Very high immunoglobulin E levels in children: when from pediatrician to immunologist?

BACKGROUND

Total serum immunoglobulin E (IgE) is increased in many situations such as allergic diseases, primary immunodeficiencies (PID), parasitosis, infections and malignancies. When IgE levels are >1000 kU/L PIDs are suspected by pediatricians. We tried to define some clinical and laboratory parameters to distinguish PID from the others.

METHODS

We evaluated 158 children between 1.7-17 years (mean: 6.6±3.4) for allergic diseases, PID, parasitosis and others. Total IgE, specific IgE, immunoglobulin levels and skin prick tests were performed to all patients. Parasite investigations, viral serological tests and detailed immunologic tests were analyzed in only patients who had suspected complaints. Hyper IgE syndrome (HIES) scoring sheet was filled out for all patients.

RESULTS

Among all patients, 114 were diagnosed as bronchial asthma, allergic rhino-conjunctivitis or atopic dermatitis. PID diagnosis was established in totally 32 patients. Immunological evaluations were normal in 126 patients. Eleven patients were accepted as parasitosis. Median HIES score was 18 (5-44 points).

CONCLUSIONS

Pediatricians may use HIES scoring sheet when they suspect a patient with PID. If the patient has very low points, they may follow the patient. If there are about 18-20 points, they should get an opinion from an immunologist for detailed immunologic tests.

Microcephaly in Infants: A Retrospective Cohort Study from Türkiye

Objectives

Microcephaly (MC) is a clinical finding mostly reflecting deficiency of brain growth. The aim of our study was to assess risk factors and follow-up features of children with MC.

Methods

Children's personal health records (n=7580) followed between 2002 and 2020 in the Unit of Well Child Clinic were assessed retrospectively. The case group was constituted of children with MC (n=49). Age and sex-matched children with normal head circumference consisted of the control group (n=98). MC was defined as head circumference SDS value ≤ -2 SDS.

Results

In this retrospective cohort study, children with MC had more disadvantaged sociodemographic characteristics such as young maternal and paternal age and low maternal and paternal education. Breastfeeding was high among controls. The resolution had been observed in 26 children with MC, whether it was mild (head circumference SDS between -2 and -2.9) or severe (head circumference SDS ≤3). Children with persistent MC had poorer developmental milestones than controls and cases with resolution. Sociodemographic features or developmental milestones in mild and severe MC were not different statistically.

Conclusion

According to our results it would be appropriate to use head circumference ≤ 2 SDS for the definition of MC not to miss the cases in the follow-ups. Some MC cases can be prevented by decreasing inequalities. Further studies are needed evaluating socioeconomic factors on MC.

Vaccination coverage of children with rheumatic diseases compared with healthy controls: a retrospective case-control study

OBJECTIVE

To reveal the vaccination status of patients with pediatric rheumatic disease (PedRD) and to compare this with healthy controls.

METHODS

The electronic health records of the Ministry of Health regarding the vaccination status of children with PedRD followed in a tertiary hospital were analyzed cross-sectionally and compared with their healthy controls. The missing vaccines were reported according to individual, age-appropriate schedule and causes of skipped vaccines in both groups were investigated with an online survey.

RESULTS

The vaccination rate of patients in the last examination was 71.4% (90/126) and 95.7% (110/115) in healthy controls (p < 0.001). Measles-mumps-rubella vaccine, diphtheria, the administration rates of the second dose of tetanus-acellular pertussis-inactivated polio and Haemophilus influenzae type B, chickenpox, and hepatitis A vaccines were significantly lower in patients than in controls (p values 0.004, 0.02, 0.01, 0.013, respectively). The pre-diagnosis incomplete vaccination proportion was significantly higher in the patient group (16.6%) than in healthy controls (4.3%) (p = 0.002). In the patient group, the proportion of incomplete live-attenuated vaccines after diagnosis (25%) was more than pre-diagnosis (61.1%) (p = 0.04), while the proportion of incomplete non-live vaccines before and after diagnosis was similar (47.2% and 50%, respectively) (p = 0.73). The major reasons for missed vaccines were physicians' recommendations (15.6%), the presence of PedRD diagnosis (12.5%), and the drugs used (12.5%).

