Case Report: Safety and Efficacy of Omalizumab in a 13-Year-Old Patient With Chronic Spontaneous Urticaria and Type 1 Diabetes

Chronic urticaria (CU) is defined by the presence of itchy wheals, sometimes accompanied by angioedema, lasting for at least 6 weeks. CU is treated with second-generation antihistamines, increased up to four times the normal doses for second-line treatment. Omalizumab (a monoclonal antibody anti-IgE) may be recommended as third-line therapy in children aged over 12 years. Few reports have suggested that glucose homeostasis is impaired in some type 2 diabetic patients receiving omalizumab, and even in non-diabetic patients, fasting blood glucose and HOMA-IR values appeared to be significantly increased. We report the case of a 13-year-old girl with diabetes mellitus type 1 and chronic spontaneous urticaria (CSU) refractory to standard recommended therapy that we treated with omalizumab at a standard recommended dose of 300 mg every 4 weeks. We observed a rapid and complete remission of CSU after treatment with this humanized monoclonal antibody without detrimental effects on the patient's glucose control especially in terms of HbA1c (glycated hemoglobin), time in glycemic range (TIR), and daily insulin needs.

COVID-19 cardiac involvement in a 38-day old infant

The spectrum of clinical manifestations of coronavirus disease 2019 in children is yet to be fully elucidated. We report the case of an infant who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and developed mild cardiovascular inflammation, a novelty for patients of very young age, that contributes to defining the puzzling nature of this disease in pediatric patients. The potential cardiovascular involvement of SARS-CoV-2 in children should always be taken into account.

Unexpected artefacts and occult pathologies under CBCT

Purpose

To present the most frequent occult pathologies unexpectedly encountered via cone-beam computed tomography (CBCT), with particular reference to the diagnostic role of the dentist and that of the radiographer, with a view to clarifying where the diagnostic responsibility lies.

Material and methods

A narrative literature review on the most diffused occult pathologies under CBCT was conducted, with iconographical guide as an example for each category.

Results

The most frequent forms of unexpected pathologies encountered are: the presence of foreign bodies, airway anomaly, and the presence of radio-opacity or -transparency in the maxillofacial district.

Conclusions

The orthodontists must know that they are responsible to recognize these frequent, and potentially serious, pathologies of the head and neck. If the dentist feels unable to take on this responsibility, he or she should, however, be sure to have the scans read by a specialist radiologist.

Orthofile®: a new approach for mechanical interproximal reduction : a scanning electron microscopic enamel evaluation

PURPOSE

The aim of this in vitro study was to evaluate the stripping achieved on different teeth (incisors, canines, and premolars) by two grades of abrasive strips used for the first and tenth time. Our second aim was to test the efficacy of these strips by calculating the time necessary to perform interproximal reductions of 0.10, 0.20, and 0.30 mm.

METHODS

Four models were constructed using extracted teeth affixed in wax. The upper and lower arches were set on plaster bases and fixed in wax, carefully creating contact points. All model mouths were treated with artificial saliva (Oral Balance®) in order to simulate the biological conditions in the oral cavity. We then tested specific air-rotor strips of different grades and degrees of wear (15-µm-grain and 25-µm-grain Orthofile® strips). Afterwards the teeth from all samples were cut lengthwise in half, and each mesial and distal portion was gold-plated and observed under SEM at incremental magnification (30, 60, and 100 µm).

RESULTS

The 25-µm-grain strip was more effective than the 15-µm-grain strip, irrespective of the tooth involved. Second, the finishing phase with specific polishing strips after interproximal reduction was fundamental in reducing the number of abrasions and irregularities created by stripping, in particular after using the 25-µm-grain strip. To achieve the best result, the entire abraded area must be polished.

CONCLUSION

This system permits a rapid and effective stripping procedure in direct proportion to the strip's grain and in inverse proportion to the wear from its use. Further research will enable us to compare this system with similar procedures.

Adult height in girls with Turner syndrome treated from before 6 years of age with a fixed per kilogram GH dose

OBJECTIVE

To evaluate adult height (AH) in 25 girls with Turner syndrome (TS) who were treated from before 6 years of age for 10.0 ± 1.7 years with a fixed GH dose of 0.33 mg/kg per week.

PATIENTS AND DESIGN

After a 6-month pretreatment assessment all patients were measured 6-monthly under therapy to assess height SDS (H-SDS) and height velocity (HV) until AH achievement.

