Financial and relational impact of having a boy with posterior urethral valves

Introduction

Childhood chronic diseases affect family functioning and well-being. The aim of this study was to measure the impact of caring for a child with PUV, and the factors that most impact the burden of care.

Patients and method

We gave a questionnaire on the familial impact of having a child with posterior urethral valves to all parents of a child included in the CIRCUP trial from 2015 onwards. The questionnaire included questions about the parents' demographics, health, professional, financial and marital status and how these evolved since the child's birth as well as the "impact on family scale" (IOFS), which gives a total score ranging from 15 (no impact) to 60 (maximum impact). We then analyzed both the results of the specific demographic questions as well as the factors which influenced the IOFS score.

Results

We retrieved answers for 38/51 families (74.5% response rate). The average IOFS score was 23.7 (15-51). We observed that the child's creatinine level had an effect on the IOFS score (p = 0.02), as did the parent's gender (p = 0.008), health status (p = 0.015), being limited in activity since the birth of the child (p = 0.020), being penalized in one's job (p = 0.009), being supported in one's job (p = 0.002), and decreased income (p = 0.004). Out of 38 mother/father binomials, 8/33 (24.2%) declared that they were no longer in the same relationship afterwards.

Conclusion

In conclusion, having a boy with PUV significantly impacts families. The risk of parental separation and decrease in revenue is significant. Strategies aiming to decrease these factors should be put in place as soon as possible.

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice

INTRODUCTION

Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; METHODS: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion.

RESULTS

Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03).

CONCLUSIONS

Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children.

LEVEL OF EVIDENCE

II - Prospective Study.

Nadir creatinine predicts long-term bladder function in boys with posterior urethral valves

INTRODUCTION

Posterior urethral valves (PUV) cause lower urinary tract obstruction leading to increased intravesical pressure during fetal urinary tract development. Though the bladder and kidneys are separate organs, with different embryological origins, they are complementary and influence each other both before and after birth. We aimed to assess the relationship between renal and bladder function in boys with PUV and whether early renal markers could predict future bladder function.

PATIENTS AND METHODS

We included all boys with prenatally suspected lower urinary tract obstruction, born between 2000 and 2013, in two University Hospitals, with at least 5 years follow-up. We excluded patients who presented a Lower Urinary Tract Obstruction other than PUV, children who presented multiple birth defects and neonatal deaths and those with incomplete long-term renal or bladder function data. We included data on nadir creatinine (NC), long-term renal function and long-term bladder function (defined by Uroflow parameters). Boys with PUV were divided into three severity groups for renal function according to their NC and three severity groups for bladder function as determined by Uroflow.

RESULTS

We included 73 boys. Average nadir creatinine was 43.4 ± 26.1 μmol/L. Twenty-nine boys (49.3%) presented a NC < 35 μmol/L, thirty-eight (52.1%) a NC between 35 and 75 μmol/L, and 6 (8.2%) a NC > 75 μmol/L. Thirty-eight (52.1%) presented normal bladder function, 23 (31.5%) presented moderately impaired bladder function and 12 (16.4%) presented severely impaired bladder function. 41.4% of boys with NC < 35 had abnormal bladder function vs 46.2% of those with an NC between 35 and 75 μmol/L and 83.3% of boys with NC > 75 μmol/L. Nadir creatinine both predicted both bladder function and renal status (table 1). Correlation between presence of grade 3-5 CKD and poor uroflow was also significant (p < 0.005).

DISCUSSION

Nadir creatinine was significantly correlated to bladder function at 5 years of age. What this study suggests is that as nadir creatinine increases so does the risk of severe bladder dysfunction. Our results, though limited to flowmeter and renal function, could help pediatric urologist tailor bladder function monitoring, and indicate which patients could benefit from more aggressive bladder therapy.

CONCLUSION

Bladder and renal function are linked in boys with posterior urethral valves. Boys with high nadir creatinine could benefit from early bladder function evaluation and management.

Nutritional status at age 1 year in patients born with esophageal atresia: A population-based, prospective cohort study

OBJECTIVE

Despite recent progress in caring for patients born with esophageal atresia (EA), undernutrition and stunting remain common. Our study objective was to assess nutritional status in the first year after birth with EA and to identify factors associated with growth failure.

STUDY DESIGN

We conducted a population-based study of all infants born in France with EA between 2010 and 2016. Through the national EA register, we collected prenatal to 1 year follow-up data. We used body mass index and length-for-age ratio Z scores to define patients who were undernourished and stunted, respectively. Factors with P < 0.20 in univariate analyses were retained in a logistic regression model.

RESULTS

Among 1,154 patients born with EA, body mass index and length-for-age ratio Z scores at 1 year were available for about 61%. Among these, 15.2% were undernourished and 19% were stunted at the age of 1 year. There was no significant catch-up between ages 6 months and 1 year. Patients born preterm (41%), small for gestational age (17%), or with associated abnormalities (55%) were at higher risk of undernutrition and stunting at age 1 year (P < 0.05). Neither EA type nor surgical treatment was associated with growth failure.

CONCLUSION

Undernutrition and stunting are common during the first year after birth in patients born with EA. These outcomes are significantly influenced by early factors, regardless of EA type or surgical management. Identifying high-risk patient groups with EA (i.e., those born preterm, small for gestational age, and/or with associated abnormalities) may guide early nutritional support strategies.

Risk factors for febrile urinary tract infection in boys with posterior urethral valves

OBJECTIVE

Boys with posterior urethral valves (PUV) present an increased risk of febrile urinary tract infection (fUTI). Identifying specific risk factors could allow for tailoring UTI prevention. The aim of this study was to use the data from the CIRCUP randomized controlled trial data to identify patient characteristics associated with a higher risk of fUTI.

PATIENTS AND METHODS

We performed a secondary analysis of the data from the CIRCUP randomized trial which included boys with PUV, randomized to circumcision and antibiotic prophylaxis vs. antibiotic prophylaxis alone and followed for 2 years. There was only 1 episode of fUTI in the circumcision group vs. 17 in the uncircumcised group. We therefore only studied the antibiotic prophylaxis alone group and compared age at prenatal diagnosis, size and weight at birth, presence of dilating VUR at diagnosis, abnormal DMSA scan at 2 months, and nadir creatinine between children who presented a fUTI and those who did not, as well as age at first episode of fUTI.

