Van Wyk-Grumbach syndrome: The importance of thyroid function tests in a child presenting with multicystic ovaries

INTRODUCTION

Van Wyk-Grumbach syndrome (VWGS) is a rare presentation of long-standing hypothyroidism, characterized by delayed bone age, enlarged bilateral multicystic ovaries, and isosexual precocious puberty.

CASE PRESENTATION

We report here the clinical details of the case of Van Wyk Grumbach Syndrome in an 11-year-old girl who was first presented to the pediatric surgeon for hemoperitoneum. The patient underwent an emergency exploratory laparotomy, which showed enlarged ovaries with multiple cysts that were bleeding. She also had severe hypothyroidism, hyperprolactinemia, hyperestrogenism, pituitary adenoma, and delayed bone age. Significant improvement in symptoms was noted after thyroid hormone replacement therapy.

IMPORTANCE AND CONCLUSION

This case highlights that it is crucial to consider thyroid assessment in a patient with multicystic ovaries to avoid misdiagnosis, unnecessary investigations for malignancy and/or surgical intervention, and possible complications.

P073 Joint manifestations of IBD: about 9 cases

Background

Joint manifestations during chronic inflammatory bowel diseases (IBD) represent the most frequent extra digestive manifestations, dominated by spondylarthropathy, isolated sacroillitis and peripheral rheumatism. We conducted a retrospective study of 9 cases of IBD collected in the pediatric services of the CHU MOHAMMED VI of Oujda over a 4 year period from July 2017 to March 2021.The objective of our study is to describe the joint manifestations in inflammatory bowel diseases in children.

Materials and methods

This is a retrospective study of 9 cases of IBD collected in the pediatric services of the CHU MOHAMMED VI of Oujda over a 4-year period from June 2017 to March 2021.

All these parameters were collected on operating sheets and reported on ExcelThe data were collected from the files registered in a pediatric hospitalization register

Results

Our study includes 9 patients with male predominance in 60% of cases, the prevalence of joint manifestations was 45% of which 3/4 of cases are in Crohn's disease and 1/4 of cases in UC.Axial joint involvement was 25% in Crohn's disease while joint involvement was peripheral in 75% of which 2/3 in Crohn's and 1/3 in UC.Peripheral involvement affects the large joints in all patients with a bilateral character. With a biological inflammatory syndrome in which the CRP was >50 mg/l and the VS more than 30All patients received corticotherapy and analgesics in 25% of cases. The evolution was marked by a good clinical and biological improvement with an average delay of 10 days.

Discussion

Ulcerative colitis (UC) and Crohn's disease (CD) are chronic cryptogenetic inflammatory bowel diseases (IBD). In addition to intestinal involvement, these IBDs are associated in 20% to30% of cases with extra digestive manifestations, with joint manifestations being the most frequent. There are essentially two types: Peripheral attacks which are the most frequent (8–20% of patients) especially during Crohn's disease; All joints can be affected, but most often asymmetric oligoarthritisAxial involvement includes sacroiliitis (SI) and ankylosing spondylitis (SpA) SI is more prevalent than SpA in both UC and CD Treatment of joint manifestations involves rest and exercise% tocontrol spinal stiffening in axial involvement; and analgesics Close collaboration between gastro-pediatricians and pediatric rheumatologists is the key to optimal management of the extra-digestive manifestations of IBD.

Conclusion

Joint involvement plays an important role in the extra digestive manifestations of IBD. It should be systematically screened in IBD patients, especially if they present a biological inflammatory syndrome, thus enabling early diagnosis and better management.

P089 Meningeal syndrome revealing Kawasaki like syndrome: a case report

Background

Multisystemic inflammatory syndrome in children is a new and rare hyperinflammatory disorder with a temporal link to the current coronavirus 2019 (COVID-19) pandemic; its main clinical signs are prolonged fever, typical features of Kawasaki disease; cardiac dysfunction; as well as gastrointestinal, renal, and/or neurological symptoms. However, the association between meningeal syndrome and the pediatric multisystemic inflammatory syndrome is poorly described in the literature. We will report the case of a boy who presented with meningeal syndrome revealing a Kawasaki-like syndrome. The objective of our work is to provide an update on this pathology which is very little known by clinicians.

