Necrotizing pneumonia in children: Report of 25 cases between 2008 and 2018 at a French tertiary care center

BACKGROUND

Necrotizing pneumonia (NP) is a serious and rare disease in children. Pediatric data on NP are limited and the impact of the 13-valent pneumococcal conjugate vaccine has been very poorly evaluated.

PATIENTS AND METHODS

We conducted a retrospective study at Toulouse University Hospital between 2008 and 2018. Children who presented with thin-walled cavities in the areas of parenchymal consolidation on imaging were included in the study.

RESULTS

The incidence of NP did not decrease during this period. Bacterial identification occurred in 56% of cases (14/25) and included six cases of Streptococcus pneumoniae, five of Staphylococcus aureus, two of Streptococcus pyogenes, and one of Streptococcus viridans. Streptococcus pneumoniae NP are more frequently associated with empyema/parapneumonic effusion compared to S. aureus NP (p = 0.02). Patients with S. pyogenes NP more often required volume expansion than did S. pneumoniae cases (p = 0.03). When comparing children born before and after implementation of the 13-valent pneumococcal conjugate vaccine, we identified a relative modification of the bacterial epidemiology, with an increase in the proportion of S. pyogenes NP and S. aureus NP and a decrease in the proportion of NP caused by S. pneumoniae.

CONCLUSION

Future studies are needed to assess the epidemiology of NP in children. Continued surveillance of identified pneumococcal serotypes is essential to document epidemiological changes in the coming years.

Keep children away from macaque monkeys!

To warn physicians and parents about the risk of macaque bites, we present two pediatric cases (a 4-year-old boy and a 10-year-old girl) of bites sustained while on holiday. The young boy developed febrile dermohypodermitis and was hospitalized for IV antibiotic treatment. He received an initial antirabies vaccine while still in the holiday destination. Except for local wound disinfection and antibiotic ointment, the girl did not receive any specific treatment while abroad. Both were negative for simian herpes PCR. When travelling in countries or cities with endemic simian herpes virus, parents should keep children away from monkeys. Travel agencies, pediatricians and family physicians should better inform families about the zoonotic risk.

Hyperglycemia is a risk factor for high-grade envenomations after European viper bites (Vipera spp.) in children

CONTEXT

Hyperglycemia has been described in severe scorpion envenomation, we wanted to analyze if it was applicable to viper bites in children.

AIM

To describe clinical, biological, and therapeutic characteristics of 83 children bitten by European viper (Vipera spp.) and to confirm that hyperglycemia is a risk factor for high-grade envenomation.

MATERIAL AND METHODS

A retrospective study was conducted between 2001 and 2014 in the pediatric emergency department of a tertiary level children's hospital. Collected data were: age and sex of children; day and time of admission; day, time and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; laboratory abnormalities, use of specific immunotherapy, associated treatments; length of stay; hospital course.

RESULTS

Eighty-three children were included (62 boys, 21 girls). The mean age was 7.4 ± 3.9 years. Bites were most often located on the lower extremities (66%). The classification of envenomation was: 83% low grade (absent or minor envenomation) and 17% high grade (moderate to severe envenomation). All high-grade envenomations received specific immunotherapy (Viperfav(TM), (Aventis Pasteur, MSD, Lyon, France). Being bitten on an upper extremity (odds ratio [OR] 51.1 95% class interval [CI] [6.1-424], p < 0.0001), during the afternoon (OR 13.4 95% CI [1.7-107.9], p = 0.015), feeling violent pain (OR 4.2 95% CI [1.1-16.5], p = 0.023), and high initial plasma glucose level (6.5 ± 1.7 mmol/L versus 5.0 ± 0.9 mmol/L, p = 0.027) were associated with a significant risk of high-grade envenomation.

CONCLUSION

We have confirmed a potential link between initial hyperglycemia and the risk of progression to high-grade envenomation as well as its association with other published predictive factors.

The use of a multiplex real-time PCR assay for diagnosing acute respiratory viral infections in children attending an emergency unit

•

Evaluate the use of multiplex real-time PCR for diagnosing respiratory infections.

•

857/966 samples from 914 children were positive for one or multiple viruses.

•

Respiratory syncytial virus and rhinovirus were the most prevalent.

•

Co-infections were associated with severe respiratory symptoms.

•

The spread of respiratory viruses returned to the one it was before the flu outbreak.