RESULTS

The study group consisted of 42 patients of which 17 presented at least on fUTI. Presence of dilating VUR was significantly associated with risk of fUTI (p = 0.03), OR: 6 [CI 95% = (1.13-27.52)]. None of the other parameters were associated with increased risk of fUTI. We observed three distinct time periods for presenting a fUTI with a decrease in infection rate after the first 40 days of life, then at 240 days of life.

CONCLUSION

In boys with PUV, presence of high-grade VUR is associated with a higher risk of presenting a fUTI. The rate of febrile UTIs seems to decrease after 9 months.

Evaluating the impact of pop-off mechanisms in boys with posterior urethral valves

INTRODUCTION

Posterior urethral valves are urethral leaflets that cause Lower Urinary Tract Obstruction (LUTO) in boys and are associated with congenital renal dysplasia and abnormal bladder function. They affect 1:4,000 to 1:25,000 births and can be responsible for End-Stage Renal Failure in childhood. There have been several studies on the effect of pop-off mechanisms in boys with posterior urethral valves, but results are contradictory. We aimed to assess and discuss the effect of pop-off mechanisms on renal function in a large cohort of patients.

PATIENTS AND METHOD

Boys with PUV with and without pop-off mechanisms (urinoma, VURD or giant bladder diverticula) were divided into three severity groups for renal function according to their nadir creatinine (low-risk NC < 35 μmol/L, intermediate-risk NC between 35 and 75 μmol/L, and high-risk NC > 75 μmol/L). We compared children with and children without pop-off mechanisms for mean renal function as well as patient distribution within each severity group.

RESULTS

We included 137 boys of which 39 had a pop-off mechanism. Patients had complete data for at least 5 years follow-up. Though there was no significant statistical difference in mean renal function between the pop-off and non-pop-off group, patient distribution within each severity group varied according to whether patients had a pop-off mechanism or not.

CONCLUSION

Though there was no significant difference in mean renal function between boys with and without pop-off mechanisms, it is possible that these are two different patient populations and direct comparison is not possible.

Circumcision and Risk of Febrile Urinary Tract Infection in Boys with Posterior Urethral Valves: Result of the CIRCUP Randomized Trial

BACKGROUND

Boys with posterior urethral valves (PUVs) have an increased risk of febrile urinary tract infections (fUTIs). Circumcision is believed to reduce the risk of fUTIs in boys, although there are no randomized trials demonstrating this.

OBJECTIVE

To determine the effect of circumcision on the risk of fUTIs in boys with PUVs.

DESIGN, SETTING, AND PARTICIPANTS

A clinical randomized trial that ran between August 2012 and July 2017 was conducted. The trial was multicentric, including 13 referral centers for pediatric urology. Male boys, aged 1-28 d, diagnosed with posterior urethral valves, confirmed by voiding cystogram, were included. The exclusion criteria included presence of a genital malformation contraindicating performing a circumcision.

INTERVENTION

Participants were randomized to neonatal circumcision + antibiotic prophylaxis (CATB) or antibiotic prophylaxis alone (ATB), and followed for 2 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was a risk of presenting fUTIs in each group. An fUTI was defined as fever (>38.5 °C) with evidence of pyuria and culture-proven infection on urinalysis, obtained by urethral catheterization or suprapubic aspiration. A bivariate analysis of the primary outcome was performed using the Kaplan-Meier method.

RESULTS AND LIMITATIONS

In total, 91 patients were included: 49 in group CATB and 42 in group ATB. The probability of presenting an fUTI was 20% in group ATB versus 3% in group CATB. The hazard ratio of presenting an fUTI within 2 yr in the ATB group compared with that in the CATB group was 10.3 (95% confidence interval: 1.3-82.5). Sixty-four children (70.3%) had a complete follow-up at 2 yr of age.

CONCLUSIONS

Circumcision significantly decreases the risk of presenting an fUTI in boys with PUVs.

PATIENT SUMMARY

In this report, we compared, in a multicentric trial, the number of febrile urinary tract infections (UTIs) in boys with posterior urethral valves who had either antibiotic prophylaxis alone or antibiotic prophylaxis and circumcision. We found that those who had a circumcision had a significantly lower risk of febrile UTIs.

Esophageal Atresia and Respiratory Morbidity

BACKGROUND AND OBJECTIVES

Respiratory diseases are common in children with esophageal atresia (EA), leading to increased morbidity and mortality in the first year. The primary study objective was to identify the factors associated with readmissions for respiratory causes in the first year in EA children.

METHODS

A population-based study. We included all children born between 2008 and 2016 with available data and analyzed factors at birth and 1 year follow-up. Factors with a P value <.10 in univariate analyses were retained in logistic regression models.

RESULTS

Among 1460 patients born with EA, 97 (7%) were deceased before the age of 1 year, and follow-up data were available for 1287 patients, who constituted our study population. EAs were Ladd classification type III or IV in 89%, preterm birth was observed in 38%, and associated malformations were observed in 52%. Collectively, 61% were readmitted after initial discharge in the first year, 31% for a respiratory cause. Among these, respiratory infections occurred in 64%, and 35% received a respiratory treatment. In logistic regression models, factors associated with readmission for a respiratory cause were recurrence of tracheoesophageal fistula, aortopexy, antireflux surgery, and tube feeding; factors associated with respiratory treatment were male sex and laryngeal cleft.

CONCLUSIONS

Respiratory morbidity in the first year after EA repair is frequent, accounting for >50% of readmissions. Identifying high risk groups of EA patients (ie, those with chronic aspiration, anomalies of the respiratory tract, and need for tube feeding) may guide follow-up strategies.

Is laterality of congenital diaphragmatic hernia a reliable prognostic factor? French national cohort study

OBJECTIVES

The objective of this study was to assess whether the laterality of congenital diaphragmatic hernia (CDH) was a prognostic factor for neonatal survival.

