Multiple oral and cerebral relapses of a Granular cell tumor (Abrikossoff Tumor) in a young girl affected by congenital dyserythropoietic anemia type II

CASE REPORT

A 14-year-old girl presented with 1 cm large whitened lesion on the ventral surface of the tongue, appeared from 1 month. Past history showed congenital dyserythropoietic anemia type II. The lesion was excised and microscopic and immunohistochemical analyses were compatible with benign Abrikossoff tumor. Total body MRI was negative. After six months the patient presented a second tongue lesion and four months later another large painful lesion in the soft palate, with the same istological diagnosis. In addition, she had other multiple lesions: two apperead at pharyngeal level (not biopsied) that remain stable over time, and one at the pituitary gland.

CONCLUSION

Granular cell tumors, with or without multiple lesions, are rare in children. About 50% of cases involve the head and neck region, with the tongue being the most affected site. Therapy is based on the surgical excision of the lesions; however some tumor forms, although their histological aspect of benignity, often have an important infiltrative power, making the therapeutic approach difficult, as in our case.

Iron Deficiency Anemia in Celiac Disease

The iron absorption process developsmainly in the proximal duodenum. This portion of the intestine is typically destroyed in celiac disease (CD), resulting in a reduction in absorption of iron and subsequent iron deficiency anemia (IDA). In fact, the most frequent extra-intestinal manifestation (EIM) of CD is IDA, with a prevalence between 12 and 82% (in relation with the various reports) in patients with new CD diagnosis. The primary treatment of CD is the gluten-free diet (GFD), which is associated with adequate management of IDA, if present. Iron replacement treatment historically has been based on oral products containing ferrous sulphate (FS). However, the absorption of FS is limited in patients with active CD and unpredictable in patients on a GFD. Furthermore, a poor tolerability of this kind of ferrous is particularly frequent in patients with CD or with other inflammatory bowel diseases. Normalization from anemic state typically occurs after at least 6 months of GFD, but the process can take up to 2 years for iron stores to replenish.

Iron Deficiency Anemia Refractory to Conventional Therapy but Responsive to Feralgine® in a Young Woman with Celiac Disease

Iron, which is an important micronutrient in the human body may be deficient in people with celiac disease (CD). Iron deficiency anemia (IDA) may be the presenting feature of celiac disease, also in the absence of diarrhea or weight loss. The treatment of IDA in patient with CD is primarily a gluten-free-diet (GFD), but it is also very important oral iron supplementation until the iron stores have been restored. However, a frequent problem in CD is the poor tolerability and poor efficacy of oral iron preparations. A new product, consisting of the combination of Ferrous Bysglicinate Chelate and Sodium Alginate (Feralgine™), has been demonstrated to be more bioavailable and well tolerated in CD. We present a case report that showed a clear efficacy of this product in a form of IDA refractory to conventional therapy in a woman with CD and we demonstrated a clear increase of serum iron after administration of this new type of ferrous.

Evolution of congenital hypothyroidism in a cohort of preterm born children

BACKGROUND

Congenital hypothyroidism (CH) is reported to be more common in preterm infants than in term infants, especially in sick preterm infants. Though a frequent possibility of transitory thyroidal alterations in this category of neonates, the evolution of CH to transient or permanent forms is unpredictable.

METHODS

We retrospectively analyzed medical records of 28 preterm infants (<37 weeks gestation) who had exhibited a positive screening for CH at birth during the period 2000-2015 followed in our Center. Children were divided into three groups: permanent CH (PCH) with thyroid dysgenesis, PCH with eutopic normal-sized thyroid gland, and transient CH (TCH) with eutopic normal-sized thyroid gland. In all groups we described clinical and biochemical characteristics. Secondly, we analyzed the differences between patients with thyroid dysgenesis and patients with eutopic normal-sized gland and we compared PCH and TCH groups with normal-sized thyroid gland in order to identify clinical or biochemical data for early detection of transient forms.

