observed in the inferior leads of the ECG with increased troponin levels. He was shown to have myocardial bridging of the left anterior descending artery. The coronary anomaly was not associated with left ventricular hypertrophy. He was asymptomatic and the ECG changes normalised on the third day after admission. The patient was restricted from strenuous exertion and metoprolol was prescribed for prophylaxis.

PO-0020 Chronic Escherichia Coli Sternal Wound Infection And Mediastinitis After Heart Surgery For Tetralogy Of Fallot

Background and aims Surgical site infections after median sternotomy and repair of congenital heart diseases are rare but have a high morbidity and mortality in paediatric patients. These patients may require repeated surgical procedures including sternal debridement. We present a case who had chronic Escherichia coli surgical site infection and mediastinitis after complete repair of tetralogy of Fallot. Methods A 2.7-year-old boy who underwent an uneventful surgical total correction procedure for tetralogy of Fallot 9 months before, was referred to our centre because of fever and swelling on sternal incision. Infective endocarditis was ruled out by echocardiographic examination. After ampicillin/sulbactam and clindamycin treatment, the abscess spontaneously drained. Cultures were positive for ESBL-producing E. coli. He had sternal debridement, appropriate antibiotic therapy and was discharged from hospital. Results Six months later, he was admitted because of effluent from sternal incision scar. MRI of mediastinum revealed a deep sternal wound infection. ESBL-positive E. coli was isolated in cultures taken from the suppurative effluent. Mediastinitis was confirmed by exploratory sternotomy. Cultures of blood and mediastinal swabs were positive for the same organism. The child had an uneventful recovery after the surgical and medical treatment. Conclusions Mediastinitis should also be considered in patients with sternal wound infections after heart surgery. Aggresive surgical and medical treatment is essential.

PO-0175 Successful Treatment Of Fluconazole-resistant Candida Albicans Endocarditis With Caspofungin In An Infant Who Had A Pulmonary Artery Banding Procedure

Background and aims Despite the application of surgery and antifungal therapy, Candida endocarditis remains a life-threatening infection with significant morbidity and mortality. We report an infant with floconazole-resistant Candida albicans endocarditis who had a congenital heart defect and was treated successfully with caspofungin. Methods A 13-month-old girl was admitted to our centre with a 3-day history of vomiting, fever and cough. She had a history of pulmonary artery banding for a large ventricular septal defect at 4 months of age. After the operation she had been hospitalised about 3 months in the intensive care unit and had been discharged with tracheostomy and home ventilation due to chronic lung disease. At admission, she had irritability, dyspnea and a severe systolic murmur. Laboratory tests revealed an increase in acute-phase reactants and anaemia. Transthoracic echocardiography showed a vegetation measuring 7 × 10 mm on the wall of right pulmonary artery, just distal to the pulmonary banding region. Blood cultures were obtained and empiric antibiotic treatment with ampicillin/sulbactam and gentamicin was started. Results C. albicans was isolated from two of her blood culture samples, which was not responsive to one-week course of fluconazole treatment. The isolate was found to be resistant to fluconazole. Patient recovered completely with a six-week course of caspofungin treatment. Conclusions Physicians should be aware of the possibility of fungal pathogens in endocarditis. Microbiologic diagnosis contributes to successful treatment of Candida endocarditis.

Severe iron deficiency anemia due to late presentation of congenital diaphragmatic hernia in a toddler.