METHODS

This was a cohort study using the French national database of the Reference Center for Diaphragmatic Hernias. The principal endpoint was survival after hospitalization in intensive care. We made a comparative study between right CDH and left CDH by univariate and multivariate analysis. Terminations and stillbirths were excluded from analyses of neonatal outcomes.

RESULTS

A total of 506 CDH were included with 67 (13%) right CDH and 439 left CDH (87%). Rate of survival was 49% for right CDH and 74% for left CDH (P < .01). Multivariate analysis showed two factors significantly associated with mortality: thoracic herniation of liver (OR 2.27; IC 95% [1.07-4.76]; P = .03) and lung-to-head-ratio over under expected (OR 2.99; IC 95% [1.41-6.36]; P < .01). Side of CDH was not significantly associated with mortality (OR 1.87; IC 95% [0.61-5.51], P = .26).

CONCLUSION

Rate of right CDH mortality is more important than left CDH. Nevertheless after adjusting for lung-to-head-ratio and thoracic herniation of liver, right CDH does not have a higher risk of mortality than left CDH.

Acute pyelonephritis revealing an intraprostatic obstructive megaureter in an adult: A rare finding

•

Duplicated renal collecting system is one of the most common congenital upper urinary tract abnormalities.

•

Estimated prevalence ranges between 0.3–6% in the general population.

•

Duplex system with ectopic obstructive megaureter in the prostatic urethra is rare and exceptionally revealed in adulthood.

•

Although considered an anatomical variant, duplex collecting system may be complicated by vesicoureteral reflux, ureterocele, or ectopic ureter.

•

In case of complicated duplex collecting, the surgical treatment may include upper pole nephrectomy or total nephrectomy. For pediatric patients, nephron-saving surgery is recommended.

•

Early diagnosis and treatment of complicated duplex system is important.

Introduction

Duplicated renal collecting system is one of the most common congenital upper urinary tract abnormalities. Duplex system with ectopic obstructive megaureter in the prostatic urethra is rare and exceptionally revealed in adulthood.

Presentation of case

We present a rare case of a 72-year-old man without any previous history of urinary symptoms, admitted through the emergency department for altered general condition associated with fever for several days. Investigations have identified left complete duplex system and intraprostatic obstructive megaureter manifesting as acute pyelonephritis. The evolution of acute pyelonephritis was favorable under urine drainage by percutaneous nephrostomy tube and antibiotherapy.

Given the multiple comorbidities of the patient, radical surgical treatment by left upper pole nephrectomy was ruled out and we opted for an iterative change of percutaneous nephrostomy tube.

Discussion

We briefly review the pathophysiology, diagnosis and therapeutic aspects.

Conclusion

Early diagnosis and treatment of complicated duplex system is important. Urologists should keep this anomaly in mind.

ZORRO: Z Omphaloplasty Repair for Omphalocele

PURPOSE

To suggest a novel technique for omphalocele closure which uses the circular base of the umbilical cord, thus allowing for a more physiological healing process and natural-looking scar.

METHODS

Among 16 neonates operated for omphalocele between 2011 and 2016, 12 were closed with a one-stage procedure using a Z omphaloplasty (ZORRO). Median gestational age was 36.5 weeks; median birth weight was 3210 g. The umbilical arteries were divided and ligated outside the peritoneal cavity above the parietal musculocutaneous plane. The upper part of the defect was closed vertically in the midline, while the lower part was closed in a circular fashion by imbricating 2 lateral cutaneous Z flaps thus forming a new cordonal base.

RESULTS

The postoperative course was uneventful in all cases. The reconstructed cordonal bases healed as would a normal umbilical cord, with central umbilication surrounded by healthy skin. With a median follow-up period of 11 months, the umbilicus was in the normal position, with a 0.6 xyphoumbilical/xyphopubic ratio.

CONCLUSIONS

This technique mimics the natural necrosis mechanism and physiological healing of the umbilicus thus allowing for an esthetic and "natural looking" umbilicus.

Preliminary experience using a tunica vaginalis flap as the dorsal component of Bracka's urethroplasty

OBJECTIVE

To evaluate clinical use of a tunica vaginalis flap as the dorsal component of a two-stage urethroplasty in boys with cripple hypospadias.

PATIENTS AND METHODS

We performed the first stage of a Bracka two-stage urethroplasty, using a tunica vaginalis flap as the dorsal component in six boys with cripple hypospadias. We analysed their clinical characteristics and the results of this technique.

RESULTS

The mean (range) age of the boys was 57 (34-120) months. The mean (range) number of previous procedures the boys had undergone was 4 (3-5). At the 6-month follow-up, all the boys presented significant fibrosis of the dorsal graft rendering it unusable for tubularisation.

CONCLUSIONS

Exposure to the external environment seems to induce retraction and fibrosis of the tunica vaginalis. We believe one should be very cautious about using tunica vaginalis as the dorsal component of a two-stage urethroplasty, as significant fibrosis might well render the flap unusable.

Results from the French National Esophageal Atresia register: one-year outcome

Background

The aim of the present national prospective population-based study was to assess the early morbidity of esophageal atresia (EA).

Methods

All 38 multidisciplinary French centers that care for patients with EA returned a specific questionnaire about the 1-year outcome for each patient. This information was centralized, checked, and entered into a database.

Results

From the total population of 307 EA patients born in 2008 and 2009, data about the 1-year outcome were obtained from 301 (98%) patients, of whom 4% were lost to follow-up and 5% died. Medical complications occurred in 34% of the patients: anastomotic leaks (8%), recurrent tracheoesophageal fistula (4%), and anastomotic stenosis (22%); all of the latter group needed dilation (median, 2 dilations/patient). A new hospitalization was required for 59% of patients (2.5 hospitalizations/patient) for digestive (52%) or respiratory (48%) reasons. Twelve percent of patients required antireflux surgery at a median age of 164 days (range, 33–398 days), and 1% underwent an aortopexy for severe tracheomalacia. The weight/age Z-score was −0.8 (range, −5.5 to 3.7 months) at 12 months. Fifteen percent of patients were undernourished at 12 months of age, whereas 37% presented with respiratory symptoms and 15% had dysphagia at the last follow-up. Significant independent factors associated with medical complications were anastomotic esophageal tension (p = .0009) and presence of a gastrostomy (p = .0002); exclusive oral feeding at discharge was associated with a decreased risk of complications (p = .007).