RESULTS

Of all patients, 21.4% showed thyroid dysgenesis while 78.6% presented eutopic normal-sized gland. Infants with thyroid dysgenesis had higher median (IQR) baseline s-TSH and levothyroxine (L-T4) dose per weight at 12 months (12 m-dose) than patients with eutopic normal-sized gland. At re-evaluation of the patients with eutopic normal-sized gland, 36% showed PCH and 64% had TCH. The age of the patients at the beginning of L-T4 treatment, gestational age (GA), birth weight, blood thyroid stimulating hormone levels (b-TSH) at first newborn screening (NBS), baseline serum thyroid stimulating hormone (s-TSH), and L-T4 12 m-dose were statistically different between the two groups.

CONCLUSIONS

Our results demonstrate that factors as GA, birth weight, b-TSH levels at first NBS, baseline s-TSH, L-T4 12 m-dose and age at the start of the treatment may be considered useful predictive elements for the evolution of CH.

Cardiac malformations in children with congenital hypothyroidism

Congenital hypothyroidism (CH) is the most common endocrine disease in children, according to literature, infants with CH have an increased risk of associated congenital malformations (CM), especially cardiac defects (CD), compared to the general population. We retrospectively analyzed medical records of 255 patients with a positive screening result for CH in the period 1991-2016 followed at our Center. At the time of enrollment, the clinical examination included looking for the presence of heart murmurs and dysmorphic features. In all patients an echocardiography with cardiological evaluation were performed. Of all patients, 191 were included in the final analysis. Of these, 51.3% (98/191) presented an eutopic normally sized thyroid gland while 48.7% (93/191) showed a thyroid dysgenesis. Among the studied infants, 13.6% (26/191) presented CD. The most frequent cardiac anomaly was atrial septal defect (ASD) which was found in 65.4% (17/26) of patients with CD. Other defects were ventricular septal defect (VSD), patent ductus arteriosus (PDA), pulmonary valve stenosis (PvS), transposition of the great vessels (TGV), aortic valve stenosis (AvS). Six patients had multiple defects. In the analysed group, there was no significant relation with sex, type of CH, median blood-TSH (b-TSH) and serum-TSH (s-TSH) values and frequency of CD. There is a high prevalence of CD in CH, indicating the need of routine echocardiography in these patients to achieve an early diagnosis and management of CD.

Camel milk: a possible alternative for children with cow's milk allergy?

BACKGROUND

Cow's milk protein allergy (CwMPA) is the most common food allergy during early childhood and its therapy consists in the elimination of cow's milk proteins (CwMP) from the diet and the introduction of alternative formulas. Evidence about clinical use of camel's milk (CM) in CwMPA in children is scarce. The aim of this study was to determine the entity of cross-sensitization between CM and CwM in children with CwMPA.

METHODS

This prospective study was performed in children affected by CwMPA. We evaluated skin prick tests (SPT) for CwM, CwMP (alpha-lactalbumin [ALA], beta-lactoglobulin [BLG] and casein [CAS]) and CM and serum levels of CwM, ALA, BLG, CAS-sIgE.

RESULTS

Sixty-seven children with CwMPA were included in this study: twenty-one resulted SPT+ to CM. Mean wheal diameters towards raw CwM, ALA, BLG and CAS resulted significantly larger in the CM SPT+ group than in the CM SPT- group (P<0.02). Likewise, mean IgE titers against CwM, ALA and CAS were significantly higher in the CM SPT+ group than in the CM SPT-group (P<0.01). The mean wheal diameter towards raw CwM was significantly larger than that towards CM (P<0.0001).

CONCLUSIONS

This study confirms the presence of cross-sensitization between CwM and CM that remains lower if compared to other mammalian milks. Small wheals at the SPT towards CwM antigens together with low IgE titers against them could work as predictors in selecting patients that are expected to have negative CM SPT and then could be fed with CM with lower risks of allergic reactions.

Camel milk: a possible alternative for children with cow's milk allergy?

BACKGROUND

Cow's milk protein allergy (CwMPA) is the most common food allergy during early childhood and its therapy consists in the elimination of cow's milk proteins (CwMP) from the diet and the introduction of alternative formulas. Evidence about clinical use of camel's milk (CM) in CwMPA in children is scarce. The aim of this study was to determine the entity of cross-sensitization between CM and CwM in children with CwMPA.