Background

The use of a multiplex molecular technique to identify the etiological pathogen of respiratory viral infections might be a support as clinical signs are not characteristic.

Objectives

The aim of the study was to evaluate a multiplex molecular real-time assay for the routine diagnosis of respiratory viruses, to analyze the symptoms associated with the pathogens detected and to determine the spread of virus during the period.

Study design

Respiratory samples were collected from children presenting with respiratory symptoms and attending the emergency unit during the 2010–2011 winter seasons. Samples were tested with the multiplex RespiFinder^® 15 assay (PathoFinder™) which potentially detects 15 viruses.

Results

857 (88.7%) of the 966 samples collected from 914 children were positive for one (683 samples) or multiple viruses (174 samples). The most prevalent were the respiratory syncytial virus (39.5%) and the rhinovirus (24.4%). Influenza viruses were detected in 139 (14.4%) samples. Adenovirus was detected in 93 (9.6%) samples, coronaviruses in 88 (9.1%), metapneumovirus in 51 (5.3%) and parainfluenzae in 47 (4.9%). Rhinovirus (40%) was the most prevalent pathogen in upper respiratory tract infections while respiratory syncytial virus (49.9%) was the most prevalent in lower respiratory tract infections. Co-infections were associated with severe respiratory symptoms.

Conclusion

The multiplex assay detected clinically important viruses in a single genomic test and thus will be useful for detecting several viruses causing respiratory tract disorders.

A comparison of adult and pediatric measles patients admitted to emergency departments during the 2008-2011 outbreak in the Midi-Pyrénées region of France

The present French and European measles outbreaks show a bimodal distribution: the two most affected populations are infants aged less than 1 year and adults older than 20 years. The purpose of this study was to determine wether there were differences in the clinical presentation and evolution of measles between adult and pediatric patients. We performed a retrospective study of adult and pediatric measles patients admitted to three tertiary-level university hospitals between January 2008 and May 2011. Data were extracted from medical charts and positive laboratory results. Collected data were age, sex, geographical origin, vaccination status, source of exposure, overseas travel before symptom onset, clinical symptoms, risk factors for complications, severity criteria on admission, type of diagnosis, biological abnormalities, complications, and treatments. A total of 305 patients (171 children and 134 adults) were included in the study. The mean age was 4.6 ± 4.4 years in children and 26.7 ± 8.1 years in adults. Children were less often hospitalized than adults (29% vs. 66%). A comparison between hospitalized pediatric (n = 49) and adult (n = 89) patients revealed that the former had a higher incidence of complications (P < 0.0001), more otorhinolaryngological complications (24% vs. 1%; P < 0.0001), and a higher incidence of severe criteria on admission (P = 0.02). Hospitalized pediatric patients differed from adults in terms of disease severity and complications.

Simultaneous detection of gastrointestinal pathogens with a multiplex Luminex-based molecular assay in stool samples from diarrhoeic patients

We have evaluated the multiplex molecular method xTAG(®) Gastrointestinal Panel (GPP) for detecting pathogens in stool samples of diarrhoeic patients. We collected 440 samples from 329 patients (male:female ratio of 1.2:1), including 102 immunosuppressed adults, 50 immunosuppressed children, 56 children attending the neonatal unit and 121 children attending the emergency unit. Of these, 176 samples from 162 patients were xTAG(®) GPP positive (102 viruses, 61 bacteria and 13 parasites) and the assay was more sensitive than the conventional test for detecting rotavirus (p <0.01), noroviruses (p <0.0001), Salmonella spp. (p <0.001), Campylobacter spp. (p <0.001) and toxigenic Clostridium difficile (p 0.005). The predominant pathogens were viruses (23.2%), with rotavirus (15.9%) being the most common. Bacterial agents were detected in 13.9%; the most common was Salmonella spp. (4.8%). Parasites were detected in 2.9%; Cryptosporidium spp. (2%) was the most common. There were 31 co-infections (7% of samples), involving two pathogens in 23 (5.2%) and three pathogens in eight (1.8%) samples. There were 113 (92.6%) positive samples from the children attending the emergency unit, 25 (17%) positive samples from immunosuppressed adults, 22 (25.3%) positive samples from immunosuppressed children and 16 (19%) positive samples from children attending the neonatal unit. The low turnaround time and technical hands-on time make this multiplex technique convenient for routine use. Nevertheless, conventional bacterial culture and parasitological stool examination are still required to detect other pathogens in specific cases and to determine susceptibility to antibiotics.