Conclusions

Digestive and respiratory morbidities remain frequent during the first year of life and are associated with difficult anastomosis and lack of full oral feeding.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-014-0206-5) contains supplementary material, which is available to authorized users.

Comparison of the ultra-low-dose Veo algorithm with the gold standard filtered back projection for detecting pulmonary asbestos-related conditions: a clinical observational study

OBJECTIVES

Radiation delivered during CT is a major concern, especially for individuals undergoing repeated screening. We aimed to compare a new ultra-low-dose algorithm called Veo with the gold standard filtered back projection (FBP) for detecting pulmonary asbestos-related conditions.

SETTING

University Hospital CHU G. Montpied, Clermont-Ferrand, France

PARTICIPANTS

Asbestos-exposed workers were recruited following referral to screening for asbestos-related conditions. Two acquisitions were performed on a 64-slice CT: the gold standard FBP followed by Veo reconstruction.

OUTCOME MEASURES

Two radiologists independently assessed asbestos-related abnormalities, pulmonary nodules, radiation doses and image quality (noise).

RESULTS

We included 27 asbestos-exposed workers (63.3±6.5 years with 11.9±9.7 years of asbestos exposure). We observed 297 pleural plaques in 20 participants (74%). All patients (100%) had pulmonary nodules, totalling 167 nodules. Detection rates did not differ for pleural plaques (Veo 87% vs FBP 97%, NS), pleural thickening (100% for both) and pulmonary nodules (80% for both). Interstitial abnormalities were depicted less frequently with Veo than FBP. False negative and false positive did not exceed 2.7%. Compared with FBP, Veo decreased the radiation dose up to 87% (Veo 0.23±0.07 vs FBP 1.83±0.88 mSv, p<0.001). The objective image noise also decreased with Veo as much as 23% and signal-to-noise ratio increased up to 33%.

CONCLUSIONS

A low-dose CT with Veo reconstruction substantially reduced radiation. Veo compared favourably with FBP in detecting pleural plaques, pleural thickening and pulmonary nodules. These results should be confirmed on a larger sample size before the use of Veo in clinical routine practice in asbestos-related conditions, especially regarding the low prevalence of interstitial abnormalities in this study.

TRIAL REGISTRATION NUMBER

NCT01955018.

Cortical transit time as a predictive marker of the need for surgery in children with pelvi-ureteric junction stenosis: preliminary study

INTRODUCTION

Postnatal management of prenatally detected hydronephrosis remains controversial. It has been suggested that cortical transit time (CTT) could successfully predict deterioration in children with pelvi-ureteric junction (PUJ) obstruction. We decided to conduct a retrospective study in our hydronephrosis population to evaluate whether initial CTT was significantly correlated with the need for surgery.

PATIENTS AND METHOD

We reviewed the charts of all our patients managed for significant PUJ obstruction (>12 mm) between 2007 and 2010 and determined CTT retrospectively, on the first diuretic scan of each of these patients. We then determined the relationship between initial CTT and the need for surgery.

RESULTS

We identified 37 patients with hydronephrosis (pelvic size >12 mm) of which 26 were diagnosed prenatally. Out of 22 patients with an initial abnormal CTT, 20 underwent surgery. Out of 15 children with a normal initial CTT, 4 underwent surgery (OR 27.5 (IC95%: 4.3-174.9)).

CONCLUSION

Initial CTT could be a reliable prognostic factor for future evolution of renal function in children with hydronephrosis. CTT is easy to determine on diuretic renal scan. A prospective trial is being devised to confirm what role it could have in the management of children with hydronephrosis.

[Anorectal malformations]

Anorectal malformations (ARM) are the result of an abnormal development of the terminal part of the digestive tract interesting anus and/or rectum that occur early between the sixth and tenth week of embryonic development. They carry a malformation spectrum of severity depending on the level of disruption of the anorectal canal and of the associated caudal malformations (sacrum and spine). ARM are associated in over half the cases with other malformations that can be integrated in some cases in known syndromes. If surgical treatment to restore anatomy as normal as possible is indispensable, post-operative care is essential for these patients whose defecation mechanisms are altered, to reach if not continence, at least a socially acceptable cleanliness.

Necrotizing enterocolitis in full term neonates: is there always an underlying cause?

OBJECTIVE

To review our experience with full-term neonates with necrotizing enterocolitis (NEC) and to compare its characteristics to those published in the literature.

DESIGN

Retrospective review of all neonates born after 35 weeks of gestation managed in Reunion Island for NEC from 2000 to 2012.

RESULTS

Among the 217 diagnosed NEC, 27 patients (12.4%) were full term neonates, who were born at a mean gestational age of 36.8 ±1.7 weeks. The mean onset of the disease was 12.1±11.2 days after birth. Twenty patients had underlying causes (15 organic pathologies of the child, 3 isolated maternal disease, and 2 infections); 7 had idiopathic NEC. Surgery was required in 12 patients (37.5%) at 23.2±20 days after birth. NEC affected most of the time the colon (n=6) and the rectum (n=3). Overall survival rate was 88.8% (24/27). Two patients required partial non-enteral nutrition for1.3 and 2.1 years.

CONCLUSIONS

NEC in full term neonates is a rare pathology. The onset of the disease in our experience was slightly later than described in the literature, but remains earlier than in the premature population. In some cases, no obvious cause can be found, suggesting a different pathogenesis. Further investigations are required in order to better understand this pathology. The goal will be to find measures to reduce global mortality.

Necrotizing Enterocolitis in Full Term Neonates: Is There Always an Underlying Cause?