Observation

Our patient is a male child aged 8 years, from a 2nd degree consanguineous marriage, with a history of the influenza-like syndrome in all family members one month before admission, He was admitted for the management of a febrile meningeal syndrome, the history of which goes back to seven days before his admission, with the onset of a non-calculated fever resistant to antipyretics, associated with peri-umbilical pain and stiffness of the neck with the notion of photophobia and constipation. The clinical examination revealed a conscious child, GCS 15/15, very asthenic, fever 39.3 degrees. The neurological examination revealed a stiff neck with a negative brudzinski and kerning sign and no sensory-motor deficit. The skin examination reveals a morbilliform exanthema with an interval of healthy skin made up of non-infiltrated erythematous macules, which fade away within vitro pressure, on the lower and upper limbs and the trunk, sparing the face, the palms, the soles, and the external genitals, associated with the presence of bilateral palmoplantar oedema without desquamation. The mucous membrane examination showed bilateral conjunctivitis, not purulent, and cheilitis with left cervical adenopathy measuring 2 cm, with an inflammatory appearance on ganglionic examination. The rest of the examination was unremarkable. In front of the meningeal syndrome, a lumbar puncture was performed and came back negative. The biological workup revealed a major inflammatory syndrome: the white blood cells were 25 000 with a predominance of PNN at 23 500, the lymphocytes at 1,000, the platelets at 278 000, the sedimentation rate at 100 and the CRP at 272, the ferritinemia at 725.12, the Pro-BNP was elevated at 1,834, the liver and kidney biological results were normal. Echocardiography revealed myocarditis with mitral leakage, slight hypokinesia of the left ventricle, ejection fraction at 50%, VGTG 40MM, dilated coronary arteries, left common trunk at 4 mm, and IVA at 3 mm with minimal pericardial effusion. Given the current epidemiological context of the clinical symptomatology in our child, the multisystemic inflammatory syndrome was strongly suspected, so a covid19 serology was performed: negative IgM, positive IgG.

Conclusions

Several recent studies have shown the presence of neurological signs in children with multisystemic inflammatory syndrome related to Covid 19 hence the interest in screening to have recommendations based on sound clinical data for better management of patients with this syndrome during this pandemic.

P062 Vasculitis in children: epidemiological, clinical and Para clinical profile in the oriental region of Morocco—about 33 cases

Background

Vasculitis in children constitute a heterogeneous group of pathologies considered as a rarity in our context and therefore deserves to be better known. Despite their individualization for more than forty years throughout the world, they continue to be a challenging condition both in terms of diagnosis and treatment. The objective of our study is to report the epidemiological profiles of vasculitis and to assess the clinical and Para clinical profile of our patients, in order to contribute to a better knowledge of these conditions in our context, whose early diagnosis allows the starting of an appropriate treatment and the improvement of the prognosis.

Material and methods

This is a retrospective study, in which we collected data of all children in whom the diagnosis of vasculitis was confirmed, and who were hospitalized in the pediatric department of the University Hospital Center (CHU) Mohamed VI of Oujda over a period of 3 years from July 2014 to July 2017.

Results

Thirty-three patients were selected; 25 boys (76%) and 8 girls (24%), including 16 patients with Kawasaki disease; 14 patients with Henoch-Schonlein purpura (HSP); 2 patients with Polyarteritis nodosa (PAN); and 1 patient with Takayasu. A male predominance was noted with a sex ratio of 3.16. HSP represented 42.42% of the cases, the most affected age group was between 5 and 9 years in 45% of cases. Purpura was the most frequent symptom (100%) with petechial appearance in 77% of cases and localized in the lower limbs in all cases (100%). Joints were affected in 13 cases (93%), abdominal symptoms were found in 81.82% of cases, with one case of melena and 3 cases of rectal bleeding. The renal symptoms were mainly biological and were dominated by urinary proteinuria (45%), microscopic hematuria in one case, macroscopic hematuria in 3 cases, hypertension in one case and nephrotic syndrome in one case. Five patients developed renal insufficiency, two children had moderate renal insufficiency and three had severe renal insufficiency. Kawasaki disease represented the majority of cases: 16 cases (48.48%), affecting children between 4 and 41 months of age with an average age of 22 months, with most affected age group was between 12 and 24 months in 55%. The appeal signs were multiple dominated by fever which represents 100% of cases, skin rash in 82%, ocular redness in 45%, enanthema in 45%, oedema of the extremities in 45%, and adenopathy in 6% (one case). The inflammatory syndrome was present in all patients. Cardiac Doppler ultrasound was performed in 14 patients. It was abnormal in 22% of cases. 11 patients received a course of IGIV (54.54%), at a dose of 2 g/Kg in a single 12-h infusion. Aspirin was administered in all patients. The evolution was favorable in 15 patients, only one case was complicated by giant aneurysms of both coronaries, which evolved to a slight decrease in size and disappearance of the pericardial effusion. Valvular abnormality was noted in one case and minimal pericardial effusion in one case.