[Hair-thread tourniquet syndrome]

OBJECTIVE

Describe the epidemiology of tourniquet syndromes and a cohort of such children admitted to the pediatric emergency department (PED), analyze the family's social situation to detect neglect behaviors, and analyze subsequent hospital admissions.

PATIENT AND METHODS

From 1st January 2003 to 31st May 2009 in the PED, all patients admitted for tourniquet syndrome were included in the study. The data collected were day and time of admission, age, sex, length of stay, medical coverage, type and location of the constrictive agent, therapeutic management, progression, and complications. PED social workers in relation with child protective services (CPS) recovered information on the family's social situation.

RESULTS

During the study period, 57 children were registered. The mean number of admissions per year was 8 (range: 2-15). The mean age was 5.5+/-4 months. The toe was the most frequent location (95%). The penis was injured in 2 cases and labia majora in 1 case. The constrictive agent was often a hair (95%). One case of abuse was detected. The analysis of family social situations showed that 53% had no or incomplete medical coverage, 67% were already followed by CPS with extreme poverty or lived in dilapidated housing. Insufficient hygiene or neglect was found in 67% of the families with incomplete or no social coverage. The analysis of 2003-2007 period for later admissions identified that 15 accidents in the home occurred in 12 children. Among these families, 58% were already known by CPS for neglect behavior.

CONCLUSION

Although most tourniquet syndromes seem accidental, this entity is often associated with a lack of hygiene. Several and distant locations (e.g., toes and genitals), multiple and/or separated knots, constrictive agents inconsistent with a safe environment for the child, and penile location in an infant require meticulous investigation because of a higher incidence of child neglect.

[Nasal foreign body in infants]

AIMS

Provide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents.

MATERIAL AND METHODS

A retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05.

RESULTS

A total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months.

CONCLUSION

Often benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parent's kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.

[Babywalker use (baby-trot, youpala): an unsafe practice]

AIM

Epidemiological analysis of accidents related to babywalker use admitted to a pediatric emergency department.

METHODS

Retrospective, descriptive study of injuries related to babywalkers admitted to the pediatric emergency department between January 1st, 2003 and December 31st, 2005.

RESULTS

One hundred and seventy-eight children were admitted due to an accident related to babywalker use. The sex ratio was 1.7 with a male prevalence. Mean age was 11+/-4 months. Seventy-eight percent of babywalker-related injuries were attributable to fall down a flight of stairs. The mean number of steps that a child fell down was 7 (range 1-20 steps). The repartition of accidents was bimodal: during the year, 1 peak in May and 1 in October; during the week: 54% of the cases occurred on Thursday or on the weekend; during the day (1 peak between 10 a.m. and 1 p.m. and 1 peak between 4 p.m. and 7 p.m.). Non-severe head traumas represented the most frequent injury (72%). Twenty-one children were hospitalised for concussion (N=15), cranial fractures (N=3), forearm fracture (N=1), dental subluxation (N=1) and extradural hematoma (N=1). A social problem (families with unsafe domestic practices) was identified in 26 children (15%), 16 of these situations were recognized due to the retrospective character of the study and the analysis of hospital admissions after the first accident.

CONCLUSION

Stairway related falls associated with babywalker use and fall down in the stairs are very frequent in children less than 1 year-old. This resulted in babywalkers being prohibited in Canada since 2004. In several countries, advocates are working to ban babywalkers. Active or passive prevention methods have shown their limits. This unsafe and dangerous practice should be banned in France.

[Necrotizing pneumonia and arthritis due to Staphylococcus aureus producing Panton and Valentine leukocidin in a 10-year-old boy]

Staphylococcal necrotizing pneumonia producing the Panton Valentine leukotoxin (PVL) has been described for many years. The french reference center for staphylococcal toxaemia defined it with precision in 1999. A 10-year-old child, died in 36 hours from respiratory distress and shock. Staphylococcal pneumonia was suspected then confirmed: S. Aureus producing PVL was isolated in lung, blood and articulations.

Dissection aortique fatale chez un garçon de 13 ans atteint d'un syndrome d'Ehlers-Danlos vasculaire

Vascular Ehlers-Danlos syndrome(EDS) is at high risk of death by arterial rupture.