Objective: To review our experience with full-term neonates with necrotizing enterocolitis (NEC) and to compare its characteristics to those published in the literature.Design: Retrospective review of all neonates born after 35 weeks of gestation managed in Reunion Island for NEC from 2000 to 2012.Results: Among the 217 diagnosed NEC, 27 patients (12.4%) were full term neonates, who were born at a mean gestational age of 36.8 ±1.7 weeks. The mean onset of the disease was 12.1±11.2 days after birth. Twenty patients had underlying causes (15 organic pathologies of the child, 3 isolated maternal disease, and 2 infections); 7 had idiopathic NEC. Surgery was required in 12 patients (37.5%) at 23.2±20 days after birth. NEC affected most of the time the colon (n=6) and the rectum (n=3). Overall survival rate was 88.8% (24/27). Two patients required partial non-enteral nutrition for1.3 and 2.1 years.Conclusions: NEC in full term neonates is a rare pathology. The onset of the disease in our experience was slightly later than described in the literature, but remains earlier than in the premature population. In some cases, no obvious cause can be found, suggesting a different pathogenesis. Further investigations are required in order to better understand this pathology. The goal will be to find measures to reduce global mortality.

Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy

Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome.

Penile length is comparable in boys with and without hypospadias

INTRODUCTION

It has been suggested that penile length is negatively correlated to the degree of hypospadias; however, there are no studies in the literature actually comparing penile length in normal patients and patients with hypospadias.

MATERIAL AND METHOD

Between January and May 2011, we measured penile length in two groups of children aged up to 5 years. The first group comprised all boys admitted for hypospadias (40 patients; 25 distal and 15 proximal hypospadias). The control group comprised 100 boys seen for other surgical procedures excluding those with endocrine disorders. We measured the length of the dorsal aspect of the penis in the flaccid state, without stretching. We then established, using our control group, a range of 'normal' values for penile length in our population and determined whether children with hypospadias were within this 'normal' range.

RESULTS

Mean penile length in the control group was 4.07 ± 0.92 cm, mean penile length in the hypospadias group was 4.36 ± 0.9 cm (4.48 ± 0.89 cm for distal hypospadias and 4.21 ± 0.79 cm for proximal hypospadias). There was no difference in penile length between the hypospadias group and the control group regardless of degree of hypospadias.

CONCLUSION

This study indicates that penile length in children with hypospadias whether proximal or distal is within the normal range.

Choosing a technique for severe hypospadias

INTRODUCTION

We participate in humanitarian missions in Madagascar during which we treat severe hypospadias. We report our experience and results with these patients, in these conditions, and discuss our choice of technique in this particular setting.

MATERIALS AND METHODS

We retrospectively reviewed the data of 27 patients operated for severe hypospadias during our humanitarian missions in Madagascar between November 2006 and September 2009. Twenty one patients underwent a modified Koyanagi procedure, three underwent a Duckett urethroplasty, two an onlay island flap, one an augmented Duckett and one a tubularised plate urethroplasty. Two patients who underwent a modified Koyanagi repair also had a Nesbitt dorsal plication.

RESULTS

Patient age at the time of surgery ranged from 22 to 198 months with a median age of 54.1 months. Mean follow-up was 16 months. Of the 21 patients who underwent a modified Koyanagi procedure, 16 presented at least one complication (76%): A fistula developed in 12 patients (57%), meatal regression developed in 7 (33%) and 2 showed complete wound dehiscence (9.5%). None developed stenosis or urethrocoele.

CONCLUSION

In this particular setting, the postoperative complication rate is high. Nevertheless, the Koyanagi technique is appropriate, because its complications are easy to treat and there is always sufficient ventral tissue for the secondary operation, if necessary.

Should we perform orchidopexy for cryptorchidism in children with severe encephalopathy?

OBJECTIVE

To conduct a survey of practices in France concerning cryptorchidism in patients presenting with severe encephalopathy.

MATERIAL AND METHOD

We conducted an e-mail survey of current practices in 27 pediatric surgery departments in 27 French university or general hospitals. The study concerned children with severe mental deficiency.

RESULTS

The survey showed a disparity in attitudes towards cryptorchidism in patients with severe encephalopathy, ranging from no treatment to orchidopexy in all cases. In most cases, the indication for surgery was the psychological aspect for the parents or accessibility to clinical examination.

CONCLUSIONS

This survey illustrates the unease concerning the pertinence of performing orchidopexy in these children. As improved fertility is not really an issue in children with severe encephalopathy, psychological aspects apply only to the family, and, as the benefit of orchidopexy for prevention or early diagnosis of testicular cancer is marginal, the risk/benefit ratio of orchidopexy for children with severe encephalopathy and cryptorchidism is unclear.

[Fractures of the ankylosed spine: MRI features]

The diagnosis of transverse spinal fractures in patients with ankylosing spondylitis and Forestier's disease (DISH) may be difficult. The MRI features of 9 such fractures at the disk, vertebral body, spinal canal and posterior elements are presented. Fractures of the posterior elements (posterior arch fractures and/or rupture of interspinous or supraspinous ligaments and contiguous soft tissue structures) were present in all cases, underscoring the importance of MR signal abnormalities of posterior structures for diagnosis of these fractures. MR is advantageous due to its ability to demonstrate signal abnormalities of the posterior elements, which combined with disk and vertebral body abnormalities, play a major role for accurate diagnosis of this type of fracture.

Successful management of a retroperitoneal kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon using alpha-interferon

It has been shown recently that Kasabach-Merritt phenomenon, the association of a vascular tumour and consumption coagulopathy, does not--as previously thought--complicate "classical" infantile hemangiomas but distinctive entities called kaposiform hemangioendothelioma (KHE) and tufted angioma (TA), both tumours on the same neoplastic spectrum. These tumours have been found in the neck, face, thorax, abdomen, retroperitoneum and limbs and are associated with a mortality rate of as high as 30 %. Several therapeutic modalities, including alpha-interferon, vincristine, radiotherapy and surgery have been reported in the literature. We report a case of retroperitoneal kaposiform hemangioendothelioma regression using alpha-interferon and discuss the current knowledge of this entity and its treatment.