CONCLUSION

Vaccination coverage of PedRD patients has been shown to lag behind the routine vaccination schedule (71.4%). In addition to new recommendations, electronic health system records for vaccination may be appropriate for the follow-up of these patients, and the addition of reminder alerts may be useful to reduce the rate of missed vaccinations.

Vaccine Adherence and Postvaccination Serological Status of Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: A Single-center Experience

Despite developing consensus guidelines addressing immunization after hematopoietic stem cell transplantation (HSCT), studies showed deviations from recommended immunization practices commonly occur. Difference between the ideal scenario presented in guidelines and real-life scenarios is one of the most recognized barriers to implementing recommended practices. Therefore, this study aimed to evaluate pediatric allogeneic HSCT recipients' adherence to revaccination schedule and evaluate the serological status after immunization. Transplant and vaccination records of children who were followed up at least 2 years after HSCT, postvaccination antibody results of vaccine-preventable diseases were evaluated retrospectively. Total of 173 patients have enrolled in this study. Median revaccination onset time was post-transplant 15 months. Adherence to revaccination program was 30% for inactive and 11.4% for live vaccines. Oral polio vaccine was given to 22 patients, and Bacille-Calmette-Guerin vaccine was applied to 3. Seropositivity after revaccination was >90% for Hepatitis B, Hepatitis A, pertussis, and measles, and it was 88.5% for rubella, 80% for mumps and varicella. Measles seropositivity was low in children with hemoglobinopathy. In subgroup assessments of pertussis, patients vaccinated with low antigen-containing pertussis vaccine (Tdap) had higher seropositivity of adenylate cyclase toxin. Our findings revealed the importance of careful monitoring of current practices in pediatric HSCT recipients.

Live-attenuated measles, mumps, and rubella booster vaccine in children diagnosed with rheumatic disease: A single-center study

To evaluate the safety profile of measles, mumps and rubella (MMR) booster in children diagnosed with rheumatic diseases receiving biological agents. The study included retrospective safety data of children administered MMR booster dose receiving biologics or biologics with methotrexate. The files of 182 patients were accessed from the pediatric rheumatology biological therapy archive, and the vaccination status of these children was obtained by accessing electronic records. Of 182 patients, 14 patients were vaccinated with MMR booster dose. Thirteen of the patients were followed up with a diagnosis of juvenile idiopathic arthritis and one with colchicine-resistant familial Mediterranean fever. None of the patients had disease exacerbation after vaccination, and three patients had mild side effects consisting of rash, angioedema, joint pain, and fatigue.    Conclusion: This study supports the data regarding evidence of the safety of MMR booster dose administration in children with rheumatic diseases receiving bDMARDs. What is Known: • MMR booster is avoided in immunocompromised pediatric patients receiving bDMARDs except in specific conditions. What is New: • The MMR booster dose may be safe in children with PedRD receiving bDMARDs or bDMARDs with MTX. These bullets can be added to the manuscript.

Hepatitis B Vaccination in Children With Ongoing Cancer Treatment: A Safety and Efficacy Study of Super-Accelerated Vaccination Scheme

OBJECTIVE

Children with cancer have an increased risk for hepatitis B virus (HBV) infections due to chemotherapy-induced secondary immunodeficiency and frequent blood transfusions. The aim of this study is to evaluate the efficacy and safety of hepatitis B vaccination during the intensive induction chemotherapy in children with cancer found to be seronegative for hepatitis B on admission.

MATERIALS AND METHODS

Children newly diagnosed with cancer were evaluated for the presence of hepatitis B surface antigen (HBsAg) and antibody on admission. The children negative for both were included in the study. A super-accelerated vaccination scheme (3 booster doses at days 1-5, 8-12, and 28-33) was administered to these seronegative children concurrently with induction chemotherapy. Antibody response was checked 4-8 weeks after the last vaccination and 6 months after the end of the treatment.

RESULTS

Eleven out of 122 children were seronegative for hepatitis B on admission (9%). Acute lymphoblastic leukemia, lymphoma, and solid tumors were diagnosed in 5, 4, and 2 children, respectively. Complete seroconversion was achieved in 4-8 weeks after the last vaccination with high titers of anti-HBs antibody, and all patients remained antibody-positive until 6 months after the completion of chemotherapy.

