Sait Karaman

Tolerance development in food protein-induced allergic proctocolitis: single centre experience

BACKGROUND Food protein-induced allergic proctocolitis (FPIAP) is characterised by inflammation of the distal colon in response to one or more food proteins. It is a benign condition of bloody stools in a well-appearing infant, with usual onset between one and four weeks of age. OBJECTIVE Our objective was to examine the clinical properties of patients with FPIAP, tolerance development time as well as the risk factors that affect tolerance development. METHODS The clinical symptoms, offending factors, laboratory findings, methods used in the diagnosis and tolerance development for 77 patients followed in the Paediatric Allergy and Gastroenterology Clinics with the diagnosis of FPIAP during January 2010-January 2015 were examined in our retrospective cross-sectional study. RESULTS The starting age of the symptoms was 3.3±4.7 months (0-36). Milk was found as the offending substance for 78% of the patients, milk and egg for 13% and egg for 5%. Mean tolerance development time of the patients was 14.7±11.9 months (3-66 months). Tolerance developed before the age of one year in 40% of the patients. Tolerance developed between the age of 1-2 years in 27%, between the age of 2-3 years in 9% and after the age of 3 years in 5% of the patients. CONCLUSIONS Smaller onset age and onset of symptoms during breastfeeding were found associated with early tolerance development. In the majority of the patients, FPIAP resolves before the age of one year, however in some of the patients this duration may be much longer.

Can neutrophil/lymphocyte ratio be a novel biomarker of inflammation in children with asthma?

Neutrophils are known to play a role in airway inflammation and are activated in inflammatory lung diseases such as asthma. In adult studies the neutrophil/lymphocyte ratio (NLR) was found to be a possible biomarker for both airway and systemic inflammation. However, there is a limited understanding regarding NLR in the pediatric age group. To assess NLR as a biomarker for inflammation in pediatric asthma, 54 children admitted to hospital with exacerbation of asthma between March and October 2013 were enrolled into our study. Complete blood counts were obtained during both exacerbation and an asymptomatic period covering at least 3 months after exacerbation. NLRs of the study group during both exacerbation and the asymptomatic period were compared and these two datasets were then compared with the control group. The study group comprised 27 boys (50%) and 27 girls (50%) with a mean age of 120 ± 36 months. Of the total number of patients, 3.7% had mild, 94.4% had moderate, and 1.9% had severe exacerbation of asthma. The NLRs of the study group were found to be significantly higher during exacerbation compared with both the asymptomatic period and the control group (P = 0.017, P = 0.003). Our study suggests that NLR may be effective and usable measurable biomarker for determining inflammation in cases of pediatric asthma during acute exacerbation period. However, a broad analysis of dependent and independent variables in further prospective studies, is still required. Trial registration: Not applicable.

Diagnostic values for egg white specific IgE levels with the skin prick test in Turkish children with egg white allergy

BACKGROUND The diagnostic values for the skin prick test (SPT) diameters and egg white-specific IgE (EW-sIgE) levels that will allow us to predict the result of the oral food challenge test (OFC) in the diagnosis of egg white allergy vary by the community where the study is carried out. OBJECTIVE This study aimed to determine the diagnostic values of SPT and EW-sIgE levels in the diagnosis of egg white allergy. METHODS 59 patients followed with the diagnosis of egg allergy September 2013 to September 2015 were included in our retrospective cross-sectional study. The patients were investigated in terms of egg and anaphylaxis history or the requirement of the OFC positivity. The demographic, clinical and laboratory findings of the cases were recorded, and they were compared with the patients with the suspected egg allergy but negative OFC (n=47). RESULTS In the study, for all age groups, the value of 5mm in SPT was found to be significant at 96.4% positive predictive value (PPV) and 97.8% specificity and the value of 5.27kU/L for EW-sIgE was found to be significant at 76% PPV and 86.6% specificity for egg white. The diagnostic power of the SPT for egg white (AUC: 72.2%) was determined to be significantly higher compared to the diagnostic power of the EW-sIgE (AUC: 52.3%) (p<0.05). CONCLUSION Along with the determination of the diagnostic values of communities, the rapid and accurate diagnosis of the children with a food allergy will be ensured, and the patient follow-up will be made easier.

Can mean platelet volume and neutrophil-to-lymphocyte ratio be biomarkers of acute exacerbation of bronchiectasis in children?