Spontaneous Pneumothorax in Wegener Granulomatosis

Spontaneous pneumothorax in Wegener granulomatosis (WG) is uncommon. Three cases of pneumothorax that occurred early in the course of this vasculitis are reported. In the first patient, the disorder was disclosed by a pyopneumothorax. In the second patient, a rupture of the subpleural cavitary nodule into the pleural space was observed. In the third patient, the pneumothorax was discovered at the same time as a pulmonary hemorrhage. The three patients improved with immunosuppressive therapy. In WG, the pulmonary nodules are predominantly in the subpleural location, which entails the risk of pneumothorax and therefore require particular attention.

Inflammatory pseudotumor of the ureter

Inflammatory myofibroblastic pseudotumors are rare solid tumors found in most soft tissue locations although mainly in the lung. Their etiology is uncertain, and they are generally considered benign although some have a potential for recurrence and dissemination. Recent studies have suggested, however, that some of these tumors are in fact neoplastic processes that harbor chromosomal aberrations similar to those seen in certain lymphomas. The authors report a case of inflammatory pseudotumor of the ureter in a child and discuss recent reports.

Infiltration foraminale L5-S1 radioguidée dans le traitement de la lombosciatique S1

OBJECTIVE

To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to intervertebral disk disorder.

METHOD

41 patients were included: prospective study (20 patients) and retrospective study (21 patients). All patients suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl 125 mg), at 8 days interval.

RESULTS

60% of patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67% at day 30 (n:41) and 67% at day 90 (n:18).

CONCLUSION

Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.

Peritoneal needle suction for intestinal perforation in the preterm neonate

A few years ago, most intestinal perforations in the premature newborn appeared within the clinical context of necrotising enterocolitis (NEC). Since then, we have observed an increase in the number of isolated perforations appearing outside typical NEC. The fact that the perforations are more often isolated, and the healing capabilities of the premature intestine, led us to propose peritoneal needle suction (PNS) alone as first treatment for intestinal perforations in the premature neonate.

MATERIALS AND METHOD

The charts of 6 consecutive premature infants presenting with intestinal perforations treated initially by PNS alone were reviewed.

RESULTS

The patients' median birth weight was 1030 g, with a median gestational age of 27 weeks. In 5 out of 6 infants (83 %), PNS achieved complete exsufflation without recurrence of the pneumoperitoneum and complete intestinal healing, allowing complete enteral feeding 30 to 71 days after perforation. One infant with recurrent pneumoperitoneum after 3 PNS and peritoneal drainage was operated. All infants survived.

CONCLUSION

We believe that for early perforations of the premature neonate, the poor diffusion of the infection and the frequent capacity of the perforation to close and subsequently heal without scars, favour a minimally invasive management using PNS.

Interest of laparoscopy in polysplenia syndrome

Polysplenia syndrome (PS) is usually discovered in symptomatic patients in association with congenital heart disease or biliary atresia. Asymptomatic patients can present associated anomalies of the digestive tract such as intestinal malrotation and gastric or splenic malfixation. We report a case of PS presenting as a left flank mass shown to be an accessory spleen by denatured red blood cell scintigraphy. Upper gastrointestinal tract studies showed intestinal malrotation. Laparoscopic exploration confirmed intestinal malrotation and showed the absence of fixation of the accessory spleen. We performed a laparoscopic Ladd's procedure followed by fixation of the accessory spleen and resection of Meckel's diverticulum through a short left-flank incision.

[Pulmonary nodules: dosimetric and clinical studies at low dose multidetector CT]

PURPOSE

To measure breast radiation dose from multidetector CT using three different low dose protocols and compare it to a standard two view chest examination. To compare the number of pulmonary nodules detected at low and standard dose.

MATERIALS AND METHODS

Thermoluminescent dosimetry was used to measure the absorbed dose on a phantom (Rando) and 10 patients. Then, we compared the standard dose to the low dose examinations. The Wilcoxon rank test and the kappa test were used to assess differences in the detection of nodules.

RESULTS

The absorbed dose of these low dose protocols correspond to the radiation dose for the acquisition of two to ten chest radiographs (two views). This study suggests that only the 30 mA protocol is sufficient for the detection of all pulmonary nodules; nodules smaller than 5 mm were overlooked at 10 mA.

CONCLUSION

A good image quality can be obtained with low dose protocols at multidetector CT (correspond to 2 to 10 chest radiographs).

Management of asymptomatic neonatal cystic adenomatoid malformations

BACKGROUND/PURPOSE

Although much is known about the prenatal course of cystic adenomatoid malformations (CCAM), the postnatal course of asymptomatic lesion is less well documented. The authors studied the pre- and postnatal course and treatment of asymptomatic CCAM.

METHODS

The authors reviewed the files of all patients referred to Necker-Enfants Malades hospital with an antenatal diagnosis of CCAM and asymptomatic at birth.

RESULTS

Files of 29 patients were studied. The first x-ray film was considered normal in 12 cases (41.3%). Computed tomography was normal in 4 cases and showed cystic lung malformations in the other patients. Postnatally, clinical manifestations occurred in 3 patients (10.3%). CCAM vanished in 6 cases. Surgical resection of CCAM was performed in 17 cases (58.6%). All the patients currently are asymptomatic.

CONCLUSIONS

CCAM can shrink or vanish during pregnancy and antenatal ultrasound findings are not predictive of the postnatal course. Thus, all infants with prenatal diagnosis of CCAM require postnatal evaluation. Normal radiographic findings at birth do not rule out CCAM persistence on CT. The treatment of asymptomatic CCAM is controversial. Surgery may be advocated because of the low morbidity and the prevention of late complications, above all, cancer. The surgical indications of small (<3 cm) and asymptomatic lesions should be discussed on a case-by-case basis with the parents.

[POEMS syndrome: imaging of skeletal manifestations, a study of 8 cases]

PURPOSE

To describe the imaging features of POEMS, and to compare our experience of 8 cases to a review of literature.

MATERIALS AND METHODS

This retrospective study included 8 patients (6 men, 2 women) with POEMS. Plain radiographs (8 patients), CT (6), MR (2) were performed.