Conclusion

This study confirmed that incidence of vasculitis in children in our context is average, this can be seen on the non-negligible number of cases (33 cases) collected over a period of 3 years. Early diagnosis of this condition key to allow an initiation of an appropriate treatment and improvement of the prognosis.

P088 Prolonged fever in a boy revealing Takayasu disease: a case report

Background

Takayasu's arteritis (TA) is a chronic inflammatory vasculitis of unknown origin. It affects the large vessels, especially the aorta, its main branches, and the pulmonary arteries. It begins acutely in children with severe general manifestations. The diagnosis of TA remains a challenge to clinicians due to many reasons such as its rarity, its great clinical polymorphism, and the lack of specific biological criteria.

Case report

A 13-years old boy with no pathological history, was admitted for prolonged fever with intermittent abdominal pain. The clinical examination has found a conscious boy, febrile with a BP of 130/90mmhg, a normal heart rate, and stable respiratory function. The cardiovascular examination noted a decrease in pedal pulses, without signs of ischaemia or necrosis, and the cardiac auscultation was normal. Examination of the lymph node areas has shown upper and left later cervical adenopathy measuring 1.7 cm in long axis, mobile, and painless. All joints were free. The complementary biological workups revealed an inflammatory syndrome (ESR: 120 mm, fibrinogen: 5 g/l, microcytic hypochromic anaemia at 9 g/dl, ferritin: 1051, low serum iron: 11µg/dl and thrombocytosis: 692 000 elements/l). Chest X-ray showed a dilated aortic button. A thoracic angioscan revealed a peri-aortitis more evident at the level of the emergence of the mesenteric artery with a pseudo-aneurysmal aspect and arteritis of the right primary carotid artery. Echocardiography was performed and showed a dilated aspect of the aorta with irregular wall. Renal ultrasound was normal. The diagnosis of Takayasu disease was made on the basis of clinical biological and essentially radiological arguments according to the diagnostic criteria of the American College of Rheumatology. The patient was treated with corticosteroid (prednisone: 2 mg/kg/d) for one month then then gradually reduced doses The disease course was marked by several relapses and the patient was then treated with mycophenolate mofetil (cellcept).

Conclusion

Takaysu's disease is a chronic inflammatory vasculitis of unknown origin, which affects the large- vessels, mainly the aorta, its main branches, and the pulmonary arteries; but it remains rare in children and its treatment is not well codified.

P074 Prolonged fever in children: Epidemiological and etiological profile in the eastern region of Morocco—about 119 cases

Background

Prolonged fevers (PF) are defined as a thermal shift >38 ° C without any immediately obvious cause (fever of unknown origin). The fever is considered as prolonged when it lasts at least 7 days in children and 5 days in infants. PF constitute a frequent reason for consultation. Our Objective is to highlight the epidemiological and etiological profile of prolonged fevers in children in the eastern region of Morocco.

Material and methods

Our work is a retrospective study of 119 cases, conducted from January 1, 2015 to July 31, 2018 in the pediatric department of the C.H.U Mohammed VI Mother-Child Hospital in Oujda, Morocco.

Results

The hospital incidence of PF in this study was 2.8%. The patients average age was 49 months. A male predominance was noted (63 boys). The patients were living in urban zone in 76% of cases. The symptom duration before first consultation was 18 days. Children with a history of suspected but not confirmed infection with notion of taking antibiotics and antipyretics were noted in 30% of cases. The functional signs were dominated by digestive symptoms in 34 patients, followed by mucocutaneous signs in 26% of cases, and cardiorespiratory manifestations in 12% of cases. The main physical signs were represented by a tumor syndrome in 34 patients, and 31 cases of cutaneous involvement. The etiologic diagnosis was confirmed by an abdominal ultrasound in 48% of cases, a myelogram in 19% of cases, a chest X-ray in 17% of cases, and a cardiac ultrasound in 14.5% of cases.