CONCLUSION

The risk of transfusion-related infections increases with a number of transfused products and donor exposures, and it is more significant for immunosuppressed children with hematologic and oncologic malignancies. Hepatitis B vaccination could safely be applied with brisk and sustained responses in this vulnerable population, based on the local epidemiological data.

Faecal calprotectin levels during the first year of life in healthy children

AIM

A high faecal calprotectin (FC) level is a non-invasive marker for inflammatory bowel disease. Nevertheless, healthy infants have elevated levels of FC with large variations. The aim of our study was to determine the levels of FC and associated factors in healthy infants aged 0-12 months.

METHODS

Infants younger than 1 year of age were in the follow-up programme of the Well Child Unit. Data on the clinical characteristics, including birth, anthropometric measurements and feeding types of infants in the unit, were obtained from their personal health records. One fresh stool sample was collected from each infant. ELISA was used to measure FC.

RESULTS

We included 84 infants younger than 1 year of age. The median FC value was 313 μg/g. The FC levels were greater in the youngest (0-30 days) group of infants than in the oldest (181-365 days) group (P < 0.001). The FC levels were higher in infants delivered by caesarean section than in those delivered vaginally (P = 0.016). The levels were also higher in infants who were solely breastfed than in those who received mixed feeding (breast milk and formula) during the first 6 months of life (P = 0.030).

CONCLUSION

The FC levels in this group of infants were high, especially in the first month of life. Several birth and environmental factors influenced the FC values. Further studies with a larger cohort of infants and serial assessment of FC over time are required to better understand the patterns of this biomarker during infancy.

Assessment of Hearing Function in Children with Inflammatory Bowel Disease

OBJECTIVES

Inflammatory bowel disease (IBD), a chronic pathology that affects many organ systems, appears after dysregulated immune response in genetically predisposed patients. Inner organ involvement has been shown in various autoimmune diseases because of its immunosensitivity. In this study, we aimed at showing sensorineural hearing loss (SNHL) as a result of possible subclinical inflammation in patients with IBD during the remission period.

MATERIALS AND METHODS

We included 32 children with IBD and 31 healthy volunteers with comparable sex and age. Detailed ear-nose-throat examination was conducted for all, and patients were excluded if they had a history of ear infectionor trauma. Thereafter, the results of pure tone audiometry (PTA), high-frequency audiometry, and distortion product otoacoustic emissions testing were compared between the groups.

RESULTS

There were no differences in terms of age, sex, and PTA values between controls and children with IBD. No statistical differences were found between responses at 250; 500; 2,000; 4,000; DP1000; DP1400; DP2000; DP2800;and DP4000 Hz as well as the signal-to-noise ratio (SNR) at 1,000 Hz when the controls and children with IBD (p>0.05 for all) were compared. However, the mean responses at 1,000; 8,000; 10,000; 12,500; 16,000; SNR1400; SNR2000; SNR2800; and SNR4000Hz of the children with IBD were significantly higher than those of the controls (p<0.05 for all).

CONCLUSION

Initial SNHL appears at high frequencies in pediatric patients with IBD.

Very high IgE levels in children: when from pediatrician to immunologist?

BACKGROUND

Total serum immunoglobulin E (IgE) is increased in many situations such as allergic diseases, primary immunodeficiencies (PID), parasitosis, infections and malignancies. When IgE levels >1000 kU/L are suspected PID by pediatricians. We tried to define some clinical and laboratory parameters to distinguish PID from the others.

METHODS

We evaluated 158 children between 1.7 - 17 years (Mean: 6.6 ±3.4) for allergic diseases, PID, parasitosis and others. Total IgE, specific IgE, immunoglobulin levels and skin prick tests were performed to all patients. Parasite investigations, viral serological tests and detailed immunologic tests were analyzed in only patients who had suspected complaints. Hyper IgE syndrome (HIES) scoring sheet was filled out for all patients.