RESULTS

Topographic localizations of POEMS were pelvis (7 cases), spine (5), femur (1), humerus (1), rib cage (1). Focal bone lesions, multiple (5 cases) or solitary (3 cases), were sclerotic in 4 cases, mixed lytic-sclerotic (lytic center and sclerotic rim) in 3 cases and one patient had an osteolytic lesion with sclerotic margins associated with many osteosclerotic lesions. Profilerative osseous changes were seen in 4 cases (pelvis, spine, tibia). MR imaging was performed in 2 patients: in one patient MR imaging revealed areas of low signal intensity on spin echo T1- and T2-weighted images in vertebral bodies, the other showed a lesion of low signal intensity on spin echo T1-weighted and high signal intensity on T2-weighted images in the ilium and adjacent soft tissue.

CONCLUSION

The imaging features commonly observed in POEMS syndrome are sclerotic and mixed lytic-sclerotic lesions, particularly in the pelvis and spine. Proliferative new bone formation is detected in 50%. MR imaging correlates with ostesclerotic or mixed lytic-sclerotic appearance.

[Priapism in the course of generalized atopic dermatitis]

BACKGROUND

Priapism is a pathologically prolonged and painful penile erection, not resulting in ejaculation. Causes include certain oral medication, perineal trauma, thrombo-embolic process or primary priapism. We report a case of priapism secondary to diffuse general atopic dermatitis.

CASE REPORT

An 11 year-old child, with atopic dermatitis, presented over the last 36 hours an irreduced painful penile erection. Other than priapism, he presented numerous scratched lesions on the body and the penis having developped over the last 2 months (treated by daily topical corticosteroid application) and consistent with atopic dermatitis exacerbation. Due to the urological emergency, a puncture of the corpora cavernosa was made, followed by an injection of etilephrine in the penis. Complete and definitive detumescence was obtained. Application of betamethasone healed the cutaneous lesions. The child was treated with ciclosporine for his atopic dermatitis with good results at 6 months.

DISCUSSION

In our case, hypothesis of myeloid leukemia, sickle-cell disease and essential thrombocythemia were turned down. The young child did not exhibit any recent perineal trauma but the scratched lesions can be considered as microtraumas. The formation of an inflammatory oedema obstructed venous drainage of the penis and provoked priapism. We can not rule out the responsibility of topical corticosteroids in the formation of the priapism in this patient. Indeed, it was the only drug therapy prescribed, and since introduction of ciclosporine, there has been no relapse.

Indications and results of surgery in patients with Crohn's disease with onset under 10 years of age: a series of 18 patients

In order to examine the presentation and course of Crohn's disease (CD) with an onset of CD before the age of 10 and to assess indications and effects of surgery, a retrospective study was performed in 18 children. One hundred and twenty-two children with CD have been followed over the last 22 years in our institution. Thirty of them had the first onset of disease before 10 years of age. Eighteen out of these 30 underwent intestinal resection (IR). The mean age at the onset of CD was 6.4 years and the average duration of follow-up was 11.1 years. Most common symptoms were abdominal pain (72 %), diarrhoea (72 %), and growth retardation (50 %). Colon and ileum were the most frequently involved areas. Most of the children (94.5 %) received extensive medical and or nutritional treatment before surgery. We performed 26 IRs and 14 other operations in 18 patients. Indications for IR were chronic intestinal obstruction (13 cases) and chronic intestinal disability (13 cases). Improvements in the general clinical state were obtained in 17 cases out of 18. IR is beneficial for chronically ill children with ineffective medical therapy. A disease-free interval after surgery may provide an important time for improved growth and pubertal development and a return to nearly normal life for a long time.

[Treatment of giant congenital nevus with high-energy pulsed CO2 laser]

All authors agree upon the need for early treatment of giant congenital nevi. The surgeon must seek to minimize the risk of malignancy. The objective calls for radical excision of all pigmented areas; this may be impossible because of the risk of leaving the patient with disfiguring scars. The aim of this study was to assess treatment of giant congenital nevi with the high-energy pulsed CO2 laser as an alternative to surgery.

PATIENTS AND METHODS

Between 1998 and 1999, the high-energy pulsed CO2 laser was used in nine newborns and five children.

RESULTS

The treatment with the high-energy pulsed CO2 laser achieved 70-90% clearing of the giant nevi in most of the children. Two children developed hypertrophic scars on a companion nevi and on giant congenital nevi. One child required a skin graft because of tissue necrosis, associated with a disseminated intravascular coagulation and septic shock.

DISCUSSION

Laser is a surface technique proposed when surgical excision cannot be performed because the surface is too large or the localization is incompatible with surgery. Early treatment, in the first 15 days, is not required for the quality of the cosmetic result. The high-energy pulsed CO2 laser provides satisfactory cosmetic results with short cicatrisation time. It allows the treatment of the companion nevi at the same time. The risk of malignant transformation is greatly but not totally reduced. Regular clinical surveillance should help reduce the risk.

[A case of hepatic pseudoaneurysm treated with percutaneous embolization in a child with multiple trauma]

Hepatic artery pseudoaneurysms are rare complications of blunt abdominal trauma in children. Diagnosis is frequently delayed and made by splanchnic angiography. Most of the indications for surgical treatment have disappeared after the development of selective catheterization and embolization. We report a case in an 8-year-old pedestrian who was struck by a car and suffered a multiple trauma with a severe blunt abdominal trauma. A severe collapse upon admission commanded immediate laparotomy that depicted a liver fracture with associated jejunal and pancreatic lesions. Recovery was progressive until the 15th postoperative day where an abrupt haemobilia occurred. A CT-scan exploration was performed and revealed a vascular mass lesion in the left lobe of the liver. The performance of a selective angiography confirmed the diagnosis of left artery pseudoaneurysm, but because of technical difficulties, no embolization could be performed by this way. A direct percutaneous puncture and embolization of the aneurysm allowed a complete exclusion of the lesion. Eventually, recovery was complete. This percutaneous technique could be a valuable alternative to classical embolization and could avoid surgical treatment that still carries a high morbidity.