At the end of the etiological investigation, the infectious causes were in 52 cases, inflammatory diseases in 32 cases, neoplasia in 27 cases, and undetermined causes 8 cases.

Discussion

The hospital incidence of prolonged fevers is difficult to estimate because of the nosological problem they pose. However, FP constitutes 0.4% to3% of the reasons for pediatric hospitalization. In our study, it was 2.8%. Regarding age, almost half of the children hospitalized for FP exploration are under the age of six. This can be explained by the high frequency of febrile diseases, in particular infectious diseases, at this age the male predominance was marked in most studies with a sex ratio ranging from 1.1–1.8. The clinical signs on admission did not allow a clear etiological orientation, and it was the repeated questioning and physical examination during hospitalization that guided the etiological investigation. The most common feature is infectious causes. There is a high percentage of neoplastic causes compared with the literature. Indeterminate causes constitute only 6.7% compared with higher figures in the literature which can be explained by the progress of examinations in the field of etiological research.

Conclusion

Prolonged fevers in children therefore remains a complex condition to handle despite advances in diagnostic means. Careful clinical examination is necessary for the management of children with PF. In fact, the patient should be regularly reassessed in search of new symptoms and other investigation leads. The reasoned prescription of additional workups and critical analysis of clinical signs are also essential steps in the etiological investigation.

[Partial facial duplication (a rare diprosopus): Case report and review of the literature]

INTRODUCTION

Diprosopus, or partial facial duplication, is a very rare congenital abnormality. It is a rare form of conjoined twins. Partial facial duplication may be symmetric or not and may involve the nose, the maxilla, the mandible, the palate, the tongue and the mouth.

OBSERVATION

A male newborn springing from inbred parents was admitted at his first day of life for facial deformity. He presented with hypertelorism, 2 eyes, a tendency to nose duplication (flatted large nose, 2 columellae, 2 lateral nostrils separated in the midline by a third deformed hole), two mouths and a duplicated maxilla. Laboratory tests were normal. The cranio-facial CT confirmed the maxillary duplication.

DISCUSSION

This type of cranio-facial duplication is a rare entity with about 35 reported cases in the literature. Our patient was similar to a rare case of living diprosopus reported by Stiehm in 1972. Diprosopus is often associated with abnormalities of the gastrointestinal tract, the central nervous system, the cardiovascular and respiratory systems and with a high incidence of cleft lip and palate. Surgical treatment consists in the resection of the duplicated components.

[A rare cause of cervical swelling in a child: Solitary plexiform neurofibroma]

Plexiform neurofibroma is a rare benign tumor of the peripheral tissue cells developed in the perineurium. Often considered pathognomonic of neurofibromatosis type 1 (NF1 or von Recklinghausen disease), it can be solitary without NF1, especially in children. The diagnosis is essentially pathological and treatment is primarily surgical to avoid malignant degeneration. We report on a case of cervical solitary plexiform neurofibroma discovered in a 9-year-old child.

[Congenital afibrinogenemia: a case report]

Afibrinogenemia is a rare autosomal recessive disease. Its clinical manifestations vary in severity, ranging from minimal bleeding to cataclysmic hemorrhage, and can begin at birth or, sometimes, later. We report a case of a female infant, 10 months of age, hospitalized in the pediatrics department because of a postvaccination hematoma. Biologic exploration found congenital afibrinogenemia. Through this case, we review the clinical features of this disease and its management.

Knowledge and management of fever among Moroccan parents

Parents often have misperceptions about childhood fever, and little information is available about the home management of feverish children in Morocco. In this study of the perceptions, knowledge and practices of families regarding children's fever, the parents of 264 febrile children aged 0-16 years were interviewed in a paediatric emergency department in Rabat in 2011. Only 3.5% of parents knew the correct temperature definition for fever, 54.4% determined their children's fever using a thermometer, and the preferred site was rectal. Most of them (96.8%) considered that fever was a very serious condition, which could lead to side-effects such as brain damage (28.9%), seizures (18.8%) paralysis (19.5%), dyspnoea (14.8%) and coma (14.8%). Paracetamol was used by 85.9% and traditional treatments by 45.1%. Knowledge about the correct definition of fever was significantly associated with parents' profession, educational level and receipt of previous information and advice from health professionals.