To the Editor, A 3-year-old female toddler was referred to our pediatric emergency unit with a 2-week history of fatigue, anorexia, progressive pallor, and vomiting. Medical history showed that iron deficiency anemia was diagnosed one year before and oral iron-sulfate was given. She also had a one year history of intermittent vomiting. Her diet seemed adequate in iron-rich foods. Chest X-ray and abdominal ultrasonographic examination performed in a medical center were normal. Complete blood count findings were as follows: Hb: 1.7 g/dL; WBC count: 8.0 x 109/L; ANC: 4.6 x 109/L; Hct: 6.9%; RBC count: 1.19 x 1012/L; RDW: 20.5; MCV: 58 fL; Plt count: 485 x 109/L; absolute reticulocyte count: 45.5 x 109/L (normal: 50-150 x 109/L). Peripheral blood smear showed hypochromic microcytic red cells, polychromasia, and nucleated red cells. Serum iron was 5 μg/dL, total iron binding capacity was 450 μg/dL, and ferritin was <1 ng/mL. She was hospitalized and given packed red cell transfusion. The following day she suddenly developed respiratory distress after breakfast. Chest X-ray showed a radiolucent lesion in the right paracardiac area (Figure). Congenital diaphragmatic hernia (CDH) was confirmed via barium gastrointestinal X-ray and computed tomography of the chest. During surgery the retrosternal diaphragmatic hernia sack was excised, and the stomach, intestines, and transverse colon were reduced to the abdominal cavity. Nissen fundoplication was also performed in an effort to prevent postoperative gastroesophageal reflux; however, another defect was noted on the left posterolateral side of the diaphragm. The defect was repaired and Thal anterior fundoplication was performed. The patient had both Morgagni and Bochdalek defects Figure X-ray of the thorax showing the radiolucent area with clear borders in the right paracardiac region. At 6 weeks post surgery the patient had no gastrointestinal symptoms, but her Hb dropped to 7.9 g/dL and fecal occult blood test findings were positive (Hct: 25.6%; RBC count: 3.63 x 1012/L; MCV: 70.5 fL; MCH: 21.9; MCHC: 31; RDW: 24; WBC count: 9.8 x 109/L; ANC: 4.3 x 109/L, Plt count: 453 x 109/L; absolute reticulocyte count: 11 x 109/L) [normal 50-150 x 109/L]). Peripheral blood smear showed hypochromic microcytic red cells. Esophagogastroduodenoscopy and esophageal biopsy showed erosions, gastroesophageal reflux, chronic inflammation, and hyperplasia of the epithelium. A proton pump inhibitor, domperidone, and anti-acid medications were started. Iron sucrose was administered twice weekly for 3 weeks and the Hb increased (Hb: 12.2 g/dL; Htc: 34.6%; RBC count: 4.76 x 109/L; MCV: 72fL; MCH: 25.6; MCHC: 35.1; RDW: 17.4; WBC count: 12.2 x 109/L; ANC: 8.2 x 109/L; Plt count: 348 x 109/L, absolute reticulocyte count: 85 x 109/L [normal: 50-150 x 109/L]; ferritin: 16 ng/mL). Blood smear showed normal red cells. At the 2-year follow-up the patient had no gastrointestinal symptoms or anemia. The coexistence of Morgagni and Bochdalek defects is rarely reported [1]. About 5%-30% of CDH cases present after the neonatal period, which poses a diagnostic challenge [2]. Such symptoms as vomiting and respiratory distress may be acute or intermittent—sometimes due to gastric volvulus or spontaneous reduction of the hernia to the abdomen. During asymptomatic periods imaging findings may be normal [3]. The presented patient had normal abdominal ultrasound and chest X-ray findings before referral to our department. The presented patient most probably had chronic occult blood loss from the gastrointestinal tract due to reflux esophagitis and mechanical trauma to the diaphragm. Sinaki et al. reported 2 patients—a 19 month-old and 6-year-old—that presented with gastrointestinal symptoms and an Hb of 5.8 g/dL and 6 g/dL, respectively [4]. Zaki et al. reported a 5-year-old patient with persistent anemia that did not respond to adequate hematinics and blood transfusion. The patient had abdominal pain, melena, an Hb of 4.8 g/dL, and multiple linear gastric erosions on the mucosal folds of the lesser curve of the stomach [5]. CDH must be included in the differential diagnosis of severe iron deficiency anemia in the absence of such obvious causes as nutritional deficiency, melena, hematochezia, and malabsorption. Physicians must be aware that a history of intermittent vomiting and/or sudden onset respiratory distress in young children are indications for imaging of the upper gastrointestinal tract and thorax.