RESULTS

Among all patients, 114 were diagnosed as bronchial asthma, allergic rhino-conjunctivitis or atopic dermatitis. PID diagnosis was established in totally 32 patients. Immunological evaluations were normal in 126 patients. Eleven patients were accepted as parasitosis. Median HIES score was 18 (5-44 points).

CONCLUSIONS

Pediatricians may use HIES scoring sheet when they suspect a patient with PID. If the patient has very low points, they may follow the patient. If there are about 18-20 points, they should get an opinion from an immunologist for detailed immunologic tests.

A rare case of syndromic severe congenital neutropenia: JAGN1 mutation

BACKGROUND

Neutrophils are essential innate cells to fight bacterial and fungal pathogens. Jagunal homolog 1 (JAGN1) mutations were recently defined as rare genetic defects causing severe congenital neutropenia. JAGN1 participates in the secretory pathway and is required for granulocyte colony-stimulating factor receptormediated signalling. This gene is required for normal ultrastructure and granulation of endoplasmic reticulum of myeloid progenitor cells. Its defect is related to increased predisposition to apoptosis. In the literature, a few cases have been reported with congenital anomalies such as cardiac and renal anomalies.

CASE

Here we report a patient in which JAGN1 deficiency was found after several years. Apart from syndromic facial appearance we were unable to detect any other systemic malformations.

CONCLUSION

The causes of multisystemic features of mutations in JAGN1 gene remain unknown. JAGN1 mutations must be considered in patients with severe congenital neutropenia especially with facial dismorphism even in the absence of systemic manifestations.

Serum amyloid A as a biomarker in differentiating attacks of familial Mediterranean fever from acute febrile infections

OBJECTIVE

To determine the capability of serum amyloid A (SAA) in differentiating attacks of familial Mediterranean fever (FMF) from acute febrile upper respiratory tract infections.

METHOD

Children diagnosed with FMF during febrile attacks were recorded as the patient group. The control group consisted of children with febrile upper respiratory tract infections. Complete blood count, serum amyloid A (SAA), C-reactive protein (CRP), and erythrocyte sedimentation rate were recorded in both groups during febrile episodes.

RESULTS

The cohort consisted of 28 children with FMF attack and 28 previously healthy children with acute febrile infection. While CRP and SAA levels were elevated in both groups, elevations during FMF attacks were significantly higher in the FMF group than in the control group. Median CRP was 85 mg/L in the FMF attack group and was 36 mg/L in the control group (p = 0.001). Median SAA was 497.5 mg/L in the FMF attack group and was 131.5 mg/L in the control group (p < 0.001). Correlation analyses showed that SAA and CRP were positively correlated in the FMF attack group (r = 0.446, p = 0.01). The best cut-off value for SAA in differentiating FMF attack from an acute febrile infection was 111.5 mg/L (sensitivity 100%, specificity 65.1%, area under curve (AUC) = 0.78, confidence interval 0.66-0.90, p < 0.001).

CONCLUSION

Serum amyloid A is a sensitive but not specific marker for demonstrating inflammation in FMF. SAA levels rise substantially in febrile upper respiratory tract infections.Key Points• SAA levels rise substantially in febrile upper respiratory tract infections.• SAA is a sensitive but not specific method for demonstrating inflammation.• SAA cut-off value for discriminating FMF attacks from febrile infection is 111.5 mg/L (sensitivity 100%, specificity 65.1%).

An extreme entity in differential diagnosis of musculoskeletal involvement-fibrodysplasia ossificans progressiva: a case based review

Çakan M, Aktay-Ayaz N, Karadağ ŞG, Keskindemirci G. An extreme entity in differential diagnosis of musculoskeletal involvement-fibrodysplasia ossificans progressiva: a case based review. Turk J Pediatr 2018; 60: 593-597. Fibrodysplasia ossificans progressiva is one of the most devastating disorder of mankind characterized by progressive heterotopic ossification. Apart from hallux valgus, other symptoms start to develop in the first decade of life. The initial symptoms are tumefactive lesions on the back that gives an impression of benign or malignant tumoral lesion. It may cause restricted motion of the neck and shoulders and magnetic resonance imaging of the lesions may be reported as myositis or myofasciitis and these children may be referred to rheumatologists. Currently there is no definitive treatment of the disease but the most important issue in these patients is `primum non nocere`, because any invasive procedure could potentially trigger a flare and heterotopic calcification. Herein, we present a young case of fibrodysplasia ossificans progressiva to remind the typical signs and symptoms of the disease to all clinicians caring for children.

