Investigating the comparative effect of vitamin D level with the type of complications in Henoch Schönlein purpura and Kawasaki disease

INTRODUCTION AND OBJECTIVES

Henoch Schönlein purpura (HSP) and Kawasaki disease (KD) are two main inflammatory diseases among childhood vasculitis. Considering the anti-inflammatory effects of 25-hydroxyvitamin D3, we decided to investigate the association of serum 25-hydroxy vitamin D3 level with the type and severity of these conditions.

MATERIALS AND METHODS

The present study was performed as a historical cohort of 254 affected children with KD and HSP vasculitis. The required data were extracted, using a researcher-made questionnaire from patients' electronic file, and then they were analyzed after collecting information of the patients.

RESULTS

In HSP group, 54% of participants were boys. Similarly, in KD group, boys were more affected than girls. The comparative 25-hydroxyvitamin vitamin D3 level in HSP patients with and without renal involvement (P=0.02), hematuria (P=0.14), and in two groups with and without heart disease, and also with and without coronary artery dilatation in KD patients (P<0.001) were significant.

DISCUSSION AND CONCLUSIONS

The findings showed that insufficient level of vitamin D3 were significantly associated with the exacerbation of complications of both diseases, and therefore it seems that vitamin D deficiency can be an effective predictive factor of severity in HSP and KD patients.

A dual H-type tracheoesophageal fistula; why not being repaired simultaneously? A case report and review of literature

BACKGROUND

H-type Tracheoesophageal Fistula (TEF) is a particular type of congenital esophageal anomalies, in which patients present with non-specific symptoms that can result in delayed diagnosis. Here, we report two pediatric cases with a rarer variant called ‟dual H-type TEFˮ.

CASE PRESENTATION

We present two cases of H-type TEF. The first was a 45-day-old boy with feeding problem and cyanosis while feeding, and the second was a three-month-old girl with cough and choking after feeding from the first day of birth. In both cases, two separate TEFs were detected during diagnostic evaluation by flexible bronchoscopy. Both were repaired simultaneously through a cervical incision. The first patient deteriorated 13 days after the surgery, disturbancing in acid-base balance and expired unfortunately.

CONCLUSION

Hence, it is necessary to consider the possibility of double TEF in any newly diagnosed H-type TEF.

Post SARS-CoV-2 infection reactive arthritis: a brief report of two pediatric cases

BACKGROUND

Although, preliminary reports of Severe Acute Respiratory Syndrome (SARS)-CoV-2 infection suggest that the infection causes a less severe illness in children, there is now growing evidence of other rare or even serious complications of disease.

CASE PRESENTATION

During the recent COVID-19 pandemic in Kerman, Iran, two children (an 8 year-old boy and a 6 year-old girl) were referred to outpatient Clinic of Pediatric Rheumatology with complaints of limping. Both children had experienced fever and mild respiratory tract infection. At the beginning of the second week of infection, they developed joint effusion. They both tested positive for coronavirus infection and were therefore diagnosed with post Coronavirus reactive arthritis. Both children were treated successfully with rest and Non-Steroidal Anti-Inflammatory Drugs (NSAID). They did not have any medical problems in the two months fallow up.

CONCLUSIONS

These two cases suggest that COVID-19 may be rheumatogenic. Highlighting the need for awareness of physicians, especially pediatricians, regarding the pathogenesis margins of this virus, as late presentations are of great importance.

Risk Factors Associated With Renal Involvement in Childhood Henoch-schonlein Purpura

Context: Henoch-Schonlein purpura (HSP) is a significant cause of chronic renal disease in children. This review determines some risk factors associated with renal involvement in childhood HSP. Evidence Acquisition: Electronic databases, including Google Scholar, PubMed, and Scopus were searched using the following keywords: “children”, “Henoch-Schonlein”, “risk factor”, “renal involvement”, and “IgA vasculitis”. This review was designed to identify the relevant electronic studies published in the English language from December 1998 to August 2018. Results: This review revealed that clinically older age at presentation, persistent rash, atypical rash, rash on unusual location, and gastrointestinal bleeding were significant risk factors for renal involvement. In contrast, joint involvement was not associated with renal involvement. Among biochemical markers, high red blood cell distribution width is a risk marker of renal involvement in HSP. In contrast, peripheral blood immunoglobulin A, antinuclear antibody, anti-streptolysin O titer, erythrocyte sedimentation rate, and C-reactive protein were not associated with renal involvement. In several studies, leukocytosis, thrombocytosis, or thrombocytopenia have been mentioned as predictors for renal involvement. Still, other studies showed the white blood cell count or platelet count are not risk factors. The effect of corticosteroids as a predictive factor of renal involvement in HSP is challenging and controversial. Furthermore, their impact was dose-dependent. Conclusions: Demographic factors, clinical features, and some abnormal laboratory findings are significant predictive factors for renal involvement in HSP.

