Glucose-6-phosphate dehydrogenase (G6PD) deficiency in girls: a diagnosis not to be missed (a case report)

Glucose-6-phosphate dehydrogenase (G6PD) is a polymorphic enzyme encoded by the X chromosome. It protects the cell against hydrogen peroxide-induced damage and ensures an oxidative balance profile within the cell. The disease is more frequent in males, and rare cases are described in girls. We report an observation of a 7-month-old Moroccan girl hospitalized for acute hemolysis after consuming fava beans. The diagnosis of a G6PD deficiency was retained after an assay of the enzymatic activity that returned collapsed. After initial conditioning, a transfusion of phenotyped retinal ganglion cells (RGCs) is performed. The rapid evolution is favorable, and the child is discharged after therapeutic education sessions for the parents on the products to be avoided. Through this observation, we insist on the importance of neonatal screening in regions with a high prevalence of hemolysis in order to avoid diagnostic delays and also to prioritize the evaluation to be requested in an acute hemolysis state, to propose an education articulated around a preventive approach in children with this disease.

[Rapunzel syndrome in a child with trisomy 21: a case report]

Trichobezoard is a rare condition characterized by a gastric mass composed of hair or fibers due to a compulsive attitude (trichotillomania) and an eating disorder (trichophagia). Gastric trichobezoar is the most common form and may extend into the small bowel, sometimes reaching the last ileal loop, or even the transverse colon, resulting in Rapunzel syndrome. We here report a case of gastroduodenal and small intestine trichoboozoar in a 6-year-old girl with facies of trisomy, presenting with recurrent abdominal pain lasting for one months and suspected gastrointestinal lymphoma. The diagnosis of trichoboozoar was based on surgery. The purpose of this study is to give an overview of the history of this rare condition and to clarify the diagnostic and therapeutic approaches used.

[Severe poisoning by traditional medication in the newborn]

The use of traditional products for therapeutic purposes in the newborn cause many cases of severe poisoning, especially in newborns. The aim of this study was to identify the main medicinal plants causing poisoning and emphasize the seriousness of poisonous plants. We report a series of eight newborns admitted for intake of poisonous medicinal plants admitted to the neonatal unit and neonatal intensive care unit at the Fez (Morocco) Hassan II University Hospital in 2014. The reasons for use were dominated by the infant's refusing to suckle. Clinical signs at admission were neurological signs and respiratory distress. The decision was spontaneously declared by the family for only two patients. A particular smell of the urine and unusual lesion associations were the main signs drawing the attention of physicians in other cases. The amounts and rates differed. Laboratory tests revealed renal failure in two cases. Transaminases (SGOT and SGPT) were greater than three times normal and the TP was below 50% in two newborns. Hemoglobin less than 9g/dL in three cases and thrombocytopenia less than 50,000/mm³ in two newborns. The main poisonous plants were identified as cade oil and henna. Medicinal plants were associated in all cases. Toxicological analysis was negative in three cases and was not done in the other five cases. The management was symptomatic and etiological. The outcome was favorable in six newborns. Death occurred in two neonates despite resuscitation. Medicinal plants must, like drugs, obey strict rules that only the standard herbal medicine specialist can answer. This necessarily involves the regulation of the profession in our country.

[Subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumorachis, and pneumoretroperitoneum revealing an unknown foreign body aspiration]

Subcutaneous emphysema develops from the spread of air essentially from the mediastinum into the subcutaneous tissue causing progressive distension and infiltration. Diagnostic and therapeutic delay expose the patient to massive air effusion and risk of compression of cervical and mediastinal structures. The initial mechanism is a breach in the tracheobronchial tree with air diffusion into the interstitial space and along the perivascular spaces toward the mediastinum, and then spread and dissection in the subcutaneous tissue. A tracheobronchial foreign body is a very rare cause of emphysema and is often localized. An association with a combination of epidural emphysema, pneumopericardium, or pneumoretroperitoneum is exceptional. Here, we present a unique case associating massive subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumorrhachis, and pneumoretroperitoneum in a 3.5-year-old child complicating an unrecognized aspirated foreign body. The extraction of the foreign body resulted in gradual regression of the symptoms and the disappearance of these emphysematous locations.

[Neonatal purpura fulminans without sepsis due to a severe congenital protein C deficiency]

Severe congenital protein C deficiency is a rare life-threatening coagulopathy. In the early hours of life, the neonate presents with extensive purpura fulminans and substantial skin necrosis contrasting with a preserved general state and a negative infectious exam. Disseminated intravascular coagulation sets in secondarily. Prenatal outset of thrombotic events is a rare situation that worsens the prognosis, especially protein C replacement in utero is not available. We report a case of a male newborn of consanguineous parents who were asymptomatic carriers of heterozygous protein C deficiency. This infant presented prenatal ventricular hemorrhage with hydrocephalus and rapidly extensive postnatal skin necrosis that was not regressive in spite of fresh frozen plasma administrated after 24h of life. Prenatal diagnosis, early recognition, and urgent therapy with protein C replacement and anticoagulant treatment are crucial to improve the prognosis, avoid further damage after delivery, and prevent the devastating consequences of severe protein C deficiency.

Gut microbiota in preterm infants with gross blood in stools: A prospective, controlled study

OBJECTIVE

Gross blood in stools is a peculiar entity in preterm infants, but little is known about its etiology. As gut microbiota can be distorted in preterm infants, we aimed to evaluate the gut microbiota in infants with gross blood in stools.