Two cases of periodic fever syndrome with coexistent mevalonate kinase and Mediterranean fever gene mutations

Çakan M, Aktay-Ayaz N, Keskindemirci G, Karadağ ŞG. Two cases of periodic fever syndrome with coexistent mevalonate kinase and Mediterranean fever gene mutations. Turk J Pediatr 2017; 59: 467-470. The periodic fever syndromes are autoinflammatory diseases that present with recurrent fever, serositis and rash. Familial Mediterranean fever is the most common periodic fever syndrome and characterized by recurrent attacks of fever, arthritis, peritonitis, pleuritis that typically last 1-3 days. Hyperimmunoglobulinemia D syndrome is another example of periodic fever syndromes and patients have recurrent fever attacks for 3-7 days accompanied by abdominal pain, rash, vomiting, diarrhea, arthralgia, arthritis, aphthous ulcers, and cervical lymphadenopathy. In some cases the clinical picture of the patient does not fit to one autoinflammatory syndrome because of the digenic inheritance. This may cause to overlap or atypical clinical features or an unexpected response to treatment. Herein we report two cases of hyperimmunoglobulinemia D syndrome that also had MEFV gene mutations and familial Mediterranean fever phenotype.

Evaluation of autonomic nervous system functions in frame of heart rate variability in children with inflammatory bowel disease in remission

Aghdasi-Bornaun H, Kutluk G, Keskindemirci G, Öztarhan K, Dedeoğlu R, Yılmaz N, Tosun Ö. Evaluation of autonomic nervous system functions in frame of heart rate variability in children with inflammatory bowel disease in remission. Turk J Pediatr 2018; 60: 407-414. Heart Rate Variability (HRV) is one of the reliable and noninvasive parameters to evaluate autonomic control of the cardiovascular system in patients. The aim of our study was to assess autonomic function in pediatric patients with inflammatory bowel disease (IBD) in remission using Power Spectral Analysis of HRV. Autonomic cardiovascular function was evaluated by time and frequency-domain indexes of spontaneous heart rate in 36 IBD children patients in remission phase and 36 sex and age matched healthy controls. Twenty children with Ulcerative Colitis (UC) and 16 patients with Crohn`s disease (CD) were diagnosed according to their history, physical and laboratory examination, endoscopic, histopathological and radiological findings of upper and lower gastrointestinal system. Significant decrease was observed at HRV parameters in IBD patients when compared with control group. These differences was found in some of time domain parameters (NNmean, SDNNtotal, SDNNday) and frequency domain parameters (TP, LF,VLF) (p < 0.05). Also, there was a significant higher minimum heart rate ratio (p < 0.04) in patients in comparison to the control group. In the IBD group, there was a relative tendency for parasympathetic suppression and sympathetic predominance which reflects an autonomic dysfunction. This imbalance has a circadian rhythm and it is more obvious during the day. These observations may suggest a previously unrecognized role of chronic inflammation for autonomic modulation in IBD.

Is there any difference regarding atopy between children with familial Mediterranean fever and healthy controls?

INTRODUCTION

There are only a few studies regarding the prevalence of atopy in Familial Mediterranean fever (FMF) patients, and their results are conflicting.

METHODS

In this study children with the diagnosis of FMF were evaluated for the presence of atopy by comparing with controls. One hundred and eighteen children diagnosed as FMF and 50 healthy age and sex matched controls were enrolled. They were evaluated for the presence of rhinitis, atopic dermatitis, urticaria and asthma. Laboratory assessment was done by measuring IgA, IgM, IgG, IgE levels, total eosinophil count and by performing skin prick test (SPT) panels for common allergens to children with FMF and healthy controls.