Determination of the Relationship Between Kobayashi, Sano, and Egami Criteria and Prevalence of Intravenous Immunoglobulin Resistance and Coronary Artery Aneurysm in Iranian Children with Kawasaki Disease

Introduction

Kawasaki disease (KD) is a systemic vasculitis that occurs mostly in children under five years old. Kawasaki affects the middle-size arteries, especially the coronary arteries. Therefore, without adequate treatment, it may cause coronary artery aneurysm in 25% of patients. The purpose of this study was to investigate the relationship between Kobayashi, Sano, and Egami criterions with coronary artery aneurysm in KD patients during the last ten years and to identify risk factors in patients with intravenous immunoglobulin (IVIG)-resistant and coronary artery aneurysms.

Methodology

Medical records of 363 Kawasaki patients referred during 2008–2017 were reviewed. Patients’ demographic data and Kobayashi, Sano, and Egami scores of each patient were calculated. Based on echocardiographic findings, cases of coronary artery aneurysm were determined. Sensitivity, specificity, positive and negative predictive value, and the accuracy of each criterion were determined to predicting IVIG resistance and detect coronary artery aneurysm.

Results

There was a slight relationship between IVIG-resistance in Kawasaki children and its prediction based on the Kobayashi risk score, but no relationship was found between the Egami and Sano criteria. Sixty-three patients (17.4%) had coronary artery lesions (CALs) on time of diagnosis. There were no statistically significant differences between gender and mean age of children with and without CALs. Also, there was no significant relationship between coronary artery aneurysm in Kawasaki children and its prediction based on the above three risk factors. The area under the ROC-curve of all three risk measures of Kobayashi, Egami, and Sano indicated that all three criteria were not useful in predicting CALs.

Conclusion

Despite the low accuracy of the three above criteria to predictive of patients with IVIG resistance, it seems that the variables of age, duration of fever, and C-reactive protein (CRP) are more useful than other variables and may be utilized to evaluate patients by establishing a more appropriate cut-off point.

Midfoot Arthritis in Children: Is There Any Relation With Malignancy?

Background:

Musculoskeletal symptoms are a presenting manifestation in a number of lymphoproliferative disorders including leukemia, especially in children. Among these primary symptoms, midfoot arthritis seems to be an important alarm for malignancy in children. The aim of this study is evaluation association of midfoot arthritis with malignancy in children.

Method:

In this cross-sectional study, all medical records of patients with arthritis were identified and reviewed. All clinical and laboratory data were recorded in the information form and data were analyzed by SPSS 25 software.

Results:

A total of 557 cases of arthritis were evaluated, of which 18 (3.2%) cases have primary symptoms of midfoot arthritis. Four of 18 patients (22.2%) had B-cell precursor acute lymphoblastic leukemia, that midfoot arthritis was their first manifestation. Also, their laboratory findings confirmed that platelet, lactic acid dehydrogenesis, and uric acid values were significantly higher in these children. Based on statistical evaluation, there was no significant difference between age and sex in these patients.

Conclusion:

According to the findings of the present study, it can be concluded that “midfoot arthritis” may be the first manifestation of leukemia in children even with a near-normal hematologic values.

Determination of diagnostic value (validity) leukocyte esterase (urine dipstick strip) in differentiating inflammatory arthritis from bacterial arthritis

BACKGROUND

The current diagnostic cornerstone for septic arthritis contains gram stains, bacterial culture, and cell count with a differential of aspirated synovial fluid. Recently, a synovial leukocyte esterase (LE) test has been used for diagnosing septic arthritis. Since this test measures the esterase activity of leukocytes, there is always a dilemma for using this test in patients with inflammatory arthritis.

METHODS

We collected the synovial fluid specimens as part of the general diagnostic protocol for patients suspected of Juvenile Idiopathic Arthritis (JIA) or Septic Arthritis (SA). Each group included 34 patients. We compared the result of the synovial LE test with the result of the culture of each patient.

