Iron supplementation in children with celiac disease

OBJECTIVE

To evaluate the effect of iron supplementation, in addition to gluten free diet (GFD), on hematological profile of children with Celiac Disease (CD).

METHODS

Children diagnosed as CD as per modified ESPGAN criteria were prospectively evaluated for their hematological profile at the time of their enrolment and after consuming GFD for at least one year. The results were compared with age and sex matched controls. Evaluation of hematological profile included hemoglobin estimation, complete blood counts, peripheral blood smear examination, serum iron, total iron binding capacity (TIBC), and serum ferritin estimation. All the enrolled cases were given iron supplementation in addition to exclusion of gluten from their diet. Repeat intestinal biopsy was performed in all the cases after completing 1 year on GFD.

RESULTS

Twenty one children (mean age 6.67 years, range 4-11 years) diagnosed as CD who completed at least one year of regular follow up on GFD (mean 1.5 years, range 1-2 years) were analysed for their hematological profile at the time of enrolment and after consuming GFD and iron supplementation. At the time of enrolment all the children had hemoglobin level <11 gm%, 78% had microcytic hypochromic anemia and 22% had dimorphic anemia, with lower mean MCV, MCH and serum ferritin levels, and a significantly higher mean TIBC as compared to controls (p<0.001). In the follow up evaluation of these cases on GFD, mean hemoglobin levels were comparable with controls but the cases continued to have lower mean MCV, MCH serum ferritin levels (p<0.05) and higher mean TIBC (p<0.05). Seven children had mild anemia. Serum ferritin levels showed a negative correlation with the grade of villous atrophy and lamina propria infiltrate.

CONCLUSION

Our results suggest that iron deficiency anemia (IDA) is commonly associated with CD and iron deficiency state continues for a longer time even after excluding gluten from the diet and iron supplementation. Apart from offering them GFD rich in iron, early detection and treatment of IDA and prophylactic iron folic acid supplementation will go a long way to optimize their mental and psychomotor functions.

Clinical and nutritional profile of children with celiac disease

This prospective study was aimed to evaluate the clinical and nutritional profile of children diagnosed as celiac disease (CD) as per the modified ESPGAN criteria, at the time of diagnosis and after institution of gluten free diet. Out of 65 enrolled cases of CD, 7 (10.8%) children did not follow a strict dietary compliance. Only 41 children with satisfactory dietary compliance on gluten free diet (GFD) who regularly attended the follow up for at least 6 months were evaluated for their nutritional and hematological status. Results were compared with age and sex matched controls. The mean age of diagnosis was 8.7 +/- 3.3 years. Diarrhea and failure to thrive were the most common presenting symptoms. At diagnosis, the nutritional and hematological indices were significantly lower in patients than in controls. Mean duration of follow up on GFD was 22 months (range 6-48 +/- 5.6 months). On follow up, height for age Z score was significantly lower, mean BMI was significantly higher, and weight for age Z score, weight for height Z score (%), mean triceps and biceps skin fold thickness, and mid arm circumference were comparable to controls. At diagnosis, 80% cases had microcytic hypochromic anemia and 20% had dimorphic anemia. On GFD for at least a period of more than 6 months, 19% had microcytic anemia and in 81% the hematological picture was normocytic normochromic. 60% cases had thrombocytosis at diagnosis in comparison to 2.3% after treatment. Institution of GFD leads to rapid improvement in clinical picture as well as most of the nutritional and hematological parameters.

Cladosporium bantianum meningitis in a neonate

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis of C. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.

Diagnostic modalities for gastroesophageal reflux

OBJECTIVE

To evaluate commonly utilized diagnostic modalities to detecting Gastroesophageal Reflux (GER).

METHODS

Sixty children aged 1-72 months (mean age 14.7 months) with symptoms suggestive of Gastroesosphageal Reflux (GER) were investigated and subjected to upper gastrointestinal endoscopy and esophageal biopsy (EB), gastroesophageal scintiscanning (GS) and 24 hour ambulatory pH monitoring.