CASE REPORT

A 13-year-old boy with vascular EDS and aortic dissection was admitted in pediatric emergency care unit. The children died after surgery by massive hemorrhage and prosthetic rupture.

DISCUSSION

The precocity of this vascular accident EDS is uncommon. It occurred despite clinical and echocardiographic follow-up. The death of the children confirmed the difficulties in surgery of vascular manifestation, even if appropriate and rapid management was already done.

CONCLUSION

Patients with vascular EDS must be identified because of its lethal complications. Friability of the vessels makes surgical treatment difficult. A trial using beta blockers therapy is ongoing.

Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis

BACKGROUND

Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population.

METHODS

We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test.

RESULTS

The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs.

CONCLUSION

There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.

The French version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report the results of the cross-cultural adaptation and validation into the French language of two health status instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health related quality of life instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. Five hundred children were enrolled including 306 patients with JIA classified into systemic (23%), polyarticular (22%), extended oligoarticular (25%), and persistent oligoarticular (30%) subtypes, and 194 healthy children. Both instruments were reliable with intra-class correlation (ICC) coefficients for the test-retest procedure of 0.91 for the CHAQ, and 0.87 and 0.89 for the physical and psychosocial summary scores of CHQ, respectively. Agreement between parents and children evaluated for the CHAQ was high with an ICC of 0.89 for the disability index; weighted kappa coefficients for the 8 domains ranged from 0.61 to 0.72. Convergent validity was demonstrated by significant correlations with the JIA core set of variables (physician and parent global assessment, scores for active joints and joints with limited range of motion, erythrocyte sedimentation rate) for both instruments. Both CHAQ and CHQ discriminated between healthy and JIA children, but only the disease specific CHAQ questionnaire discriminated clearly between the 4 JIA subtypes. In conclusion, the French versions of the CHAQ and the CHQ are reliable, and valid health assessment questionnaires to be used in children suffering from JIA.

[Chronic meningococcemia: 3 cases in the immunocompetent child]

Chronic meningococcemia is a part of extra meningeal manifestations of meningococcal disease. Its diagnosis can be difficult because of lack of sensitivity of blood cultures.

CASE REPORT

Three cases, concerning immunocompetent children, respectively aged of 14, 10 and 4 years are reported. The clinical course was characterized by recurrent fever, inflammatory joint manifestations and diffuse maculopapules secondary centered by petechiae. Microbiological findings revealed in one case a positive throat culture and presence of meningococcal soluble antigens in blood and urine. In the other two cases, diagnosis was done after done after positive blood culture at the 7th, and 13th days of course.

CONCLUSION

The diagnosis should be considered in any children with a prolonged, recurrent fever and cutaneous and joint manifestations even if blood cultures remain negative. The response to therapy by usual antimeningococcal antibiotics is dramatic and curative while a prolonged untreated course may be complicated by metastatic infection.

[Pseudo-periodic disease with hyperimmunoglobulinemia D: a never-ending story with probable prenatal onset]

Diagnosis of inflammatory non-infectious diseases with a neonatal onset is often retrospective. It may lead to aggressive and iatrogenic procedures.

PATIENT

A 6-year-old boy was suffering, since birth, from recurrent febrile attacks including rashes, gastrointestinal manifestations and inflammatory joint involvement. This syndrome, partially improved with steroids, could have been of antenatal onset. Since the age of 4 years, the patient is considered as having hyper-IgD syndrome (HIDS).

DISCUSSION

HIDS must be distinguished from familial Mediterranean fever. Patients suffer from recurrent fever concomitant to inflammatory joint involvement, abdominal distress, skin lesions, swollen lymph nodes and hepatosplenomegaly (especially seen in children). All patients have high serum IgD (> 100 UI/mL) and IgA levels. Nevertheless, a high IgD level is not specific. Our case could also be part of the CINCA (chronic, infantile, neurological, cutaneous and articular) syndrome, which includes similar early manifestations associated with a constant neurological and frequent ophthalmological involvement and epiphyseal changes; to date, these last three manifestations are not present in our patient.

CONCLUSION

HIDS and CINCA syndrome are not known to be modified by any effective therapeutic agent. When presenting at birth, these inflammatory diseases must be considered as entities with a rarely described potential severity.