RESULTS

Following initial acceleration, HV declined after the first 4 years of therapy. At the end of the sixth year of therapy, H-SDS gain was 1.9 ± 1.1. Thereafter, H-SDS gain from baseline decreased, becoming 0.9 ± 0.9 SDS at AH achievement. Bone maturation velocity did not significantly change throughout the prepubertal period. According to Lyon standards for TS, mean AH SDS was significantly higher than pretreatment H-SDS (P<0.0001), with a mean H-SDS change of 0.9 ± 0.9. However, the prevalence of patients with AH <-2 SDS (according to Sempé standards) was close to those recorded at the start of therapy (16/25 vs 18/25). No significant differences in terms of AH were found between patients with either X monosomy or X-chromosomal abnormalities and between girls with either spontaneous or induced puberty.

CONCLUSIONS

We infer that the therapeutic regimen adopted in this prospective study is sufficient to induce a significant growth acceleration during the first year, but the response waned after 6 years of treatment.

Estrogen exposure in a child from hair lotion used by her mother: clinical and hair analysis data

Premature estrogenic effects may result from exogenous exposure to estrogenic substances. We report the case of a 36-month-old girl who presented with vaginal bleeding, uterus enlargement, and thelarche. Questioning of the parents revealed that the child's mother had used hormone-based hair lotions on her own scalp and that the child was in the habit of playing with her mother's hair while falling asleep, and that the girl played with her mother's combs and the empty lotion vials. The onset of hyperestrogenic syndrome was temporally related to the handling of lotions containing ethynylestradiol 0.5%. Analysis of long scalp hairs from the girl and her mother identified ethynylestradiol in concentrations of 10.6 and 46.6 microg/g, respectively. Six months after the mother discontinued use of the estrogen-containing hair lotion, the girl's hyperestrogenic signs resolved. This case highlights the importance of obtaining histories of possible food and non-food environmental sources of contamination, the suitability of hair sampling to identify the origin of the contamination, and the opportunity to warn parents about hazards related not only to oral contraceptives, but also custom-compounded topical hormone preparations.

Early treatment with GH alone in Turner syndrome: prepubertal catch-up growth and waning effect

OBJECTIVE

In order to ascertain the advantages of early GH treatment in Turner syndrome (TS), we started a prospective study aimed at evaluating prepubertal height gain in a cohort of 29 girls who were treated with the same pro-kilo GH dose (1.0 IU/kg per week) since they were less than 6 years old and for at least 5 years before entering puberty.

PATIENTS AND DESIGN

Following a minimum of 6 months of baseline observations, 29 girls with TS were enrolled for this prospective study provided that they (a) were less than 6 years old, (b) were below -1.0 standard deviation score (SDS) for height, (c) had a projected adult height (PAH) lower than the respective target height (TH) and (d) had a height velocity (HV) lower than -1.0 SDS. All the selected girls underwent a 5-year treatment with biosynthetic GH at a stable dose of 1.0 IU/kg per week and were periodically measured during the treatment period in order to evaluate height, HV and PAH.

RESULTS

After a dramatic acceleration during the 1st year, HV was attenuated during the subsequent years, reaching its nadir at the 5th year. Height deficiency under therapy progressively decreased from entry onwards, shifting from -2.4+/-0.7 to -1.0+/-1.2 SDS. In the same period, mean PAH progressively increased, although after 5 years it remained lower than the average TH.

CONCLUSIONS

(a) An effective growth-promoting strategy in TS should be based on early GH treatment, as suggested by our results. (b) This strategy could result in a prepubertal normalization of height, thus allowing the appropriate timing for the induction of puberty. (c) An initial GH dose of 1.0 IU/kg per week may be suitable during the first years of therapy, as shown by our data documenting an important waning effect of GH therapy only after the 4th year of treatment. (d) No acceleration of bone maturation was observed under this treatment regimen.

Turner's syndrome

Turner syndrome (TS) is the most common sex-chromosome abnormality in females. Short stature and hypogonadism are the classical clinical findings. The spontaneous final height (FH) ranges between 139 and 147 cm, representing a growth deficit of about 20 cm with respect to the unaffected population. GH therapy improves FH and should be started during childhood at a high dose of about 1 IU/kg/week (range 0.6-2 IU/kg/week). Some authors advocate combined therapy with an anabolic steroid at various doses (e.g. oxandrolone 0.05-0.1 mg/kg/day). This treatment results in a significantly increased FH, a large proportion of treated girls reaching a FH of more than 150 cm. Gonadal function is compromised during adolescence in about 80% of girls with TS, whilst in about 20% pubertal development occurs spontaneously. Oestrogen therapy should be started at the age of 13-14 years in hypogonadic patients; early onset of treatment (before 12 years) seems to compromise FH. Other concerns in these patients are fertility and osteopenia.

