Severe vaginal laceration in a 5-year-old girl caused by sudden hydro-distention

BACKGROUND

Severe vaginal trauma in young girls is uncommon. We describe a 5-year-old girl who presented a vaginal laceration following sudden hydro-distention.

CASE

A 5-year-old girl was transferred to our institution for vaginal trauma with severe bleeding. Her brother had directed the nozzle of a functioning garden hose against her vulva. She presented pain and persistent vaginal bleeding without external genital lesions. Surgical exploration revealed a laceration of the right vaginal wall. The vagina was sutured and the bleeding stopped.

SUMMARY AND CONCLUSION

This case illustrates a rare mechanism of severe vaginal laceration, in a young girl, by hydro-distention. Though there are often no external lesions the internal lesions can be severe causing significant bleeding. Certainly in these cases aggressive diagnostic evaluation is necessary.

Genetics of toll like receptor 9 in ANCA associated vasculitides

OBJECTIVES

To investigate the contribution of genetic polymorphisms of toll like receptor (TLR) 9 and related genes on the susceptibility and clinical manifestation of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitides (AAV).

METHODS

Four single nucleotide polymorphisms (SNPs) in TLR9 were genotyped in 863 German AAV cases and 1344 healthy controls. Significant results were replicated in a cohort of 426 Dutch and British AAV cases. 11 polymorphisms in TLR9 related genes were studied concomitantly.

RESULTS

A strong association of TLR9 genotypes and haplotypes with granulomatosis with polyangiitis was observed as well as a contrariwise association with microscopic polyangiitis. The association was confirmed when cases were compared according to ANCA status rather than to clinical entity. This was partly replicated in the second cohort leading to a striking overall difference in TLR9 allele/haplotype frequencies between proteinase 3 (PR3) ANCA+ and myeloperoxidase (MPO) ANCA+ cases (p=0.00000398, pc=0.000016, OR 1.68 (95% CI 1.35 to 2.1) for rs352140; p=0.000011, pc=0.000044, OR 1.64 (95% CI 1.31 to 2.04) for a 3-SNP haplotype). No significant association or epistatic effect was detected for TLR9 related genes: interleukin 6, interleukin 23 receptor, myeloid differentiation primary response 88, TNF receptor-associated factor 6, interleukin-1 receptor-associated kinase 4, discs large homolog 5 and nucleotide-binding oligomerisation domain containing 2.

CONCLUSIONS

We provide further evidence that PR3-ANCA+ AAV differs genetically from MPO-ANCA+ AAV. TLR9 signalling may be involved in disease pathology, favouring models of infectious agents triggering AAV development.

Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy

Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome.

Delayed diagnosis of neurological bladder following spinal cord injury without radiological abnormality

Spinal cord injuries are a well-known cause of neurological bladder and a well-known complication of high-velocity trauma. They can, however, be difficult to diagnose in young children, in whom the absence of initial neurological symptoms and normality of the radiological workup can be falsely reassuring. Management of associated injuries can further delay diagnosis. We present 2 cases of spinal cord injuries without radiological abnormality revealed by delayed bladder retention.

Penile length is comparable in boys with and without hypospadias

INTRODUCTION

It has been suggested that penile length is negatively correlated to the degree of hypospadias; however, there are no studies in the literature actually comparing penile length in normal patients and patients with hypospadias.

MATERIAL AND METHOD

Between January and May 2011, we measured penile length in two groups of children aged up to 5 years. The first group comprised all boys admitted for hypospadias (40 patients; 25 distal and 15 proximal hypospadias). The control group comprised 100 boys seen for other surgical procedures excluding those with endocrine disorders. We measured the length of the dorsal aspect of the penis in the flaccid state, without stretching. We then established, using our control group, a range of 'normal' values for penile length in our population and determined whether children with hypospadias were within this 'normal' range.

RESULTS

Mean penile length in the control group was 4.07 ± 0.92 cm, mean penile length in the hypospadias group was 4.36 ± 0.9 cm (4.48 ± 0.89 cm for distal hypospadias and 4.21 ± 0.79 cm for proximal hypospadias). There was no difference in penile length between the hypospadias group and the control group regardless of degree of hypospadias.

CONCLUSION

This study indicates that penile length in children with hypospadias whether proximal or distal is within the normal range.

Evolution of the management of acquired neurogenic bladder in children using intradetrusor botulinum toxin type A injections: 5-year experience and perspectives

OBJECTIVE

To report the clinical and urodynamic results of repeated intradetrusor botulinum toxin type A injections in children with an acquired neurogenic bladder.

PATIENTS AND METHOD

We reviewed the data of 8 patients presenting an acquired neurogenic bladder treated between 2005 and 2010. Their mean age was 12.4 years old (range: 5-18). They were all on clean intermittent catheterization. All patients presented detrusor overactivity resistant to oral anticholinergic treatment. They received between 2 and 6 injections at a dose of 12 botulinum toxin units (BU)/kg (maximum 300 BU). Cystometry was performed 4-8 weeks after treatment.

RESULTS

Five patients became completely dry, 2 were only rarely wet, and data are lacking for 1 patient. Febrile urinary tract infections ceased after 1 or 2 injections. The mean maximal detrusor pressure decreased below 40 cmH(2)O after 1, 2 and 3 injections. The normalized safe capacity rose significantly after 1, 2 and 3 injections. The normalized maximal bladder capacity rose similarly after 1, 2 and 3 injections although not always significantly.

CONCLUSION

Intradetrusor botulinum toxin-A injections significantly reduce detrusor pressure and can be repeated with efficacy. They have their place in between anticholinergic treatment and surgery. The procedure could be simplified and the dosage reduced.