METHODS

This prospective study was performed in children affected by CwMPA. We evaluated skin prick tests (SPT) for CwM, CwMP (alpha-lactalbumin [ALA], beta-lactoglobulin [BLG] and casein [CAS]) and CM and serum levels of CwM, ALA, BLG, CAS-sIgE.

RESULTS

Sixty-seven children with CwMPA were included in this study: twenty-one resulted SPT+ to CM. Mean wheal diameters towards raw CwM, ALA, BLG and CAS resulted significantly larger in the CM SPT+ group than in the CM SPT- group (P<0.02). Likewise, mean IgE titers against CwM, ALA and CAS were significantly higher in the CM SPT+ group than in the CM SPT-group (P<0.01). The mean wheal diameter towards raw CwM was significantly larger than that towards CM (P<0.0001).

CONCLUSIONS

This study confirms the presence of cross-sensitization between CwM and CM that remains lower if compared to other mammalian milks. Small wheals at the SPT towards CwM antigens together with low IgE titers against them could work as predictors in selecting patients that are expected to have negative CM SPT and then could be fed with CM with lower risks of allergic reactions.

Prediction of Transient or Permanent Congenital Hypothyroidism from Initial Thyroid Stimulating Hormone Levels

OBJECTIVE

To identify factors that discriminate between transient and permanent congenital hypothyroidism.

METHODS

Retrospective evaluation of 58 children with congenital hypothyroidism and eutopic thyroid gland. Gender, gestational age, birth weight, TSH and serum thyroxine levels at diagnosis and L-thyroxine dose at 12 and 24 months of age were analyzed.

RESULTS

Median (IQR) initial TSH levels were 73.3 (276.5) µIU/mL in permanent hypothyroidism and 24.24 (52.7) µU/mL in transient hypothyroidism (P =0.0132). The optimum cut-off value of initial TSH to predict transient hypothyroidism was 90 µIU/mL. Mean (SD) L-thyroxine doses at 24 months of age were 2.64 (0.98) µg/kg/day in permanent hypothyroidism and 1.91 (0.65) µg/kg/day in transient hypothyroidism. Requirement of L-thyroxine dose at 24 months of ≤0.94 µg/kg/day had the highest sensitivity (100%) to predict transient hypothyroidism.

CONCLUSIONS

L-thyroxine doses at 24 months can predict transient hypothyroidism in patients with eutopic thyroid gland earlier than at 36 months.

Oral iron absorption test with ferrous bisglycinate chelate in children with celiac disease

BACKGROUND

Celiac disease (CD) is an immunologically-mediated enteropathy resulting in small-bowel mucosal villous atrophy with crypt hyperplasia. Iron malabsorption is usually observed in CD. Only few studies investigated oral iron absorption in subjects with gastrointestinal diseases and Iron Deficiency Anemia (IDA), using the oral iron absorption test (OIAT). We considered useful to investigate the OIAT, using ferrous bisglycinate chelate (FBC), in patients with CD at diagnosis or on gluten free diet (GFD) from at least 1 year.

METHODS

A total of 25 patients with CD (3-18 years old) and iron depletion, at diagnosis of CD (N.=12) or on GFD from at least 12 months (N.=13), were considered. Serum iron was evaluated at baseline (T0) and after 3 hours (T1) from the oral iron ingestion. Statistical analyses were conducted using SPSS 21.0 software for Mac.

RESULTS

OIAT was well tolerated by all patients. An important increase of the serum iron at T1, of at least twice the baseline values, occurred in all patients except in one (P value <0.0005).

CONCLUSIONS

These results demonstrated good efficacy of the FBC, not only in patients with CD on GFD but also in children with newly diagnosed CD with the characteristic intestinal lesions.

Iron deficiency anemia in newly diagnosed celiac disease in children

BACKGROUND

Celiac disease (CD) in children may occur with a wide spectrum of clinical manifestations: anemia is the most frequent extraintestinal manifestation, iron deficiency anemia (IDA) is the common presentation. In our study we aimed to assess IDA condition in a large cohort of pediatric patients with newly diagnosed CD.

