The Effect of Amino Acid, Carbohydrate, and Lipid Metabolism Disorders on Eyes

Inherited metabolic disorders (IMDs) are a class of genetic disorders. Each metabolic disorder may have different forms with different age of onset, clinical manifestations, severity, and even type of inheritance. Ideally, a group of different specialists, including ophthalmologists, pediatricians, biochemists, and medical geneticists are needed for the final diagnosis and management of IMDs. Because of the importance of the aforementioned issue, we investigated the effect of IMDs on the eye in this review. Metabolic disorders can induce abnormalities in conjunctiva, cornea, lens, retina, optic nerve, and eye motility.  In this study, the authors aimed to address the effect of metabolic diseases of amino acids, carbohydrates, and lipids on eye metabolism. Because of the direct toxic mechanisms of abnormal metabolites on the eyes and regarding the effect of eye monitoring on follow-up, management, and treatment of IMDs, a detailed ophthalmological assessment is essential.

A novel pathogenic variant of SRD5A2 in an Iranian psuedohermaphrodite male

Deficiency of the 5‐alpha‐reductase may have an important role in 46,XY DSD in some cohorts. The prenatal ultrasonography and karyotyping can trigger the attention toward the presence of a DSD in fetus.

An uncommon overlap of two common rheumatological disorders

Juvenile systemic lupus erythematosus (SLE) is a heterogeneous multisystem autoimmune disease. Kawasaki disease is a common vasculitic disorder in children that manifests with fever and mucocutaneous involvement. While overlap of childhood SLE with other rheumatological disorders has been described, it is extremely unusual in the context of Kawasaki disease. We report two children who had SLE and developed features of Kawasaki disease simultaneously, and the second child had myocarditis which could be a manifestation of Kawasaki disease rather than SLE. Two or more rheumatological diseases may coexist at the same time and one must always be vigilant.

Clinico-laboratory profile of Kawasaki disease with arthritis in children

Kawasaki disease (KD) is associated with several musculoskeletal manifestations. Although arthritis has been reported to occur in 2.3-31% of children with KD, there is paucity of detailed studies on the subject. We report our experience on arthritis in children with KD. Data were collated from a review of records of patients diagnosed with KD and arthritis during the period January 1994-June 2019. Eight hundred sixty-five children (male:female 29:11) were diagnosed with KD during this period-of these, 40 (4.6%) had arthritis. Median day of diagnosis of KD was 17 days. Twenty-nine (72.5%), 8 (20%), and 3 (8.6%) children developed arthritis in acute, subacute, and convalescent phases of KD, respectively. Oligoarticular involvement was observed in 32 (80%) children and among these, 7 (20%) had monoarthritis. Predominant joints involved were knee (74.3%), ankle (40%), and hip (28.6%). Thirty-two children (80%) were treated with non-steroidal anti-inflammatory drugs (NSAIDs). Median duration of arthritis was 10 days (range, 2-180 days) with uneventful recovery in all cases. Three (7.5%) children had coronary artery ectasia which regressed on follow-up.Conclusion: Arthritis in KD is usually non-erosive, self-limiting, and responds well to a short course of NSAIDs.What is Known:• Arthritis has been reported to occur in 2.3-31% of children with KD.• Arthritis in KD is usually oligoarticular, non-erosive, and responds well to short course of non-steroidal anti-inflammatory drugs.What is New:• Children with KD and arthritis do not appear to be at increased risk of development of coronary artery abnormalities.• Arthritis in children with KD can result in diagnostic confusion, and diagnosis of KD may get delayed.

The effect of concurrent resistance-aerobic training on serum cortisol level, anxiety, and quality of life in pediatric type 1 diabetes

Background Given the importance of anxiety and quality of life for the mental health of children with type 1 diabetes (T1D), exercise prescription can be of crucial significance. The present study aims to explore the effect of concurrent resistance-aerobic training on serum cortisol level, anxiety, and quality of life among pediatric T1D. Methods Forty children (aged 8-14 years) were randomly assigned to experimental (n = 20) and control groups (n = 20) for 16 weeks. The exercise training program was composed of 16 weeks of interval concurrent resistance-aerobic training with a duration of 60 min performed three times a week. The subjects first performed the resistance training (20 min of Pilates exercises and 20 min of body weight-bearing exercises). Then, the aerobic exercises were performed with an intensity of 50-75% of maximum heart rate. Before and after the training, blood tests including cortisol were carried out on the subjects by RIA kit. Anxiety and quality of life were measured by the Revised Children's Manifest Anxiety Scale (RCMAS) and Pediatric Quality of Life (PedsQL), respectively. Body composition was measured by InBody. Data were analyzed by paired and independent t-test at p < 0.05 significance level. Results Sixteen weeks of concurrent resistance-aerobic exercise significantly reduced the anxiety index (p = 0.001) and increased the quality of life (p = 0.003). Although the cortisol index was increased, it did not reveal any significant differences between the experimental and control groups (p = 0.781). No significant differences were observed in the indices of quality of life, anxiety, and cortisol in the control group. Conclusions A 16-week program of concurrent resistance-aerobic training can improve the quality of life and anxiety among children suffering from T1D, but it may not influence the cortisol level (p > 0.05).