Introduction Bronchiectasis (BE) is a parenchymal lung disease evolving as a result of recurrent lung infections and chronic inflammation. Although it has been shown in adult studies that mean platelet volume (MPV) and neutrophil-to-lymphocyte ratio (NLR) can be used as biomarkers of airway inflammation, knowledge is limited in the paediatric age group. The aim of our study is to investigate the potential of MPV and NLR as biomarkers that may indicate acute exacerbations of non-cystic fibrosis BE in children. Material and methods Children with non-cystic fibrosis BE (n = 50), who were followed in the division of Paediatric Pulmonology of our hospital between June 2010 and July 2015, were involved in the present retrospective cross-sectional study. Haemogram values during acute exacerbations and non-exacerbation periods, and a control group were compared. Results In children with bronchiectasis, the average leukocyte count (p < 0.001), platelet count (p = 0.018), absolute neutrophil count (p < 0.001), and NLR (p < 0.001) were higher, as expected, when compared with the control group. NLR values, in the period of acute exacerbation were significantly higher than the values of both the non-exacerbation periods (p = 0.02) and the control group (p < 0.001). In contrast, MPV values in the period of acute exacerbation did not exhibit a significant difference from those of non-exacerbation periods (p = 0.530) and the control group (p = 0.103). Conclusions It was concluded that leukocyte count, platelet count, absolute neutrophil count, and NLR can be used to show chronic inflammation in BE, but only NLR and absolute neutrophil count can be used as biomarkers to show acute exacerbations.

Unusual Radiological Sign in Bronchial Atresia

Bronchial atresia is usually diagnosed by incidentally detecting opacitiy at hilar ragion and hyperinflation around this opacity on chest X-ray. It may rarely be detected as air sac like atresic bronchus. The breath sounds in the right hemithorax were heard less when compared to the left hemithorax in the auscultation of a 16-year-old male patient with allergic rhinitis. The patient had no pulmonary complaints, and this finding was not recorded in his previous follow-up. In order to determine the etiology of hyperinflation seen on chest X-ray, computed tomography was performed. Hyperinflation was identified in the lower lobe superior segment of the right lung, which could be secondary to bronchial atresia. It was confirmed that in the evaluation of computed tomography with three-dimensional reconstruction, lower lobe superior segment bronchus of the right lung was atresic and contrary to expected mucus opacity in the distal of atresia, dilated bronchus was filled with air. This case was especially presented to lay emphasis on careful auscultation and share its unusual radiological presentation which had been reported twice before.

Can mean platelet volume be used as a biomarker for asthma

Introduction Platelets play important roles in airway inflammation and are activated in inflammatory lung diseases, including asthma. Aim We evaluated the mean platelet volume (MPV), used as a marker of platelet activation, in asthmatic patients during asymptomatic periods and exacerbations compared to healthy controls to determine whether MPV can be used as an indicator of inflammation. Material and methods Our patient group consisted of 95 children with exacerbation of asthma who were admitted to our allergy clinic. The control group consisted of 100 healthy children matched for age, gender, and ethnicity. Mean platelet volume values of the patient group obtained during exacerbation of asthma were compared to those of the same group during the asymptomatic period and with the control group. We investigated factors that can affect the MPV values of asthma patients, including infection, atopy, immunotherapy treatment, and severity of asthma exacerbation. Results The patient group consisted of 50 (52.6%) boys and 45 (47.4%) girls with a mean age of 125 ±38 months old. Mean MPV values in the exacerbation period, the healthy period, and in the control group were 8.1 ±0.8 fl, 8.1 ±1.06 fl, and 8.2 ±0.9 fl, respectively; there were no significant differences between groups (p > 0.05). The severity of asthma, severity of asthma exacerbation, immunotherapy, coinfection, eosinophil count, and IgE level also had no effect on MPV (p > 0.05). Conclusions Although platelets play a role in the pathophysiology of asthma, MPV measurement is insufficient to detect inflammation through platelets.

Five years of experience in transient hypogammaglobulinemia of infancy

Objective: Transient hypogammaglobulinemia of infancy (THI) is a transient primary immune deficiency stemming from delay in immunoglobulin synthesis which spontaneously, and completely resolves with age. In this study, cases which were followed with the initial diagnosis of hypogammaglobulinemia and received the diagnosis of THI were retrospectively evaluated. Methods: A total of 193 patients, who received the diagnosis of THI in the Department of Immunology of Dr. Behçet Uz Children’s Hospital, and Pediatric Surgery between January 2011 and December 2015, were included in the study. Clinical, laboratory and demographic data, prophylactic treatments they received, their follow-up periods, and age of onset of disease resolution were retrospectively analyzed. Results: In the study, 70.5% of 193 cases were male. The age of onset of symptoms was 11.7±7.0 month, the age of hypogammaglobulinemia recovery was 30.6±10.5 month. The cases were most frequently admitted (40.9%) for the recurrent upper respiratory tract infection. Only one case had immunodeficiency in the family history. At the admission, the immunoglobulin levels were as follows; IgG: 420.2±110.6 mg/dL, IgA: 29.8±23.3 mg/dL, IgM: 71±3.1 mg/dL. In vaccine responses; anti tetanus 75.9% (60/79), anti HBs 91.6% (141/154) and anti hemophilus influenza type B was 86.4% (51/59) positive. Twenty five (13%) of the patients received only antibiotic prophylaxis, 19 of them (9.8%) received only IV gamma globulin replacement, and 6 of them ( 3.1%) received both. There was no statistically significant difference between age of recovery and infection frequency, clinical presentation, vaccination response, IV gamma globulin replacement and antibiotic prophylaxis (p>0.05). Conclusion: THI is usually recovers spontaneously around 3 years of age. There is no relationship between age of recovery and clinical presentation, vaccine responses, IV gamma globulin replacement and antibiotic prophylaxis. The cases must be monitored regularly for correct diagnosis.