RESULT

GER was detected in 28 (46.7%) cases by one or more diagnostic modalities. Ambulatory 24 hour pH monitoring was positive in higher proportion (43.3%) of cases in comparison to other modalities, followed by EB (38.3%) and GS (30%). Considering 24 hour pH monitoring as the gold standard, esophageal biopsy was positive in 22/26 cases (84.6%) detected by 24 hour pH monitoring with a specificity of 97.1% as compared to 17/26 cases (65.4%) by gastroesophageal scintiscanning with a specificity of 97.1%. When compared with EB results, amongst various parameters measured during 24 hour pH monitoring, Reflux index (RI) ranked highest (sensitivity 95.6 % and specificity 89.2 %) followed by duration of longest episode > 20 minutes and Euler Byrne score. Oscillatory index, calculated from tracings of pH monitoring, even though ranked lower because of its low sensitivity helped to pick up 2 cases missed by EB and RI.

CONCLUSION

Our results suggest that a combination of diagnostic modalities may be required to diagnose GER in young children. Ambulatory 24 hour pH monitoring appears to be the single best investigation and combining it with EB and/or GS can help to detect maximum number of cases.

Association of gastroesophageal reflux disease in young children with persistent respiratory symptoms

Forty children aged between 3 months and 3 years (median age 14 months) with persistent respiratory symptoms beyond 4 weeks or recurrence of respiratory symptoms were investigated for gastroesophageal reflux (GER). Diagnostic tests included upper gastrointestinal endoscopy, oesophageal biopsy, gastroesophageal scintiscan and 24 h ambulatory oesophageal pH monitoring. GER was detected in 14 (35 per cent) of these patients; which included 38 per cent of the enrolled cases of recurrent bronchopneumonia, 40 per cent cases of reactive airway disease, and 22 per cent cases of persistent cough. Amongst the cases detected to have GER, the age of onset of respiratory symptoms was less than 1 year in 86 per cent of cases (p < 0.01), nocturnal symptoms of cough and wheeze were reported in 78 per cent (p < 0.05), and 86 per cent cases did not present with typical gastrointestinal symptoms (p < 0.01). Family history of asthma was absent in all cases of GER-related reactive airway disease (p < 0.01). Cases detected to have GER were followed for 3-6 months after starting anti-reflux therapy. A significant (p < 0.01) decrease was noticed in the number of further episodes in children with GER-related recurrent bronchopneumonia and reactive airway disease after starting anti-reflux therapy. Improvement was also noticed in nocturnal symptoms and nutritional status after anti-reflux therapy was started. Our results suggest that GER may be one of the possible contributing factors in any child with recurrent and persistent respiratory complaints. Early diagnosis and anti-reflux therapy in cases with GER-related respiratory complaints can result in significant improvement in symptoms.

Evaluation of the utility and cost-effectiveness of obtaining histopathologic diagnosis on all routine tonsillectomy specimens

OBJECTIVES

To evaluate the use and necessity of obtaining histopathology on patients undergoing tonsillectomy, and to provide indications and guidelines for requesting histopathology on tonsillectomy patients.

STUDY DESIGN

At the University of Mississippi Medical Center, we have been routinely obtaining histopathologic diagnoses on every patient undergoing tonsillectomy or tonsillectomy and adenoidectomy. Specimens are separated into left and right tonsils and adenoids. This study was designed at our tertiary care academic center to evaluate the necessity for obtaining histopathologic diagnosis on each of these patients.

METHODS

A retrospective review of histopathologic reports on all patients in both pediatric and adult age groups undergoing tonsillectomy or tonsillectomy and adenoidectomy between January 1994 and December 1999 was performed.

RESULTS

A total of 2438 reports were reviewed. There were 2099 in the pediatric age group and 339 were adults. None of the children had an unusual histopathology finding other than lymphoid hyperplasia. Of the 339 adults, 34 had squamous cell carcinoma and 6 had lymphoma; however, these findings were suspected preoperatively by history and clinical manifestations.