Resurfacing CO2 laser treatment of linear verrucous epidermal nevus

The term linear epidermal nevus (LVEN) refers to benign hyperplasia of the epidermis. Three types of LVEN can be distinguished: localized, systemic and inflammatory form. All have in common resistance to treatment and risk of recurrence. We report the observations of 5 patients with inflammatory linear verrucous epidermal nevus and 5 patients with linear verrucous epidermal nevus. Management by superpulsed CO2 laser was performed as follows: test treatment, completed by removal of the lesion in one or more sessions. Treatment was effective in all cases but 2. Satisfactory cosmetic results were obtained; slight hyperpigmentation, transitory desquamation and erythematous papules were observed. There was no recurrence in two years follow-up. We suppose that for the two patients with recurrence, our treatment failure is due to the lower laser parameters used in these patients compared to the others, because of their younger age.

Urological complications after renal transplantation using ureteroureteral anastomosis in children

PURPOSE

Ureterovesical reimplantation is most often performed for renal transplantation in children. We reviewed our experience to evaluate the safety and efficacy of ureteroureteral reimplantation in pediatric renal transplantation.

MATERIALS AND METHODS

We retrospectively evaluated the charts of 92 boys and 72 girls who underwent a total of 166 ureteroureteral anastomoses for renal transplantation from January 1990 to December 1999. Spatulated end-to-end anastomosis was performed between recipient and graft ureters without stenting and with a bladder catheter for at least 10 days.

RESULTS

Mean patient age at transplantation was 11.2 years (range 1 to 21.5). There were 22 living related donor and 144 cadaveric grafts. Urological anomalies and nephropathy were the cause of end stage renal disease in 146 and 20 patients, respectively. Urological complications were noted in 14 of the 166 transplantations (8.4%) in 10 boys and 4 girls, including 12 initial and 2 repeat grafts from 2 living related and 12 cadaveric donors. Five of these patients had undergone previous urological surgery. The 2 children (1.2%) with acute ureteral obstruction underwent repeat intervention after stent failure. Anastomotic leakage in 7 cases (4.2%) was treated conservatively in 1 and with a Double-J stent (Medical Engineering Corp., New York, New York) only required in 3. Reoperation was required in 3 cases. One patient (0.6%) with late ureteral stenosis underwent repeat anastomosis, 1 (0.6%) required reimplantation for recurrent pyelonephritis due to vesicoureteral reflux in the graft, 1 (0.6%) with a valve bladder required bladder augmentation and ureteral reimplantation, and 1 (0.6%) with lymphocele and 1 (0.6%) with lithiasis were successfully treated conservatively. Complications were associated with acute rejection in 6 cases. Mean followup without graft loss in patients who presented with versus without complications was 58.3 months (range 1 to 112) versus 75 (range 1 to 118). In the former patients with a mean age of 16 years 9 months versus those without urological complications mean serum creatinine was 116 and 108 mol./l., respectively. Two grafts were lost in patients with urological complications, including 1 who died of pulmonary embolism and 1 with refractory chronic rejection. Seven patients were lost to followup after 54 months (range 12 to 113) of adequate graft function.

CONCLUSIONS

Ureteroureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate, which may be due to better vascularization of the shorter ureteral end of the graft. Our results should encourage the use of this technique in pediatric renal transplantation. Efforts to preserve the recipient ureters should be made at nephrectomy.

[An assessment of low-dose high resolution CT in the detection of benign asbestos-related pleural abnormalities]

PURPOSE

To assess the reliability of low-dose high-resolution computed tomography (HRCT) in the detection of benign asbestos-related pleural abnormalities.

METHODS

Fourty-one patients exposed to asbestos were imaged on two occasions; the first time with conventional HRCT parameters: 140kVp, 220mAs; the second time with low-dose HRCT parameters: 120kVp, 60mAs.

RESULTS

The qualitative assessment dit not show any difference in the visibility of benign pleural abnormalities from one technique to the other in 98% cases.

CONCLUSION

The detection of pleural plaques and thickening did not vary with the two scanning protocols and, when compared with conventional HRCT, low-dose HRCT allows reduced radiation exposure by at least 76.5%, with an absorbed dose close to that delivered when using conventional chest radiography. Nevertheless, low-dose HRCT is a complementary study to helical acquisitions.

Spontaneous pneumomediastinum in children

SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

[Zinc deficiency in mucoviscidosis]

Zinc deficiencies can induce dermatitis in subjects presenting cystic fibrosis.

CASE REPORT

A patient, Clement, presented with a digestive form of cystic fibrosis. At four months of age, he presented a dermatitis similar to acrodermatitis enteropathica. Early clinical diagnosis and treatment led to a rapid response to zinc sulfate therapy.

DISCUSSION

Less intestinal absorption, malnutrition, and diet are just some of the numerous reasons for the zinc deficiency in this case. Biological support is not necessary to begin the treatment.

[Solar urticaria: one case treated by intravenous immunoglobulin]

BACKGROUND

Solar urticaria is a rare photodermatosis which often begins from the third to the fifth decade. Usual treatment consists of photoprotection measures and antihistamines although disease control is sometimes unsatisfactory with both. We report herein a very severe case of solar urticaria we treated with intravenous immunoglobulins.

CASE-REPORT

A 55-year-old woman suffered for 3 years from very severe solar urticaria which resisted treatment. Phototests revealed two action spectra: the first in UVA near 380 nm with a minimal urticarian dose of 0.025 J/cm(2), the second near 500 nm in visible light.

RESULTS

As last resort treatment, we gave our patient intravenous immunoglobulins. After the third course of treatment, the improvement was impressive as the patient could tolerate visible light and 15 minutes of intense solar exposure. The minimal urticarian dose was raised from 0.025 J/cm(2) to 27 J/cm(2) in UVA. One year after treatment, the solar urticaria has disappeared.

CONCLUSIONS

We report herein the first case of solar urticaria treated with success with immunoglobulin. Intravenous immunoglobulin treatment is well for its effectiveness in many autoimmune diseases such as autoimmune thrombocytopenic purpura, and also, as recently proven, in some cases of severe idiopathic chronic urticaria.