Risk of systemic allergic reactions to allergen immunotherapy in a pediatric allergy clinic in Turkey

OBJECTIVES Even though allergen immunotherapy is an effective treatment method that has been used on rhinitis, asthma and venom anaphylaxis for over 100 years, systemic reactions (SRs) limit the use of this treatment method. We classified SRs associated with subcutaneous immunotherapy (SCIT) according to the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System. Risk factors for the SRs were assessed. METHODS In this study 67,758 injections to 1350 children with allergic rhinitis and/or asthma were analyzed throughout January 1999-December 2014. RESULTS A total of 51 systemic reactions were observed in 39 patients (0.075% per injection, %3 per patient). Mean age of SRs observed patients was 13±2.6 years (range 9.5-16 years) and 64.1% were male, 35.9% were female. 51.3% of SRs were grade 1, 38.5% grade 2, 7.7% grade 3 and 2.6% grade 4. SRs were early onset in 41% of the patients and delayed onset in 59%. 76.9% of SRs were seen during maintenance therapy and 56.4% during peak pollen season. In 28.2% of cases previous local reactions and in 30.8% previous grade 1 reactions were determined. There was no fatal outcome from any of the SRs. CONCLUSION SCIT related SRs are generally of mild severity. Although only 10% of the SRs were grade 3 or 4, there is a still a small risk of severe reactions. 76.9% of SRs were observed during maintenance therapy. Delayed-onset SRs rate in our study is 59%. So both clinicians and parents should be alert about the delayed reactions after SCIT.

Seizures as a rare but serious adverse effect of leukotriene receptor

Leukotriene receptor antagonists (LTRAs) are used widely in the treatment of allergic rhinitis and asthma in children.1,2 LTRAs are safe in combination with antihistamines in patients with chronic urticaria who respond inadequately to antihistamines alone.3 Several clinical trials have emphasized that LTRAs can be considered safe. Nevertheless, many adverse effects associatedwith LTRAs have been reported. Most of the adverse events aremild (headache, gastrointestinal disorders, pharyngitis, fatigue, upper respiratory tract infection, cutaneous rash, and reversible changes in the serum transaminase levels). Although adverse events, such as seizures, are probable, no case reports of LTRAs leading to or triggering convulsions have been reported.1,2 We describe 3 patients who had convulsions after beginning treatment with LTRAs. Patient 1 was a 15-year-old girl with atopic asthma who was monitored for 2 years. She started using valproic acid for epilepsy 1 year ago. No seizures were observed while she was taking inhaled corticosteroids and valproic acid. Three days after adding an LTRA to her asthma treatment, she started having seizures during sleep. Initially, her physicians and family did not associate the convulsions with the LTRA. While she was hospitalized for her convulsions, the LTRA could not be given because the family left it at home. No seizures were observed during the hospitalization, and the patient was discharged. When she returned home and started using the LTRA again, the seizures during sleep returned. Consequently, the LTRA was blamed for triggering the seizures and was stopped. seizure further seizures were observed. Patient 2 was a 6-year-old girl who had been followed up with a diagnosis of epilepsy for 1.5 years. She was using antiepileptic medication but had not had any seizures in the last year. When she had attacks of wheezing, an LTRAwas added to treat mild persistent asthma. With resumption of use of the LTRA, she started having seizures again. The family suspected the LTRA and discontinued its use. The seizures disappeared. A few weeks later, when the patient’s asthmatic symptoms increased, the patient started using the LTRA again, and the seizures returned. We recommended discontinuing use of the LTRA, and the seizures were controlled. Patient 3was a 21⁄2-year-old boywith an episode of urticaria that lasted for 1.5 months and was treated with antihistamines. His pediatrician added an LTRA to the treatment when the antihistamines failed to control the urticaria. Three days after adding the LTRA to his treatment, the patient had an afebrile convulsion for the first time in his life. At that time, the antihistamines were held responsible for the seizure. All medications were cut for 1 week, and the patient’s seizures disappeared. Three days after starting use of only an LTRA for the ongoing urticaria, the patient had another