CONCLUSIONS

The general practice guidelines mandate obtaining histopathologic diagnoses on most of the tissues received. Based on our review, histopathology of tonsillectomy and/or adenoidectomy may not be necessary, especially in children. In this era of cutting excess costs of health care dollars, waving histopathology in these cases may have major implications without compromising delivery of quality care.

Sinusitis complicated by meningitis: current management

OBJECTIVES

Meningitis is the most common intracranial complication of sinusitis. We review the incidence, current management, outcomes, and complications of this serious infection. Our study also examines the evolving roles of endoscopic sinus surgery and other new therapeutic and diagnostic modalities in our armamentarium.

STUDY DESIGN

A retrospective chart review was performed at a tertiary academic medical center of all patients diagnosed with sinusitis with complications between January 1985 and December 1999.

METHODS

The patients were divided into two main groups: intracranial versus orbital complications. Meningitis was the most common intracranial complication. Data on patients with sinusitis and meningitis were collected and analyzed.

RESULTS

Intracranial complications were present in 39 of 82 patients whereas orbital complications were noted in 43 patients. Twenty-one of the 39 intracranial complications were meningitis. The most common computed tomography finding in adults (54%) was sphenoid sinusitis. All patients with AIDS (6 of 21) had unique cryptococcus meningitis. In patients without AIDS, the most common organism was Streptococcus pneumoniae (10 of 21). The most common sequela was seizure disorder (4 of 21). Endoscopic sinus surgery was performed on 7 of 21 patients. One patient with AIDS who had sinusitis and meningitis died.

CONCLUSIONS

Meningitis as a complication of sinusitis may still pose a serious threat. Although outcomes are encouraging, sequelae such as seizure disorders and hearing loss are common complications. The introduction of high-resolution computed tomography scans and magnetic resonance imaging and the availability of wide-spectrum antibiotics have improved our management significantly.

Feeding problems in children with cerebral palsy

OBJECTIVE

To determine the magnitude and extent of feeding problems in children with cerebral palsy (CP) and to evaluate the effectiveness of nutritional interventions.

DESIGN

Prospective hospital based interventional study.

METHOD

Children with cerebral palsy of either sex were enrolled randomly and their parents were interviewed for their perception about feeding problems, nutritional status and for their views about the expected outcome of feeding problems. Each case was assessed for feeding problems based on Gisel and Patrick feeding skill score; for nutritional status by measurement of weight, skinfold thickness (at biceps, triceps, suprailiac and subscapular), mid arm circumference and caloric intake; neurologically for type and severity of cerebral palsy and for developmental age by Gasell s developmental scale. Equal number of age and sex matched controls were included for comparison of nutritional status and developmental quotient. Various rehabilitation procedures were applied and their response was observed in the followup ranging from 3-10 months.

RESULTS

One hundred children (76 boys and 24 girls) with cerebral palsy of mean age 2.5 years (range 1 to 9 years) and mean developmental age of 7.6 months (range 1 to 36 months) were included in the study. Oral motor dysfunction (OMD) was found in all cases and in each category. Spastic quadriplegic cerebral palsy (SQCP) and hypotonic patients had significantly poor feeding skill score (p < 0.001). Mean duration of feeding session was 31.5 minutes (range 10-60 minutes). Main food of children with cerebral palsy consisted of liquid and semisolid diet. Children with poor OMD were unable to take solid food. Cases with seizures had significantly more feeding problems than those without seizures (p < 0.001). Parental awareness about feeding problems of their children was significantly low and they overestimated the nutritional status of their children. Anthropometric indicators were significantly lower than controls (p < 0.001). Spastic quadreparesis, hypotonia and poor feeding skill score had negative effect on nutritional status. Thirty per cent parents of cerebral palsy patients were pessimistic about the possibility of any improvement in feeding problems. After nutritional rehabilitation, good improvement was seen in feeding problems, OMD and nutritional status.

CONCLUSION

Nutritional status of children with cerebral palsy is poor due to summation of several factors. Therefore, they should be thoroughly assessed for feeding problems and nutritional status in order to start timely nutritional rehabilitation which can significantly improve their nutritional status and quality of life.