METHODS

Our study includes a cohort of 518 children (340 females and 178 males), 6 months-18 years old, joined between January 1990 and January 2013. We have analyzed hematological parameters and iron balance: serum iron, serum ferritin and serum transferrin levels. The diagnosis of IDA was considered on the basis of hemoglobin levels below -2SD, associated with serum iron and ferritin reduction, serum transferrin increase; all compared with the normal reference values for age.

RESULTS

Of all patients, 156 patients (30.1%) had anemia, including 103 females (19.8%) and 53 males (10.2%); of these, 112 (21.62%) had IDA (in 18 cases associated with α- or β-thalassemia trait), 22 were thalassemic trait without iron deficiency and the remaining 19 suffered from other forms of anemia. One hundred fifteen patients (22.20%) with low ferritin levels but normal hemoglobin levels were considered as preanemic iron deficient patients.

CONCLUSION

Our data confirm that iron depletion and IDA represent a frequent finding at the diagnosis of CD. This significant relation existing between CD and iron deficiency should be considered by pediatricians at the diagnosis of CD in order to treat the patients.

[Diet and lifesyle of a cohort of primary school children]

INTRODUCTION

The obesity is the disease of the new millennium, because it affects about 300 million people in the world, and especially it has a high prevalence in children. Obesity is a significant risk factor for cardiovascular disease, diabetes mellitus type II, hypertension, problems of adaptation and relationship with other, lower self-esteem and depression.

AIMS

The objective of our study is to identify children at risk of overweight/obesity in order to primary prevention. We have organized meetings with children, families and school's members where we discussed the results of our investigation about the importance of healthy diet and lifestyle.

PATIENTS-METHODS

The study was carried out on 545 children (282F, 263M), age 6.-10 years, of two primary schools in Catanzaro, from 2008 to 2010. The valuation parameters were: gender, age, weight, height, blood pressure and waist circumference. To children were also administered a questionnaire about dietary habits and lifestyle.

STATISTICAL ANALYSIS

Fisher's test.

RESULTS

We had that 62% of children was normal weight, 27% overweight, 11% obese. A particularly relevant datum is that the percentage of overweight-obese boys of 8 and 9 years old was higher (56%) than that of normal weight. We found cases of hypertension only in obese children. 98% of obese, 80% of overweight and 24% of normal weight children had a high waist circumference. We did not find differences in food quality among normal weight and overweight/obese children. Instead, we found significant differences in behavior between children: 90% of obese, 64% of overweight and 53% of normal weight children passed more than 2 hours in the afternoon watching television, playing computer and video games. 70% of normal weight, 82% of overweight and 95% of obese children practiced physical activity.

DISCUSSION/CONCLUSION

Our study shows a alarming fact about the increase of the obesity in children. In particular the most important problem is that this condition could predispose to cardio-metabolic, endocrine, respiratory, musculoskeletal and psychological consequence. So it is important that everybody who lives with children, especially parents and school's members, educates children to have healthy lifestyles. These attentions may slow the worryng epidemic of obesity.

Antral nodularity and positive CagA serology are distinct and relevant markers of severe gastric inflammation in children with Helicobacter pylori infection

BACKGROUND

The aim of this study was to assess whether the endoscopic finding of antral nodularity and serum IgG antibodies to CagA are associated with higher grades of gastric inflammation.

MATERIALS AND METHODS

The comprehensive data of two previously published trials were reanalysed. One hundred and fifty-three children (median age 9.5 years) who underwent gastroscopy were included. Biopsy specimens from the antrum and corpus were taken to assess Helicobacter pylori status, gastritis score and lymphoid follicles. During endoscopy, antral nodularity was noted. Serum samples were assayed for IgG antibodies to CagA.