Pulmonary Hemosiderosis in a Child With Systemic Lupus Erythematosus: A Rare Presentation

Pulmonary hemorrhage is an uncommon manifestation in children and is often associated with systemic lupus erythematosus. We report a case of an adolescent girl who presented to our hospital with recurrent episodes of fever, cough, and breathlessness. Later on, she was diagnosed with pulmonary hemosiderosis as a manifestation of systemic lupus erythematosus. She was started on immunosuppressive therapy initially with prednisolone and subsequently with azathioprine and hydroxychloroquine, which improved the clinical status of the child.

Self-healing juvenile cutaneous mucinosis, a sclerodermoid disorder simulating juvenile dermatomyositis: a case-based review

Self-healing juvenile cutaneous mucinosis (SHJCM) is a rare childhood disease with characteristic cutaneous and rheumatic manifestations. Cutaneous manifestations include a combination of nodules affecting peri-articular (especially interphalangeal joints) and head and neck areas; and linearly arranged ivory white papules over an erythematous indurated skin. Despite a benign course, an abrupt onset of symptoms with extensive cutaneous involvement often leads to parental anxiety, overenthusiastic evaluation and sometimes aggressive treatment. A peculiar cutaneous distribution in SHJCM including nodular lesions and periorbital edema, arthritis and arthralgia in a few cases, may simulate juvenile dermatomyositis. It is, therefore, important for dermatologists and pediatricians to be aware of this entity. In this report, we describe two cases of SHJCM and briefly review similarly reported cases in children.

Long-term outcome in children with juvenile dermatomyositis: A single-center study from north India

INTRODUCTION

Juvenile dermatomyositis (JDM) is the commonest childhood inflammatory myopathy. Outcome of children with JDM has improved significantly with current treatment protocols. We undertook this study to evaluate long-term outcome of these children using validated outcome measures.

METHODS

All children diagnosed as JDM and on follow-up for more than 2 years were eligible for enrolment. Cross-sectional examination was performed to assess signs of disease activity, damage, physical function and complications by using multiple validated outcome measures/tools.

RESULTS

Thirty-seven patients were enrolled, 19 were male. Median duration of disease at time of enrolment was 73 months (range 24-219 months) and median duration of follow-up was 60 months (range 24-218 months). Disease course was monocyclic in two-thirds of patients. Eight children were still on therapy at the time of enrolment. On Manual Muscle Testing 8, 3 and 7 children had severe weakness and mild to moderate weakness, respectively. Neck flexors were the most commonly affected muscle group. On abbreviated Cutaneous Assessment Tool, 14 children had evidence of cutaneous activity. More than 50% had at least 1 sign of cutaneous damage, most common signs being calcinosis and lipodystrophy. Nearly two-thirds of patients had damage in at least 1 organ using Myositis Damage Index. Nine children had physical dysfunction when assessed by Child Health Assessment Questionnaire.

CONCLUSIONS

Skin disease continued to be active in a significant proportion of patients. Features of damage, namely calcinosis and lipodystrophy, were seen in more than half. Muscle disease normalized in a large proportion of patients.

An update on the genetics and pathogenesis of hereditary angioedema

Hereditary angioedema (HAE) is an uncommon genetic disorder characterized by recurrent episodes of edema involving subcutaneous tissue and submucosa. The pathogenesis of HAE reflects an intricate coordinated regulation of components of complement, kinin and hemostatic pathway. Till date, mutations in 4 different genes have been identified to cause HAE which includes serine protease inhibitor G1 (SERPING1), factor XII (F12), plasminogen (PLG) and angiopoietin 1 (ANGPT 1). These mutations lead to increased bradykinin 2 receptor mediated signalling via increased production of bradykinin except mutations in ANGPT1 gene that disturbs the cytoskeletal assembly of vascular endothelial cells. In this review we aim to summarize the recent advances in the pathogenesis and genetics of HAE. We also provide an overview of possible future prospects in the identification of new genetic defects in HAE.