Brush cytology: an adjunct to diagnostic upper GI endoscopy

Endoscopic brush cytology (EBC) was performed in antral and duodenal brushings of children subjected to upper GI endoscopy for the detection of H. pylori (Hp) and trophozoites of Giardia lamblia (Glt) in addition to routine endoscopic grasp biopsy (EGB). It was hospital based prospective study. EBC was performed in children subjected to upper GI endoscopy with a sheathed cytology brush. Mucosal brushings were collected from antrum, body of the stomach and second or third part of duodenum by gently rubbing the surface of the brush with the mucosal wall in all the directions, brush withdrawn and brushings performed on a glass slide. The smears were placed in 95% ethyl alcohol and later examined for Glt and Hp using Giemsa and Hematoxylin & Eosin stain. EGB was taken from antrum, body of the stomach and duodenum from sites other than those used for brushings. One hundred and seventy children between 1-13 years (median age = 5 years) were subjected to upper GI endoscopy for malabsorption (n = 94), recurrent abdominal pain (n = 49), failure to thrive (n = 16) and recurrent vomiting/regurgitation (n = 11) and EBC was performed in addition to routine EGB. Thirty five children (20.4%) were colonized by Hp, 14 (8.2%) were detected to have Glt and in 6 cases (3.5%) both Hp as well as Glt were detected. Out of 41 cases colonized by Hp, 24 cases (58.5%) were detected by EGB and 27 cases (65.8%) were detected by EBC. Out of 20 children in whom Glt were detected from their duodenum, the detection was by EBG in 12 cases (60%) and by EBC in as many as 19 cases (95%). Comparison of EGB and EBC suggested that detection rates with EBC were higher than EGB. Detection by EBC was significantly higher for Glt than Hp. There were no complications attributed to EBC and procedure time for endoscopy was not significantly prolonged. On the contrary, detection of Hp and particularly Glt in higher proportion of cases with the help of EBC was helpful in their appropriate management. Our results suggest that EBC is a safe and useful tool to enhance the value of diagnostic endoscopic procedure when used in combination with routine EGB.

Tracheobronchial extension of recurrent respiratory papillomatosis

Endobronchial and pulmonary dissemination reportedly occurs in 5% of patients with laryngeal papillomatosis. It is more frequently observed in the juvenile form, and carries significant implications for treatment. In this study, we review our experiences with pulmonary and endobronchial extension of laryngeal papillomatosis. The records of the 52 patients with laryngeal papillomas treated at our institution since 1980 were reviewed. Twenty-nine percent of the patients (N = 15) developed tracheobronchial extension; 7% (N = 4) demonstrated pulmonary involvement. The birth history, race, sex, age at onset of symptoms, presenting symptoms, site and type of papillomas, surgical procedures, other methods of treatment, complications, and mortality data were analyzed. Eighty percent of the patients with tracheobronchial involvement were born to mothers with a positive history of vaginal condylomas. Pulmonary changes in 4 patients were observed on either chest radiographs or computed tomography and were manifested as multiple parenchymal nodules in 3 of the 4 patients. Pneumatoceles, cavitary empyema, and multiple recurrent pneumonias were the predominant complications of pulmonary involvement. Of the 15 patients with tracheobronchial extension, 80% (N = 12) required tracheotomy before their presentation to us. The number of multiple surgical procedures performed to remove papillomas ranged from 7 procedures in 1 patient with a solitary tracheobronchial lesion to more than 100 procedures in 2 patients with diffuse bronchopulmonary papillomatosis. As our study shows, tracheobronchial involvement continues to complicate surgical treatment in this challenging disease process.