RESULTS

The presence of antral nodularity (nod+) and positive CagA serology (CagA+) were each found in 32 of the 77 (41.5%) children who had evidence of H. pylori infection. Cross tabulation showed that 20 children (26%) were nod+/CagA+, 12 (15.5%) nod+/CagA-, 12 (15.5%) nod-/CagA+ and 33 (43%) nod-/CagA-. Gastritis score was significantly lower in nod-/CagA- children than in nod+/CagA- (p =.004), nod-/CagA+ (p =.002) and nod+/CagA+ (p <.001), both in the antrum and corpus. Completely normal gastric histology was only found in the nod-/CagA- subgroup of H. pylori-infected children (eight of 33, 24%). Regression analysis showed that antral nodularity and positive CagA serology were related to severe gastric inflammation independently of each other and age. Separate analysis showed that inflammation (p <.001), activity (p <.001) and H. pylori density (p =.002) scores were significantly lower in nod-/CagA- children compared with nod+/CagA+ children. The number of lymphoid follicles in the gastric mucosa was related to antral nodularity (p =.003) and positive CagA serology (p =.043), independently of each other.

CONCLUSIONS

Antral nodularity and positive CagA serology are distinct and relevant markers of severe gastric inflammation in children with H. pylori infection. The lack of both findings in the same child reflects low-grade or no gastritis.

Antral nodularity identifies children infected with Helicobacter pylori with higher grades of gastric inflammation

BACKGROUND

The endoscopic pattern of antral nodularity is a peculiar finding in children with Helicobacter pylori infection. The aim of this study was to determine whether this finding is related to more severe gastritis.

METHODS

One hundred seventy-four consecutive children (median age 8.7 years) referred for gastroscopy were studied. Biopsy specimens from the antrum and body of the stomach were taken to assess H pylori status, gastritis score, and lymphoid follicles. Clinical diagnosis, major symptoms and endoscopic findings were recorded.

RESULTS

Eighty-four (48%) children (median age 10.5 years) had evidence of H pylori infection. The endoscopic pattern of antral nodularity was found only in children infected with H pylori (34/84, 40.5% vs. 0/90, 0%, p < 0.0001% 100% specificity, 40.5% sensitivity). Among all children infected with H pylori, the gastritis score was higher (p < 0.0001) in those with antral nodularity (n = 34) than in those without (n = 50). Completely normal gastric mucosal histology was never found in children infected with H pylori with antral nodularity. The presence and number of lymphoid follicles was strongly related to the finding of antral nodularity (p < 0.01).

CONCLUSIONS

The endoscopic pattern of antral nodularity identifies children with H pylori infection, severe gastritis, and increased lymphoid follicles.

Evidence favouring the gastro-oral route in the transmission of Helicobacter pylori infection in children

OBJECTIVE

Several studies support the view that Helicobacter pylori is acquired in early life and within families. However, the exact route of transmission remains unknown. Given that H. pylori colonizes only the human gastric mucosa, the hypothesis that history of vomiting in siblings may be a relevant risk factor was tested in a paediatric setting.

METHODS

One hundred urban children (age range 0.8-16.6 years, median 9), 44% with evidence of active H. pylori infection, were recruited. A structured questionnaire dealing with socio-economic issues was completed. Vomiting siblings and siblings of vomiting index children were screened for H. pylori by means of (13)C-urea breath test. Serum samples from index children were assayed for immunoglobulin G to hepatitis A (HAV) and Epstein-Barr virus (EBV) in order to check for faecal-oral and oral-oral exposure, respectively.

RESULTS

Vomiting siblings of H. pylori-infected index children and siblings of H. pylori-infected vomiting index children had a high rate of active H. pylori infection (60 and 67%, respectively). History of vomiting in siblings was positively associated with active H. pylori infection in the index children (multivariate odds ratio 2.4, 95% confidence interval 1.3-4.3). Seropositivity for HAV and EBV was found in 1 and 68 index children, respectively. The agreement between active H. pylori infection and EBV seropositivity was not significant (kappa = 0.26).

CONCLUSIONS

History of vomiting in siblings is an independent risk factor for H. pylori. Nowadays, transmission of H. pylori in urban children may involve the gastro-oral route more than the faecal-oral or oral-oral pathways.