Platelets in Kawasaki disease: Is this only a numbers game or something beyond?

Kawasaki disease (KD) is a medium vessel vasculitis with predilection to cause coronary artery abnormalities. KD is now the most common cause of acquired heart disease in developed countries. Thrombocytosis is consistently found in patients with KD, usually in 2nd to 3rd week of illness. Thrombocytopenia has occasionally been reported in the acute phase of KD. An increase or decrease in platelet number in patients with KD was initially considered to be a benign phenomenon. However, recent literature on platelet biology in KD has suggested that platelets are not only increasing but are rather activated. This phenomenon has been found to increase the risk of thrombosis in these patients. Similarly a fall in platelet counts during acute stage of KD has also been found to be associated with increased severity of disease. In this review, we update on the current best understanding about pathogenic role of platelets in patients with KD.

Cardiovascular Involvement in Kawasaki Disease Is Much More Than Mere Coronary Arteritis

Kawasaki disease (KD) is now a common cause of acquired heart disease in children. Coronary artery involvement is the most serious complication in children with KD. Several non-coronary complications have now been identified in this condition but these are often overlooked. Myocarditis is an integral component of KD and may be more common than coronary artery abnormalities. Pericardial involvement and valvular abnormalities have also been observed in patients with KD. KD shock syndrome is now being increasingly recognized and may be difficult to differentiate clinically from toxic shock syndrome. Endothelial dysfunction has been reported both during acute stage and also on follow-up. This may be a potentially modifiable cardiovascular risk factor.

Diagnostic accuracy of 3-T lung magnetic resonance imaging in human immunodeficiency virus-positive children

BACKGROUND

More than 70% of human immunodeficiency virus (HIV)-positive children sustain respiratory diseases in their lifetime. Imaging plays an important role in establishing early and correct diagnosis.

OBJECTIVE

To evaluate the diagnostic accuracy of 3-Tesla (T) thorax MRI in HIV-positive children, using chest CT as the gold standard.

MATERIALS AND METHODS

We included 25 children with confirmed HIV-positive status and pulmonary complaints who were referred for chest CT. All children had 3-T thorax MRI using T2-W turbo spin-echo sequence, steady-state free precession gradient echo sequence, T2-W turbo spin-echo MultiVane XD sequence, and T1-weighted modified Dixon sequences. We evaluated the images for various pulmonary and mediastinal findings and calculated the sensitivity and specificity of 3-T thoracic MRI.

RESULTS

Sensitivity of 3-T MRI was 100% for detecting nodules >4 mm (95% confidence interval [CI] 66.3-100%), pleural effusion (CI 29.2-100%) and lymphadenopathy (CI 81.5-100%). It demonstrated a specificity of 100% for nodules >4 mm (CI 79.4-100%), pleural effusion (CI 84.6-100%) and lymphadenopathy (CI 59-100%). For consolidation/collapse, sensitivity and specificity were 93.8% (CI 69.8-99.8%) and 88.9% (CI 51.8-99.7%), respectively. The sensitivity and specificity for detecting bronchiectasis were 75% (CI 42.8-94.5%) and 100% (CI 75.3-100%), respectively, while for ground-glass opacity, sensitivity and specificity were 75% (CI 34.9-96.8%) and 94.1% (CI 71.3-99.9%), respectively. Nodules <4 mm were not well detected on MRI, with sensitivity of 35% (CI 15.4-59.2%).

CONCLUSION

Thoracic MRI at 3 T demonstrates a high sensitivity and specificity for detecting nodules >4 mm, effusion and lymphadenopathy in HIV-positive children.

The Association Between Hemoglobin HbA1c with Serum Inorganic Phosphate in Children with Type 1 Diabetes

BACKGROUND

Diabetes mellitus is one of the most common chronic metabolic diseases in children and adolescents, which changes the cellular metabolism. Phosphorus is an essential element for metabolism. Early in the progression of diabetes, a paradoxical metabolic imbalance in inorganic phosphate (Pi) occurs that may lead to reduced high energy phosphate and tissue hypoxia. While low and high uncontrolled blood sugars can be easily recognized by clinical symptoms, low and high plasma inorganic phosphate remain unrecognizable. Therefore, we aimed to assess the association between hemoglobin A1c (HbA1c) with serum inorganic phosphate in children with type 1 diabetes.

MATERIALS AND METHODS

This cross-sectional study was conducted on 102 patients selected from a pediatric ward in 17th Shahrivar hospital in Rasht, North of Iran. Clinical data including age, sex, height, weight, BMI, duration of diabetes, the level of HbA1c, and phosphorus were gathered. The level of HbA1c was adjusted by age in the final analysis.