RESULTS

One hundred and eighteen children (61girls and 57 boys) diagnosed as FMF with a median age of 120±47 months (range 36-204 months) were compared with 50 healthy controls (31 girls and 19 boys) having a median age of 126±37 (range 48-192 months). The mean percentage of total eosinophil count of patients was similar to that of the control group. The mean level of IgE was significantly higher in children with FMF than controls (136±268, 87±201, respectively; p values <0.05). The percentage of skin prick test positivity was similar for both patients and controls (13% and 8.2%, respectively; p>0.05). The prevalences of atopic dermatitis, allergic rhinitis, and asthma in the patient group were 5.08%, 28.8%, and 15.25%, respectively, while the control group had the prevalences of 0%, 36%, and 14% respectively.

CONCLUSION

Children with FMF did not show an increase of atopic dermatitis, allergic rhinitis and asthma with respect to controls.

Kawasaki disease shock syndrome: a rare and severe complication of Kawasaki disease

Kawasaki disease is an acute systemic vasculitis that occurs most commonly in young children. It affects medium-sized muscular arteries and the coronary arteries are the predominant site of involvement. Morbidity and mortality is generally due to coronary artery aneurysms that develop during the chronic phase. Although it is well known that Kawasaki disease can cause myocarditis, tachycardia and heart failure during acute stage, Kawasaki disease shock syndrome has been recently described. It is characterized by hypotension, signs and symptoms of poor perfusion and a shock-like state. Herein we describe two cases of Kawasaki disease shock syndrome that were treated in the pediatric intensive care unit and followed a course without morbidity or mortality.

Does familial Mediterranean fever affect cognitive function in children? Electrophysiological preliminary study

OBJECTIVES

Familial Mediterranean fever (FMF) is a periodic autoinflammatory disease with subclinical inflammation occurring between attacks. The aim of the study was to prospectively evaluate the cognitive function of children diagnosed with FMF that were under colchicine therapy and compare them with healthy controls through electrophysiologically event-related potentials (ERPs) study.

METHODS

Twelve children with FMF and 12 healthy controls were included in the study. During the electroencephalography recordings, all participants were instructed to discriminate rare stimuli (target stimuli) from frequent stimuli (standard stimuli) by pressing a botton on a mouse immediately following the target stimulus. P300, the cognitive component of ERP, was obtained in response to target stimuli and its amplitude and latency were measured.

RESULTS

The amplitude of the P300 of the FMF patients was higher and the latencies of the P300 of the FMF patients were shorter than the amplitudes and latencies of control patients, respectively. The difference between the groups was statistically significant for amplitude but not for latency.

CONCLUSIONS

Cognitive processing reflecting allocation of attention and visual processing speed seems not to be negatively affected in FMF patients with homozygous M694V mutations undergoing colchicine treatment. As this study is unique in its evaluation of the cognitive function of children with FMF, these findings may be helpful for counseling families and patients affected by the condition.

Immediate adverse reactions to intravenous immunoglobulin in children: a single center experience

Intravenous immunoglobulin (IVIG) is commonly used in primary and secondary immunodeficiency diseases as well as autoimmune conditions as immunomodulatator treatment. Immediate adverse events which are generally mild and occur during infusion are seen in 6 hours. Reported immediate adverse events are in a wide range from 1%-40% in pediatric patients. 115 patients who received IVIG (except newborns) were included into this crosssectional study. IVIG was given to patients for primary immunodeficiencies (n=8), ITP (n=65), Kawasaki disease (n=11), secondary immunosupression (n=28), and passive immunization (n=3). 5%, 10% IVIG preparations and pentaglobin were used. Headache, fever, chills, nausea, rash, arthralgia, myalgia and back pain were accepted as mild immediate events. There were 62 (54%) boys and 53 (46%) girls aged 1 month-18 years. Mean age of the group was 7.4±4.6 years. Immediate adverse events due to IVIG infusions were seen in 29 (25.2%) of all patients. Gender and types of the disease were not different in significance regarding the presence of adverse events. The rate of adverse events did not change with receiving pre-medication. The most common reaction was fever/chills. Immediate reactions were seen in first 6 hours in 7 patients and during infusion in the remaining. They were treated with slowing of the infusion rate and infusion was stopped in 3 patients because of moderate events. Because of the increasingly use of IVIG therapy, it is important to know the side effects. High doses, high infusion rates, accompanying infection may worsen the adverse effects especially in primary immunodeficiency diseases.