Testing for serum IgG antibodies to Helicobacter pylori cytotoxin-associated protein detects children with higher grades of gastric inflammation

BACKGROUND

Little information is available about the relationships between Helicobacter pylori cytotoxin-associated protein (CagA) and clinicopathologic features in children. The purpose of this study was to test whether determining serum IgG antibodies to CagA is a useful tool for detecting more severe disease.

METHODS

One hundred twenty-seven consecutive children (age range, 0.75-17.8 years; median, 9.4 years) referred for gastroscopy were included in the study. Antral and corpus biopsies were taken for gastric histology and H. pylori detection. Major symptoms and endoscopic findings were recorded. A serum sample was drawn from each child and assayed for IgG antibodies CagA by a commercial enzyme-linked immunosorbent assay.

RESULTS

Sixty-three (50%) children had no evidence of H. pylori infection, 28 (22%) were H. pylori positive/CagA positive, and 36 (28%) were H. pylori positive/CagA negative. There were no differences in clinical diagnosis and occurrence of any predominant symptom according to H. pylori and CagA status. Findings of antral nodularity were more frequent (p = 0.003) in H. pylori-positive/CagA-positive children than in H. pylori-positive/CagA-negative children. The gastritis score was significantly higher in H. pylori-positive/CagA-positive children than in H. pylori-positive/CagA-negative children (5.7 +/- 1.9 vs. 3.8 +/- 1.6, respectively; p = 0.0003), either in the antral (p = 0.0002) or in the corpus (p = 0.001) mucosa. Inflammation (p = 0.0001) and activity (p = 0.0001) scores were both higher in H. pylori-positive/CagA-positive children than in H. pylori-positive/CagA-negative children, but the H. pylori density score was not significantly different (p = NS). In no case was normal gastric mucosa found in H. pylori-positive/ CagA-positive children. Lymphocytic gastritis (p = 0.0008) and lymphoid follicles (p = 0.000003) were a more frequent finding in H. pylori-positive children than in H. pylori negative children, irrespective of CagA status.

CONCLUSION

Testing for serum IgG to CagA detects higher grades of gastric inflammation among children with H. pylori infection. It may be useful in targeting H. pylori-positive/ CagA-positive children for antimicrobial therapy while reducing the need for endoscopy and gastric biopsy.

Helicobacter pylori infection in children with celiac disease: prevalence and clinicopathologic features

BACKGROUND

Celiac disease is frequently associated with chronic gastritis. Helicobacter pylori is the main etiologic agent of chronic gastritis. The aim of this study was to assess the prevalence of H. pylori, the related symptoms, and the endoscopic and histologic gastric features in children with celiac disease.

METHODS

Eight-one (24 boys, 57 girls; age range: 1.4-17.7 years, median 6.8) children with celiac disease were studied. All children had a blood sample taken. In a subgroup of 30 children who underwent endoscopy, three gastric biopsy specimens were taken for histology (hematoxylin and eosin, Giemsa, immunohistochemistry) and urease quick test. Symptom complaints were recorded. Age- and sex-matched (one case, one control) children without celiac disease were used for comparison. Serum H. pylori IgG were measured by means of a locally validated commercial enzyme-linked immunoassay.

RESULTS

Overall, 15 of 81 (18.5%) children with celiac disease and 14 of 81 (17.3%) control children were positive for H. pylori. The percentage of H. pylori positivity was similar in children with untreated and treated celiac disease. Recurrent abdominal pain was the only symptom that helped to distinguish between H. pylori-positive and H. pylori-negative children. However, symptoms disappeared in patients with celiac disease after gluten withdrawal, irrespective of H. pylori status. All endoscopic (erythema, nodularity) and histologic (superficial-, interstitial-, lymphocytic-gastritis, activity, lymphoid follicles) findings did not differ between celiac and nonceliac H. pylori-positive children.

CONCLUSIONS

Prevalence and clinical expressivity of H. pylori infection is not increased in children with celiac disease. The clinicopathologic pattern of the infection is not specifically influenced in this condition.