STUDY DESIGN

In a prospective, controlled, single-center study, we enrolled all infants born before 34 weeks of gestational age presenting gross blood in stools that was either completely isolated or associated with mild clinical symptoms or radiological signs. Each case was paired with two controls who were hospitalized in the same unit and were matched for gestational age and birth weight. The diversity of the gut microbiota was analyzed using 16S rRNA gene PCR and temporal temperature gel electrophoresis. We calculated a diversity score corresponding to the number of operational taxonomic units present in the microbiota.

RESULTS

Thirty-three preterm infants with gross blood in stools were matched with 57 controls. Clinical characteristics were similar in cases and controls. There was no statistically significant difference in the diversity score between the two groups, but microbiota composition differed. The proportion of infants with Escherichia coli was significantly higher in cases than in controls (p=0.045) and the opposite pattern occurred for Staphylococcus sp. (p=0.047).

CONCLUSION

Dysbiosis could be a risk factor for gross blood in stools in preterm infants. Additional, larger studies are needed to confirm the implications of the presence of different genotypes of E. coli and to evaluate preventive actions such as the prophylactic use of probiotics and/or prebiotics.

[Congenital chylothorax: rapid and complete response to polyvidone iodine]

Idiopathic congenital chylothorax refers to abnormal accumulation of lymphatic fluid within the pleural space due the disruption of the thoracic duct or its lymphatic tributaries. It is a relatively rare disease and a cause of neonatal respiratory distress with major nutritional and immunological consequences. Therefore, it is critical to decrease pleural effusion promptly. Conservative treatment is always started as soon as the diagnosis is made, and refractory cases require chemical pleurodesis or surgery. However, the choice and timing of therapeutic escalation is not clear in the neonatal period and long waiting periods may have adverse consequences for the baby. We report a case of congenital idiopathic chylothorax who did not respond to conservative treatment after 18 days in whom one intrapleural injection of 5 mL of 4% concentrated Betadine stopped the pleural effusion promptly, effectively, and definitively, with no side effects observed, thus challenging such delayed administration.

[Overdose or hypersensitivity to vitamin D?]

Vitamin D intoxication with severe hypercalcemia is rare in the neonatal and infancy period. Through nine cases of hypercalcemia, secondary to taking 600,000 units of vitamin D (Sterogyl(®)), a review of vitamin D requirements and possible mechanisms of toxicity including hypersensitivity to this vitamin will be discussed. We report nine cases of babies admitted to our department between the ages of 25 and 105 days for treatment of severe dehydration. The pregnancies were normal, with no incidents at delivery. Clinical signs were dominated by weight loss, vomiting, and fever. Examination on admission revealed dehydration whose degree ranged from 8 to 15% with preserved diuresis and loss weight between 100 and 1100 g. Laboratory tests objectified hypercalcemia between 113 and 235mg/L, hypercalciuria (urinary calcium/creatinine mmol/mmol >0.5), and a low-level of parathyroid hormone. The vitamin D values in nine patients were toxic (344-749 nmol/L; normal >50 nmol/L; toxicity if >250 nmol/L). Abdominal ultrasound objectified renal nephrocalcinosis in seven patients. The DNA study, performed in eight patients, did not reveal a mutation of the vitamin D 24-hydroxylase gene (CYP24A1). The treatment consisted of intravenous rehydration with treatment of hypercalcemia (diuretics and corticosteroids). Serum calcium returned to the normal range within 4-50 days, with weight gain progressively over the following weeks. The follow-up (2 years for the oldest case) showed the persistence of images of nephrocalcinosis. Genetic susceptibility and metabolic differences appear to modulate the threshold of vitamin D toxicity. However, respect for recommended doses, recognized as safe in a large study population, reduces the risk of toxicity.

Risk factors of mild rectal bleeding in very low birth weight infants: a case control study

BACKGROUND

Mild rectal bleeding (MRB) is a particular clinical entity different from necrotizing enterocolitis, which significantly influences neonatal care in preterm infants. We aimed to determine the risk factors and to evaluate prospectively the clinical course of MRB.

METHODS

We consecutively included in a case-control study all infants with birth weight ≤ 1500 g or gestational age ≤ 32 weeks admitted to our unit, and presenting MRB, defined as either isolated or associated with mild clinical or radiological signs. We matched each Case with two Controls. Clinical data before, after and at time of MRB were collected, together with stool cultures at time of MRB (or at similar postnatal age in Controls). Multiple logistic regression analysis was performed to determine independent risk factors for the development of MRB.

RESULTS

During 4 years, among 823 very low birth weight (VLBW) infants admitted to our unit, 72 (8.8%) had MRB. The median duration of rectal bleeding was 1.1 [1-2] days and the fasting period lasted 2.9 [2-10] days. A relapse occurred in 24% of cases. In multivariate analysis, only hypertension during pregnancy (p = 0.019), growth restriction at onset of bleeding (p = 0.026), and exposure to ibuprofen (p = 0.003) were independent risk factors for MRB. In Cases there were more infants with Clostridium Difficile in stools than in Controls (p = 0.017).

CONCLUSION

Hypertension during pregnancy, even without intrauterine growth restriction, appeared to carry the same risk for MRB as exposure to ibuprofen and extrauterine growth restriction.