Chronic intestinal pseudo-obstruction syndrome in pediatric patients

The aim of this study was to report the presentation and outcome of 22 consecutive children (13 female) who presented with a syndrome of chronic intestinal pseudo-obstruction with or without urinary tract involvement. We analyse the main clinical and histopathological features and discuss therapeutic management. Ten patients had signs of intestinal obstruction at birth, in which 6 presented antenatally with megacystis on ultrasound. Six children presented with constipation and/or obstruction between 1 and 6 months of age and in 6 other patients diagnosis was made between the ages of 1 and 12 years. There was a family history in 4 patients. Investigations showed diffusely dilated gut on x-ray with slow transit on small bowel follow through. Absent or abnormal motor migrating complex with low amplitude contractions were demonstrated on duodeno-jejunal manometry in 12/13. Megacystis occurred in 15/21 and megaureter in 2/21. Full thickness biopsies (n = 22) revealed involvement of muscle layers in 8, and abnormal myenteric plexus on histochemistry in 13. In 1, the biopsies were inconclusive. Recurrent urinary tract infections occurred in all with structural urinary tract abnormality and most had bacterial overgrowth. Severe recurrent episodes of obstruction which required parenteral nutrition (PN) occurred in all patients. Drugs were unhelpful and decompression ileostomies or colostomies were performed in 20/22. Five children died from sepsis (n = 3) or sudden death. Eleven patients remain partially or totally dependent on PN despite decompression ileostomy in 10/11. Six patients underwent colectomy and ileorectal pull-through, 2 of which remain on long-term PN, while the others are totally orally fed. Despite careful histological study pointing to 2 main forms, myopathy and neuropathy, the etiology of primary intestinal pseudoobstruction syndromes remains unknown. It may present antenatally while most of the time the gut and the urinary tract are diffusely involved. The condition has a high morbidity with a percentage requiring long-term PN. Although the mortality rate is high (23%), careful treatment of urinary tract infections and bacterial overgrowth, decompression surgery and judicious use of PN allows survival to adult life.

[Exanthematic pustulosis of pregnancy: favorable evolution using calcium and vitamin D2]

A 26-year-old pregnant woman was hospitalized in an emergency setting for a skin eruption. She had developed pustules distributed on round patch-like areas of rash localized at the umbilicus and the larger skin folds. She was given calcitriol and calcium with good results. Systemic steroids are usually given for exanthematic pustulosis of pregnancy but with variable efficacy. Few cases of successful treatment with calcium and vitamin D have been reported. We suggest this alternative treatment could be useful in other cases.

[Is there criteria to allow the selection of patients exposed to asbestos which is relevant to thoracic computed tomography screening?]

OBJECTIVE

This study was undertaken to determine whether certain criteria could be used to select among asbestos-exposed subjects those who could benefit from computed tomography screening.

MATERIALS AND METHODS

Search for criteria enabling the selection of patients who should undergo a CT screening exam after occupational exposure to asbestos was conducted in 150 subjects. All subjects were explored with selected high-resolution CT scans. Studied parameters were age, exposure data, pulmonary function test results.

RESULTS

None of the exposure data or pulmonary function test results suggested with certainty the presence or absence of asbestos-related pleural and parenchymal lung disease. The studied parameters could not be used to select patients who could benefit from CT screening.

CONCLUSION

None of the studied parameters enabled a selection of asbestos-exposed subjects who should undergo chest CT screening.

[Congenital pigmented nevus: prognosis and therapeutic possibilities]

Congenital pigmented nevi are found in approximately 1% of newborn infants. Two main factors determine their management: 1) the risk of malignancy (melanoma); 2) the aesthetic consequences, these factors being themselves dependent upon the size and the localization of the nevi. Thus, if the systematic resection of small nevi is not required, early treatment of giant nevi which carry a high risk of malignancy before the age of ten years, is highly recommended. Main methods of treatment are surgical resection (with the help of skin grafts, or cutaneous expansion or mobilization, in giant nevi), dermabrasion and curettage.

[Focal familial palmoplantar keratoderma with punctate hyperkeratosis of the palmar creases]

BACKGROUND

Keratosis punctata of the palmar creases is a variant of punctata palmoplantar keratoderma.

CASE REPORT

Keratosis punctata of the palmar creases was observed in a 53 year-old North African male. The lesions presented as small keratotic papules confined exclusively to the flexion creases of the palms and digits, with a bilateral localization on the soles. The lesions were sensitive to pressure. The proband's 19 year-old son had similar lesions.

DISCUSSION

Keratosis punctata of the palmar creases is characterized by the development of small round keratotic papules, electively and exclusively found in the palmar, digital, and uncommonly soles creases. The etiology is unknown. The frequency is higher in the black population. Although considered as an hereditary palmoplantar keratoderma with autosomal dominant transmission, familial cases with localizations on the soles is uncommon.

Thoracoscopic treatment of mediastinal cysts in children

BACKGROUND/PURPOSE

The development of thoracoscopic surgery has made many procedures possible, including the treatment of mediastinal cysts in children. The authors report their experience with this procedure between 1992 and 1997.