Effect of tympanic perforations on the detection of distortion-product otoacoustic emissions

The detection of distortion-product otoacoustic emissions (DPOAEs) depends on the viability of the ear's conduction apparatus. However, tympanic membrane perforations and other conductive disorders have not been fully investigated with regard to the examination of DPOAEs. Using the guinea pig model, we made perforations of different sizes and loci on the tympanic membrane and collected DPOAEs data for frequencies between 2,193 and 5,508 Hz for each condition. We found that small perforations, up to 25% of the area of the tympanic membrane, still allow us to detect emissions at the specified frequencies. However, perforations of 50% and larger, as well as those accompanied by traumatic perilymph fistulas and ossicular disarticulations, severely interfered with the detection of DPOAEs. We discuss the clinical relevance of these findings with respect to the potential uses of DPOAEs.

Value of radiologic imaging and computer assisted surgery in surgical decisions of the anterior skull base lesions

The role of radiologic imaging in surgical decision making of anterior skull base lesions has been found to be critical in the endoscopic surgical management of these lesions. The non-invasive radiologic imaging may include the use of CT scans, MRI scans, MRA scans and their subtraction technique. The imaging offers an understanding of the vascularity of the lesion, the relationship to the nearby neurovascular structures and the type of tissue density of these lesions. The addition of image guided applications offers one a sagittal reconstruction and a 3-D imaging capacity which has immensely improved the accuracy and precision in endoscopic surgical applications in these areas.

Yolk sac tumor of the temporal bone: report of a case

Yolk sac tumor (endodermal sinus tumor) is rarely encountered in the temporal bone. Facial nerve paralysis can be a primary manifestation of this condition. Histologically, the tumor can be difficult to diagnose, although elevated levels of alpha fetoprotein can facilitate its identification. In this report, we describe the case of an 18-month-old girl who developed peripheral VIIth nerve palsy and a polypoid mass in the left external ear canal 3 months following myringotomy. Computed tomography and magnetic resonance imaging revealed that the tumor involved the left external ear canal, middle ear space, and mastoid air cells. Biopsies were consistent with a yolk sac tumor. Special staining demonstrated that only a very few tumor cells were positive for alpha fetoprotein, despite the markedly elevated level of alpha fetoprotein in her serum. The patient was treated with chemotherapy, which included cisplatin, etoposide, and bleomycin. Within a period of weeks, she experienced a complete reversal of her left VIIth nerve palsy, a marked decrease in her serum alpha fetoprotein levels, and a dramatic resolution of the tumor as demonstrated radiographically. Such a successful chemotherapeutic response in this case argues against surgical intervention in other cases, particularly in view of the risk of serious complications with surgery.

Goldenhar syndrome with rare associations

Goldenhar syndrome is a malformation complex involving the structures arising from first and second branchial arches, the first pharyngeal pouch, first branchial cleft and primordia of the temporal bone. Though the syndrome itself is not very rare, the presence of polydactyly and hydrocephalus, which are rare associations, prompted us to report this case.

Hepatic dysfunction in childhood dengue infection

Hepatic functions of 61 children, diagnosed to have dengue infection (DI), aged 2 months to 12 years comprising 37 cases of dengue fever (DF), 16 with dengue hemorrhagic fever (DHF), and eight with dengue shock syndrome (DSS) were prospectively studied during the acute attack. Hepatomegaly (74 per cent), epistaxis (26 per cent), jaundice (25 per cent), and petechial rashes (18 per cent) were the common clinical manifestations of DI. On admission, levels of serum aspartate transaminase (AST), serum alanine transaminase (ALT) and serum alkaline phosphatase (AP) were raised in 80-87 per cent of children with hepatomegaly (group I) and 81 per cent of cases without hepatomegaly (group II). During the second week of hospitalization the proportion of cases with raised levels of AST, ALT, AP and serum bilirubin increased and the mean levels were significantly higher (p < 0.05) in both the groups. These levels gradually declined over the next 2-3 weeks. All the cases with DSS and DHF had raised AST, ALT and AP levels and the mean levels of these enzymes were significantly higher (p < 0.05) as compared to DF. Our results suggest a transient derangement of liver functions in childhood DI, more so in DSS and DHF, with or without hepatomegaly.