RESULTS

The mean age of samples was 9.98±3.91 years old and 46 participants (45.1%) were male. It was found that HbA1c had a reversed and significant relationship with BMI (r=-0.215 and P=0.03), but there was no correlation between phosphate, age, height and weight, duration of diabetes mellitus, or rate of insulin consumption with HbA1c (P>0.05).

CONCLUSION

The finding showed that HbA1c had a reversed relationship with BMI but there was no correlation between phosphate and HbA1c.

Kawasaki Disease in Children Older Than 10 Years: A Clinical Experience From Northwest India

Background: Kawasaki disease (KD) is predominantly seen in young children (<5 years). Diagnosis of KD is often delayed in older children and adolescents, leading to a higher risk of coronary artery abnormalities (CAAs). There is a paucity of literature on KD in older children. Methods: Data were collated from a review of records of patients diagnosed with KD who were aged ≥10 years at the time of diagnosis, during the period from January 1994 to June 2019. Results: Eight hundred and sixty five patients were diagnosed with KD during this period. Of these, 46 (5.3%; 26 boys and 20 girls) were aged 10 years or older at the time of diagnosis. The median age at diagnosis was 11 years (range of 10-30 years). The median interval between the of fever and the diagnosis of KD was 12 days (range of 4-30 days). Eight patients (17.4%) presented with hypotensive shock. Coronary artery abnormalities (CAAs) were seen in six patients (13.04%), and three patients had myocarditis. Patients with CAAs were found to have significantly higher median platelet counts and higher median C-reactive protein levels. First-line treatment included intravenous immunoglobulin. Adjunctive therapy was given in five patients (infliximab in four patients and steroids in one patient). The median time between the onset of fever and the administration of IVIg was 13.5 days (range of 6-2). The total duration of follow up is 2,014.5 patient-months. Conclusion: Diagnosis of KD in children older than 10 years is usually delayed, and these patients are thus at a higher risk of CAAs.

CT Coronary Angiography Studies After a Mean Follow-up of 3.8 Years in Children With Kawasaki Disease and Spontaneous Defervescence

Background: There is paucity of literature on follow-up of children with Kawasaki disease (KD) who have spontaneous defervescence during the acute stage and do not receive intravenous immunoglobulin. We report herein the role of computed tomography coronary angiography (CTCA) as an imaging modality in such situations. Methods: This prospective observational study was carried out during the period January 2016-June 2017. Children underwent CTCA on 128-slice Dual Source CT (DSCT) scanner (Somatom Definition Flash, Siemens; Germany), and 2D-echocardiography on the same day. Results: Mean age at time of diagnosis was 6.52 ± 3.13 years; range 2-14 years. Mean age at time of study was 11.03 ± 5.10 years; range 3.75-23.30 years. Mean interval between diagnosis of KD and time of present study was 3.84 ± 2.27 years. None of the patients showed any coronary artery abnormalities on either 2D-echocardiography or CTCA. While assessment of proximal segments of left main coronary artery, proximal right coronary artery, and left anterior descending artery was comparable on both 2D-echocardiography and CTCA, left circumflex artery, and distal right coronary artery could be clearly visualized only on CTCA. Conclusion: In our experience, patients with KD who have spontaneous defervescence during the acute stage and do not receive IVIg may not have significant long-term coronary sequelae. CTCA is a useful imaging modality for delineation of coronary artery in patients with KD on long term follow-up especially in older children with thick chest walls and poor acoustic windows.

Paraoxonase 3: Structure and Its Role in Pathophysiology of Coronary Artery Disease

Spanning three decades in research, Paraoxonases (PON1) carried potential of dealing with neurotoxicity of organophosphates entering the circulation and preventing cholinergic crisis. In the past few years, the Paraoxonase multigene family (PON1, PON2, PON3) has been shown to play an important role in pathogenesis of cardiovascular disorders including coronary artery disease (CAD). The PON genes are clustered in tandem on the long arm of human chromosome 7 (q21, 22). All of them have been shown to act as antioxidants. Of them, PON3 is the least studied member as its exact physiological substrate is still not clear. This has further led to limitation in our understanding of its role in pathogenesis of CAD and development of the potential therapeutic agents which might modulate its activity, expression in circulation and tissues. In the present review, we discuss the structure and activity of human PON3 enzyme and its Single nucleotide variants that could potentially lead to new clinical strategies in prevention and treatment of CAD.