METHODS

Surgery was performed on 22 children aged from 1 month to 9 years (median, 27 months), weighing 5 to 49 kg (median, 12.5 kg). Diagnosis was made by antenatal ultrasound scan in six cases (27%), with a chest x-ray performed for respiratory symptoms in 14 cases, and with a chest x-ray performed for positive tuberculin intradermoreaction in two cases. Decision to resect the cyst was determined by thoracoscopy in 21 of the 22 cases, and by open surgery in one case only (subcarinal compressive cyst with left lung distension and a mediastinal shift).

RESULTS

Eighteen of the 21 (86%) cases were treated successfully by thoracoscopy. In three cases of bronchogenic cysts, we performed an associated thoracotomy because the dissection was too difficult and dangerous. In three cases, a small part of a common wall between the cyst and the bronchus was not removed. The pathological diagnosis was bronchogenic cysts in 15 cases (71%), pleuropericardiat cysts in three cases (14%), esophageal duplication in two cases (10%), and cystic hygroma in one case (5%). Two postoperative complications were observed: one esophageal wound and a case of recurrent pneumothorax after chest tube removal. Patients were discharged after 2 to 11 days (median, 3 days). Follow-up was uneventful.

CONCLUSIONS

Treatment of mediastinal cyst by thoracoscopy is feasible in most cases. Compressive cysts with lung distension and mediastinal shift remain a contraindication. If the cysts have a common wall with the bronchus or esophagus, or if they are subcarinal, the dissection may be difficult and dangerous, and thoracotomy may be preferable.

[What is new in pediatric pneumology?]

Have been selected for this review: 1) the recent and impressive development of high-resolution and spiral CT scan in pediatric thoracic imaging; 2) the emerging of new and promising therapies for asthma (long acting inhaled beta 2-agonists, leukotriene antagonists, anti-IgE monoclonal antibodies); 3) the multifactorial origin of asthma in childhood; 4) the development of thoracoscopic surgery, a minimal-invasive approach beneficial in numerous circumstances.

[Congenital eccrine angiomatous hamartoma]

BACKGROUND

Eccrine angiomatous hamartoma is an uncommon skin disease with vascular and sudoral components: less than thirty cases have been reported in the literature.

CASE REPORT

A 3.5 month-old female infant developed a painful angiomatous plaque on the abdomen which was first seen 15 days after birth. Histology showed numerous vessels and eccrine sudoral glands in the dermis. Exeresis could not be complete and was followed for 15 years. There has been a slight hyperpigmentation with localized hyperhidrosis over the plaque. This hypersudation confirms the diagnosis which could not be confirmed on the initial biopsies.

DISCUSSION

This case of congenital eccrine angiomatous hamartoma could only be diagnosed late in the clinical course. This is the first case report on the abdomen, 80 p. 100 of the previous reports were on the limbs. After a 15 year follow-up, there was no progression of the hamartoma and pain regressed gradually. Without secondary development of localized hyperhidrosis, the diagnosis could not have been made. Careful comparison of pathology findings and clinical expression are essential for the diagnosis of eccrine angiomatous hamartoma.

Computed tomographic appearance of three intrapulmonary lymph nodes

Intrapulmonary lymph nodes are rare lesions, usually appearing as small subpleural nodule (coin lesion), at or under the height of the carina. Computed tomography (CT) is very accurate in their detection. Three observations are reported.

[Lichenoid eruptions in the child]

Lichenoid eruptions are represented by lichen planus and lichen striatus. They are characterized clinically by a papulous eruption, and histogically by a dermal superficial infiltrate of lymphocytic cells and a cytotoxic reaction directed against basal keratinocytes. The main differential diagnosis is hamartoma, the differentiation being important because of the possible association of haemartoma with malformations.

CHARGE syndrome: report of 47 cases and review

The acronym CHARGE refers to a syndrome of unknown cause. Here we report on 47 CHARGE patients evaluated for the frequency of major anomalies, namely coloboma (79%), heart malformation (85%), choanal atresia (57%), growth and/or mental retardation (100%), genital anomalies (34%), ear anomalies (91%), and/or deafness (62%). In addition, we comment on anomalies observed very frequently in neonates and infants with the CHARGE syndrome, including, minor facial anomalies, neonatal brain stem dysfunction with cranial nerve palsy, and, mostly, internal ear anomalies such as semicircular canal hypoplasia that were found in each patient that could be tested. We propose several criteria for poor survival including male gender, central nervous system and/or oesophageal malformations, and bilateral choanal atresia. No predictive factor regarding developmental prognosis could be identified in our series. A significantly higher mean paternal age at conception together with concordance in monozygotic twins and the existence of rare familial cases support the role of genetic factors such as de novo mutation of a dominant gene or subtle sub-microscopic chromosome rearrangement. Finally, the combination of malformations in CHARGE syndrome strongly supports the view that this multiple congenital anomalies/mental retardation syndrome is a polytopic developmental field defect involving the neural tube and the neural crests cells.