Study of diagnostic modalities and pathology of Helicobacter pylori infection in children

To evaluate various diagnostic tests for Helicobacter pylori (Hp) in children, and to study the spectrum of endoscopic and histological changes in the stomach and duodenum of children with gastroduodenal disorders, associated with Hp infection Children below 12 years of age with various gastroduodenal disorders requiring upper gastrointestinal endoscopy were studied. Endoscopic biopsy specimens were collected from duodenum and antrum. Apart from histopathological examination of biopsy material, rapid urease test (RUT) of the antral biopsy specimen and blood examination to estimate specific IgG antibodies to Hp by Indirect Solid Phase Enzyme Immunoassay was performed. Forty seven children were included. Nine (19.1%) of them were positive both by serology and RUT. Seven (14.9%) were positive by histology. A significant correlation of Hp was noticed with chronic antral gastritis (p = 0.002) and chronic duodenitis (p = 0.006). Age equal to or more than 10 years was found to be significant risk factor for acquiring Hp infection. Prevalence of Hp in children with gastroduodenal complaints was found to be 19%. Both RUT and serology were found to be reliable diagnostic tests for Hp as compared with histology. Antral gastritis and chronic duodenitis had a significant correlation with Hp colonization.

Magnetic resonance navigation for head and neck lesions

OBJECTIVE

Review applications of interventional magnetic resonance imaging and describe methods, procedures, and additional instrumentation for the magnetic resonance "operating theater." Describe advantages of magnetic resonance navigation for biopsies of head and neck tumors.

STUDY DESIGN

Patients with palpable and nonpalpable head and neck and cranial base tumors were recruited into the study. Patients underwent magnetic resonance-guided biopsy. Retrospective analysis of 21 patients was conducted.

METHODS

0.5 Tesla superconducting open magnetic resonance imaging was used for navigation of the biopsy needle. Patient records and magnetic resonance images were reviewed. The type, size, and location of the lesions were tabulated. Type of anesthesia and monitoring method were analyzed. The histopathologic correlation was conducted in patients who required further surgeries or open surgical biopsies.

RESULTS

Twenty-two biopsies were carried out in the magnetic resonance suite. One patient required general anesthesia and the other biopsies were conducted under intravenous sedation. There was only one case of nonconcurrence in a patient with Wegener's granulomatosis of the posterior orbit. Overall, a 92% concurrence rate between image-directed fine-needle aspiration, open biopsy, and surgical therapy was encountered. No complications occurred.

CONCLUSIONS

The use of interventional magnetic resonance imaging to assist with fine-needle aspiration core biopsy has made the biopsy procedure safer and more accurate. Potentially morbid and disfiguring surgeries have been avoided in some patients. Deeper lesions have been more easily approached, as the needle for biopsy is under constant magnetic resonance guidance. Improved visualization for critical structures allows safer performance of biopsies. The primary difficulties of open magnetic resonance imaging relate to the need for nonferromagnetic instrumentation and equipment and their high costs. An inverse relationship exists between the imaging quality and the "dead time" required to acquire images.

Electroneurography during facial nerve expansion

With the use of tissue-expansion techniques, it is possible to elongate the facial nerve without impairing its function. The rate of expansion is limited by ischemic events imposed by stretching of the nerve and by anatomic characteristics of the nerve segment. In this study, we used various electroneurography techniques to determine the first sign of facial dysfunction during expansion. The main objective of the study was to ascertain test-retest variability of electroneurography techniques. Facial nerves were expanded in 16 cats with the use of a tissue expander secured more deeply to the main trunk. We conducted electroneurography measurements with the use of surface electrodes, temporary needle electrodes, and permanently implanted electrodes. Technique-dependent variations encountered with the surface electrodes made this method unreliable. Using implanted electrodes, we noted gradual worsening of the compound-action potential amplitude with increasing expansion. During acute expansion, reduction in compound-action potential amplitude was correlated with clinically observed deterioration of facial-nerve function. In this study, electroneurography with implanted electrodes was found to be the most reliable predictor of the rate of successful facial nerve expansion.