[Acute orbital myositis and idiopathic inflammatory pseudotumor in children: three cases]

Orbital pseudo-tumors account for approximately 8% of the orbital tumors. They are scarcely described in children and raise diagnostic dilemas, especially when they present as an isolated extra-ocular muscle swelling called idiopathic orbital myositis (IOM).

CASE REPORTS

A diagnosis of inflammatory orbital pseudotumors (IOPT) was made in three children aged 7, 13 and 14 years from clinical and CT scan and/or MRI findings associated with histological data in two of them. Two of these IOPT presented as IOM. Analysis was made in a effort to eliminate intra-orbital tumors, especially rhabdomyosarcoma.

CONCLUSION

The abrupt onset of the orbital signs, often related in the literature, was not a specific diagnostic criterion regarding to embryonic rhabdomyosarcoma. The inconstant presence of inflammatory signs and the absence of local osseous defect could be more discriminating. Although diagnostic procedure, including histological documentation, was difficult, even dangerous, surgical biopsy should be recommended. Eventually, considering the mandatory multidisciplinary care, steroid therapy response should be evaluated as a diagnostic test.

[Pseudotumor forms of neurosarcoidosis in children. Diagnostic difficulties and therapeutic management]

In systemic sarcoidosis, neurologic manifestations are possible and occurred in 5 p. 100 of cases. The diagnosis is easier when sarcoiddosis is known, but in half case neurologic symptoms are inaugural. In these cases, involvement of other sites (liver, lung, eyes or skin) by the disease is needed to confirm sarcoidosis. Main manifestations in neurosarcoidosis are cranial nerve palsy, diabetes insipidus or chronic aseptic meningitis, but sometimes sarcoidosis can present as an intracranial mass. The diagnosis of neurosarcoidosis may be difficult and could be confused with infection (such tuberculosis or mycosis), with inflammatory diseases (such multiple sclerosis) or with neoplasm, particularly in case of oedema. Brain biopsy may be necessary in isolated neurosarcoidosis if no peripheral histology evidence of noncaseating granulomas has been obtained. Treatment with steroids alone is the best choice for initial therapy but must be prolonged. It is difficult to predict accurately the response to steroids and relapse may be possible after a long time. Other immunosuppressive therapeutics or radiotherapy have been used in patient with refractory neurosarcoidosis. Sequential magnetic resonance imaging is the useful mean for the follow-up of neurosarcoidosis.

[Acute intermittent porphyria associated with epilepsy in a child: diagnostic and therapeutic difficulties]

BACKGROUND

Acute intermittent porphyria is an autosomal dominant inborn error of heme biosynthesis. The diagnosis of acute porphyria is rare before puberty. Its association with epilepsy induces difficulties in diagnosis and seizure treatment.

CASE REPORT

A case of acute intermittent porphyria in a 9-year old boy with epilepsy is reported. The diagnosis was made only after the third hospitalisation, with the measurement of enzyme activity and identification of family members with latent disease. Adjustment of antiepileptic treatment was necessary 7 months later.

CONCLUSION

Most antiepileptic drugs are unsafe because they have demonstrated porphyrinogenicity. Low doses of clonazepam can be used in this situation.

[Association of venous angioma and cavernoma of the posterior fossa]

BACKGROUND

Association of venous angioma to cavernous malformation is rare. If bleeding occurs, it must be assigned to the cavernous malformation.

CASE REPORT

A 4 year-old boy suffered from an acute ataxia. Investigation showed a venous angioma and a cavernoma malformation in the posterior fossa. The patient was admitted again at the age of 8 years for a new episode of acute ataxia due to cerebellar hematoma. A conservative treatment was settled because of the risk of venous infarction.

CONCLUSION

Venous angiomas are rarely symptomatic and are considered as normal venous variants. Indeed, the cavernomas are true malformations with a high bleeding potential. When both lesions are associated and bleeding occurs, only the cavernous malformation has to be removed if surgically accessible.

Localized lipoatrophia with persistent circulating autoantibodies and partial immunoglobulin A deficiency in a child

A 7-year-old Caucasian girl developed lipoatrophic areas on the abdomen and left thigh. Laboratory tests showed a partial IgA deficiency, circulating autoantibodies (ANAs, double- and single-stranded anti-DNAs, rheumatoid factor). The clinical aspect resembles lipodystrophia centrifugalis abdominalis infantilis, but autoimmune abnormalities suggest connective tissue panniculitis which underlines the overlap between the different forms of localized lipoatrophias.