HAX-1 deficiency: Characteristics of five cases including an asymptomatic patient

BACKGROUND

Mutations in the HAX-1 gene cause an autosomal recessive form of severe congenital neutropenia (SCN), which particularly manifests with recurrent skin, lung and deep tissue infections from the first few months of life.

OBJECTIVE

We retrospectively evaluated the clinical and laboratory findings of the patients diagnosed with SCN carrying HAX1 gene mutations.

METHODS

A total of five patients with SCN, carrying a HAX1 gene mutation, were evaluated in terms of clinical and laboratory findings. Mutation analysis of the candidate genes (HAX1, ELANE and CSF3R) was performed.

RESULTS

All of the patients lived in Turkey; four of them were of Kurdish origin and one was Turkish. Of the five patients, three were girls and two were boys, and the mean age of the patients was 8.8 years old (range 4-15 years). The mean age of diagnosis was 25.8 months (range 2 months-5 years). The infections diagnosed included recurrent gingivitis, stomatitis, and skin and soft tissue abscesses. Developmental retardation and epilepsy were present in only one patient, whereas speech retardation was present in two. All of our patients had a HAX1 mutation, and are still alive and none of them has shown malignant transformation yet.

CONCLUSION

Complete blood count should be performed and absolute neutrophil count should be evaluated in patients with recurrent severe infections. In the event that neutropenia is detected, they should be investigated in terms of SCN and mutation analysis should be performed.

Coexistence of early onset sarcoidosis and partial interferon-γ receptor 1 deficiency

Pediatric sarcoidosis comprises a spectrum of childhood granulomatous inflammatory conditions. Pathological hallmark of the disease is granuloma formation that is seen in the affected tissues and almost any organ or system can be involved. There are two forms of pediatric sarcoidosis. One is seen in older children and the clinical picture is very similar to that of adult sarcoidosis and the other one is seen in early childhood. Sarcoidosis in early childhood can be divided as Blau syndrome (familial form) and early onset sarcoidosis (sporadic form). In both of the diseases there is a defect in the NOD2/CARD15 gene. The typical triad of early onset sarcoidosis is polyarthritis, dermatitis and uveitis. Interferon-γ receptor 1 deficiency is caused by defects in the IFNγR1 gene and non-tuberculosis mycobacterial pathogens are the leading causes of infections that start in early childhood. Herein we report a patient who presented with the symptoms of early onset sarcoidosis and also had partial interferon-γ receptor 1 deficiency that presented with BCG-osis. In addition to anti-mycobacterial treatment, methotrexate and prednisolone were used in therapy.

Systemic onset juvenile idiopathic arthritis with macrophage activation syndrome and coronary artery dilatation misdiagnosed as Kawasaki disease

Systemic onset juvenile idiopathic arthritis (SoJIA) is characterized by arthritis, fever and visceral organ involvement including hepatosplenomegaly, lympadenopathy and serositis. This is a case of SoJIA misdiagnosed as Kawasaki disease (KD) and developed machrophage activation syndrome (MAS) secondary to Ebstein-Barr virus (EBV) infection. It is presented to point out the conditions that may come along. First of all, SoJIA should be kept in mind while making the differential diagnosis of coronary arterial ectasias and dilatations usually seen in vasculitic diseases like KD. Second, as a very fatal complication MAS should always be considered while following a patient with the diagnosis of SoJIA. Infections like EBV may be the potential triggers for development of MAS especially in immunesupressed patients.

Effects of selenium supplementation in the early stage of autoimmune thyroiditis in childhood: an open-label pilot study

AIM

The aim of the study was to evaluate the role of selenium (Se) in childhood autoimmune thyroiditis regarding its effect on thyroid-stimulating hormone (TSH), free thyroxine (fT4), thyroid peroxidase antibodies (TPOAb), thyroglobulin antibody (TgAb), and thyroid morphology.