RESULTS

The mean ages of patients were 64.14 ± 31.27 and 50.88 ± 23.19 months in the JIA group and septic arthritis group, respectively. The LE test results were positive in 30 specimens, trace in 3 and negative in one in the first-time test and were positive in 31 specimens and trace in 3 in the second-time test, while it was negative in all patients with JIA. Hence, the sensitivity of the synovial LE test was 80.8%, the specificity, PPV, and NPV were 78.6, 70.0, 86.8% respectively based on a positive culture.

CONCLUSION

The leukocyte esterase strip test can be used as a rapid, bedside method for diagnosing or excluding bacterial infections in different body fluids. The synovial LE test can be used as an accurate test to rapidly rule in or out an acute articular bacterial infection, even in patients with concurrent inflammatory arthritis.

Peripheral gangrene: A rare presentation of systemic lupus erythematosus in a child

Patient: Female, 12

Final Diagnosis: Antiphospholipid positive SLE

Symptoms: Gangrene • Raynaud’s phenomenon • autoamputation of the terminal phalanx of the second left hand finger

Medication: Prednisolone • mycophenolate mofetil • captopril

Clinical Procedure: Renal Biopsy • treatment of lupus nephritis • control of hypertension

Specialty: Pediatric rheumatology

Modified ilioinguinal approach to the acetabulum and pelvis from beneath the inguinal ligament: a subinguinal approach

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis. The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia. The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.

Sudden peroneal nerve palsy in a varus arthritic knee

Peroneal nerve palsy has been reported in association with traumatic and nontraumatic causes. We encountered a 75-year-old man whose peroneal nerve palsy developed suddenly following varus deformity of the arthritic knee. A review of the literature found 1 other report describing a progressive peroneal nerve palsy associated with a varus deformity of the knee due to arthritis. Our patient had progressive intractable knee pain; 3-compartment, severe degenerative changes in the knees; varus knee malalignment and laxity; right peroneal nerve palsy; and decreased sensation to light touch and pinprick on the dorsum of the right foot. The preoperative WOMAC score was 36. Nerve conduction studies confirmed acute peroneal neuropathy with conduction block at the fibular neck and secondary axonal degeneration. Magnetic resonance imaging of the knee showed osteophytes and cysts surrounding the fibular neck. Although their compression could be responsible for the nerve palsy, the sudden process made this less possible. Thus, the patient underwent total knee arthroplasty of both knees without exploration of the nerve. At 5-month follow-up, the WOMAC score was 78. The patient walked with a cane with no varus thrust, and his right knee had no varus laxity in full extension. The peroneal nerve did not retain its function. Sensory examination and postoperative nerve conduction studies showed no improvement.

Determination of terbinafine in tissues

Terbinafine and N-demethyl terbinafine concentrations were determined simultaneously in rat tissues by a high-performance liquid chromatography method. This method involved the homogenization of tissues (except for skin) followed by a liquid-liquid extraction. Skin samples were dissolved in sodium hydroxide prior to extraction. Terbinafine and its N-demethylated metabolite were assayed using a C(18) reversed-phase column with a mobile phase of acetonitrile and water (40:60) containing ortho phosphoric acid (0.02 M) and triethylamine (0.01 M), and UV detection (at 224 nm). The standard curve for the assay (constructed using clotrimazole as internal standard) was linear over the concentration range 100-3000 ng/g in skin and 10-600 ng/g in all other tissues. The inter- and intra-day precision for both terbinafine and metabolite was between 0.2% and 16%. The limit of quantification was 10 ng/g in all tissues and 100 ng/g in skin. This assay was found to be reliable and reproducible for the determination of terbinafine and N-demethyl terbinafine concentration in all rat tissues and has been used for tissue distribution studies.

Determination of propofol in rat whole blood and plasma by high-performance liquid chromatography

A simple, accurate and sensitive high-performance liquid chromatographic method was developed for the determination of propofol, an intravenous anaesthetic agent, in rat whole blood or plasma samples. The method is based on precipitation of the protein in the biological fluid sample and direct injection of the supernatant into an HPLC system involving a C18 reversed-phase column using a methanol-water (70:30) mobile phase delivered at 1 ml/min. Propofol and the internal standard (4-tert.-octylphenol) were quantified using a fluorescence detector set at 276 nm (excitation) and 310 nm (emission). The analyte and internal standard had retention times of 6.3 and 10.5 min, respectively. The limit of quantification for propofol was 50 ng/ml using 100 microl of whole blood or plasma sample. Calibration curves were linear (r2=0.99) over a 1-10 microg/ml concentration range and intra- and inter-day precision were between 4-11%. The assay was applied to the determination of propofol whole blood pharmacokinetics and propofol whole blood to plasma distribution ratios in rats.