[Management of pediatric liver abscess]

Liver abscess in the pediatric population remains uncommon in developed countries, except in cases of septicemia or in children with major debilitating diseases, granulocyte dysfunction, or immunosuppression. Although much is known about the etiopathogenesis of liver abscess, the gold standard of investigations and treatment is still debatable in developing countries. We report the case of a 6-year-old child living in Reunion Island, with no medical history, presenting with right and pyretic abdominal pain in the right upper quadrant. Ultrasound and CT scan showed a large hypodense nonenhanced area in segment IV. Final diagnosis was, by exclusion, pyogenic liver abscess based on negative serology, recent liver lesion, and normal tumor test results, even if blood culture remained negative. No percutaneous puncture was done because of positive outcome after 4 days of antibiotics. Treatment consisted in three intravenous antibiotics (ceftriaxone, aminoxide, and metronidazole) until complete biological normalization. Ultrasound remained normal 3 months later. Even if liver abscess is uncommon in developing countries, the diagnosis must be raised in cases of isolated liver tumor with fever. Management in the nonimmunosuppressed child must be discussed associating parenteral antibiotic therapy, percutaneous drainage, or surgery in very uncommon cases, according to the liver location and first day's progression. Etiological investigation such as colonoscopy in adults must be adapted to pediatric data.

Giant hepatic cysts: prenatal findings and uncommon postnatal outcome

With modern prenatal imaging, liver cysts are being diagnosed more often. Although large cysts are usually asymptomatic, they may present as an abdominal emergency requiring surgery in the first weeks of life. We report a series of 3 patients with prenatal diagnosis of isolated cystic liver lesions diagnosed at 22, 31 and 33 weeks of gestational age. The hepatic origin of the cysts was confirmed prenatally by a MRI in 2 cases, with visualization of a normal gallbladder. The prenatal course was uneventful. Postnatal ultrasound confirmed the diagnosis of liver cyst, showed normality of the biliary tract and in one case, rupture of the cyst during delivery. Because of an uncommon rapid increase in size, the 3 children underwent surgical excision of the cysts within the first weeks of life. These were non-bile-containing intrahepatic cysts arising from segment IV. Long-term follow up was uneventful.

Neutrophil chemotaxis in granulomatosis with polyangiitis (Wegener's) and idiopathic pulmonary fibrosis

The presence of antineutrophil cytoplasmic antibodies in granulomatosis with polyangiitis (Wegener's) (GPA) implicates the neutrophil as a key effector cell. Previous studies have reported elevated neutrophil counts in the lung, although the determinants of neutrophil chemotaxis in the GPA lung are unknown. Bronchoalveolar lavage fluid (BALF) cell counts, myeloperoxidase (MPO) and chemokines were measured in 27 patients with GPA, 20 disease controls with idiopathic pulmonary fibrosis (IPF) and six healthy controls. CXC chemokine ligand (CXCL)8, interleukin (IL)-1β, epithelial neutrophil-activating protein 78, granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony-stimulating factor were measured by ELISA. The neutrophil chemotactic potential of BALF was investigated using the under-agarose method, and specific antibodies were used to examine the role of CXCL8 and IL-1β. GPA BALF had an increased neutrophil percentage, and elevated MPO, CXCL8 and G-CSF concentrations compared with healthy controls. Chemotaxis of control neutrophils towards BALF from patients with active (p=0.006) and remission (p=0.077) GPA, and IPF (p=0.001) patients was increased compared with normal controls. BALF-induced chemotaxis correlated with BALF IL-1β (r=0.761, p=0.001) and CXCL8 (r=0.640, p=0.012) in GPA, and was inhibited by anti-CXCL8 (85%; p<0.001) and anti-IL-1β (69%; p<0.001). Our study confirms a neutrophilia and pro-inflammatory alveolar milieu that persists in clinical remission. CXCL8 and IL-1β appear to play important roles in the neutrophil chemotactic response to BALF.

ANCA-associated vasculitis is linked to carriage of the Z allele of α₁ antitrypsin and its polymers

BACKGROUND

Small studies have linked α1 antitrypsin (α1AT) deficiency to patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).

OBJECTIVE

To test the validity and the mechanism of this association between α1AT and AAV.

METHODS

The distribution of α1AT deficiency alleles Z and S was compared between 856 White Europeans with AAV and 1505 geographic and ethnically matched healthy controls. Genotyping was performed by allelic discrimination assay.

RESULTS

were compared between cases and controls using χ(2) tests. The serum and renal biopsies for α1AT polymers were compared using the polymer-specific 2C1 antibody. The role of α1AT polymers in promoting inflammation was investigated by examining their ability to prime neutrophils for ANCA activation as assessed by CD62L shedding, superoxide production and myeloperoxidase degranulation. Results The Z but not the S allele was over-represented in the patients compared with controls (HR=2.25, 95% CI 1.60 to 3.19). Higher concentrations of polymers of α1AT were detected in serum from patients carrying the Z allele than in those not carrying the Z allele (median (IQR) 1.40 (0.91-3.32) mg/dl vs 0.17 (0.06-0.28) mg/dl, p<0.001); polymers of α1AT were also seen in the renal biopsy of a patient with vasculitic glomerulonephritis. Polymers of α1AT primed neutrophils with CD62L shedding and increased superoxide production following ANCA activation. Carriage of the Z allele was not associated with disease severity, survival or relapse.

CONCLUSIONS

The Z but not the S deficiency allele is associated with AAV. Polymers of α1AT are present in the serum and glomeruli of at least some patients with the Z allele, which may promote inflammation through priming of neutrophils.