METHODS

Newly diagnosed 23 euthyroid children (mean age, 12.3 +/- 2.4 years) with Hashimoto thyroiditis (HT) received only 50 microg L-selenomethionine per day for 3 months. The baseline basal urinary iodine level, serum Se, TSH, fT4, TPOAb, and TgAb concentrations, and thyroid morphology by ultrasound were detected. We reanalyzed the TPOAb and TgAb changes at the 3rd month and then compared the thyroid morphology with 30 healthy individuals (mean age, 12.1 +/- 2.1 years) at the 6th month.

RESULTS

Serum TPOAb, TgAb, and thyroid echogenicity were unchanged with Se supplementation. A prominent decrease in thyroid volume was noteworthy; 35% of patients showed a thyroid volume regression rate of > or = 30%.

CONCLUSION

In terms of TPOAb and TgAb, Se may not benefit in the euthyroid period of HT, but Se supplementation seems to lead a favorable response in thyroid volume regression.

Miliaria rubra and thrombocytosis in pseudohypoaldosteronism: case report

Pseudohypoaldosteronism type 1 (PHA1) is a disease involving a state of renal tubular unresponsiveness to the action of aldosterone and characterized by excessive salt loss in the urine, hyperkalemia, and metabolic acidosis. In kidney, PHA1 may occur primarily by mutations in the subunits of the sodium channel or in the mineralocorticoid receptors, and secondarily by several renal disorders. Miliaria rubra and thrombocytosis are reported in a 6-month-old girl with PHA1. In patients with PHA1, miliaria rubra-like cutaneous eruptions are suggested to occur due to obstruction of eccrine sweat glands through inflammation caused by excessive sodium excretion in sweat during hyponatremic crises. The presence of thrombocytosis in patients with PHA1 has not been previously reported. A hypothesis is proposed suggesting that sympathetic activation which provides vascular tonus during sodium excretion in sweat and salt-depletion crisis may play a role in the development of eruptions and thrombocytosis in patients with PHA1.

AUDITORY ON- AND OFF-RESPONSES AND ALPHA OSCILLATIONS IN THE HUMAN EEG

In the present study, the wide band alpha and sub-bands of alpha in the auditory on- and off-responses to different stimulation frequencies were evaluated. Auditory on- and off-responses of 12 healthy volunteers (average 17 years old) were recorded from five locations (Fz, Cz, Pz, P3, and P4). The auditory stimuli of 80 dB SPL and 1000 ms duration were delivered at six different stimulation frequencies (f1-f6; 0.2, 0.6, 1, 2, 3, and 4 kHz, respectively). In using individual alpha frequency (IAF) as individual anchor point, wide band alpha and three different alpha frequency sub-bands with a bandwidth of 2 Hz each were defined: lower-1 alpha, lower-2 alpha, and upper alpha. The Root Mean Square (RMS) values of the alpha frequency bands were computed for two time periods: +/- 3 sd around the mean peak latency of the auditory on-responses (t1-on and t2-on) and a time window of the same length of the auditory off-responses (t1-off and t2-off). The alpha RMS values of both on- and off- responses showed significant differences between t1 and t2 periods on wide band, lower-1 and lower-2 alpha bands, especially at 0.2, 0.6, 1, 2, and 3 kHz stimulation frequencies in all recording places. Amplitudes in anterior locations (Fz, Cz) were higher than the others. These observations may provide a preliminary but nonetheless important understanding of how information may be processed in the brain.

Event-related potentials to visual, auditory, and bimodal (combined auditory-visual) stimuli

The purpose of this study was to investigate the response properties of event related potentials to unimodal and bimodal stimulations. The amplitudes of N1 and P2 were larger during bimodal evoked potentials (BEPs) than auditory evoked potentials (AEPs) in the anterior sites and the amplitudes of P1 were larger during BEPs than VEPs especially at the parieto-occipital locations. Responses to bimodal stimulation had longer latencies than responses to unimodal stimulation. The N1 and P2 components were larger in amplitude and longer in latency during the bimodal paradigm and predominantly occurred at the anterior sites. Therefore, the current bimodal paradigm can be used to investigate the involvement and location of specific neural generators that contribute to higher processing of sensory information. Moreover, this paradigm may be a useful tool to investigate the level of sensory dysfunctions in clinical samples.