Precocious puberty and body composition: effects of GnRH analog treatment

INTRODUCTION

Body composition changes with age and sex differences become significant only after puberty. Boys and girls before the age of 8 yr do not differ in fat, lean or bone mineral mass. Hormonal influences during pubertal development determine the physiological adult male and female body composition phenotype.

AIM

The aim of our study was to evaluate body composition changes due to central precocious puberty (PP) and the specific effects of therapy on these modifications.

SUBJECTS AND METHODS

Sixteen patients (14 girls, 2 boys) were included in the study. They were diagnosed as affected by idiopathic PP according to standard hormonal and clinical criteria; anatomic alterations of hypothalamus-hypophysis region were excluded by MRI. Mean age at diagnosis was 5.9 +/- 1.9 yr. All patients received GnRH analog (Leuprolide or Triptorelin) treatment subcutaneously every 4 weeks for at least 1 yr. Mean period of treatment was 3.4 +/- 1.9 yr. Standard anthropometry and body composition analysis were performed at baseline and every 6-12 months. A group of healthy subjects with normal timing of puberty was matched (for age or for pubertal stage) served as the control group (CA or CP, respectively).

RESULTS

Patients with PP showed at baseline a significant increase of BMI and relative body weight; lean and fat compartments were also increased but not significantly. During treatment, the PP group showed increased fat mass compared to CA (p<0.05), while no difference was found between PP and CP. Lean mass was similar to CA but lower than in CP (p<0.05). During treatment a significant increase in lean mass (both as total as well as limb mass) was observed. After stopping treatment there was no difference between PP and CP, except for lower lean mass (p<0.04).

CONCLUSION

When puberty occurs precociously, lean and fat mass are not significantly different from age-matched control subjects. Data collected during treatment confirm a shortening of prepubertal lean mass development and the block of further lean mass development due to puberty itself, while fat mass accumulation continues. The net result of these modifications determines a typical body composition pattern in PP patients, after the end of therapy: lean mass is reduced by a shortening of the prepubertal growing period and by the "menopausal effect" of treatment itself. Fat mass is increased as a consequence of therapy and could lead to future obesity.

Etiology of central precocious puberty in males: the results of the Italian Study Group for Physiopathology of Puberty

We reviewed the hospital records of 45 boys, followed in 13 pediatric departments throughout Italy, who had undergone computed tomography and/or magnetic resonance imaging for central precocious puberty (CPP). Twenty-seven patients (60%) had idiopathic CPP and 18 (40%) neurogenic CPP. A hamartoma of the tuber cinereum was found in six patients (33%). All patients with hypothalamic hamartoma had earlier onset of symptoms than patients with idiopathic CPP. Five patients (27%) were affected by type 1 neurofibromatosis, two had ependymoma and five patients had an intracranial anomaly. Basal LH and basal and peak LH/FSH ratio were greater, but not significantly, in boys with neurogenic CPP than in boys with idiopathic CPP. The highest LH peak levels were observed in patients with hamartoma; however, no correlation was observed between LH peak and the size of the hamartomas. In addition, bone age at diagnosis was more advanced in patients with hamartoma than in patients with other conditions. In conclusion, gonadotrophin-dependent precocious puberty may be of idiopathic origin or may occur in association with any CNS disorder. Further studies are needed in order to evaluate the effects of nutritional, environmental and psychosocial factors on the timing of sexual maturation, to explain the high incidence of idiopathic CPP in our male patients.

Factors influencing final/near-final height in 12 boys with central precocious puberty treated with gonadotrophin-releasing hormone agonists. Italian Study Group of Physiopathology of Puberty

Gonadotrophin-releasing hormone agonists (GnRHa) have been demonstrated as the therapy of choice for central precocious puberty (CPP). Few studies have provided male patients' adult height data. In our multicenter study we evaluated long-term effects of different GnRHa preparations and final/near-final height (FH) in 12 boys with CPP and analyzed the factors influencing FH. Patients' mean chronological age at the time of diagnosis was 7.6 +/- 0.9 yr. Three patients were treated only with triptorelin at a mean dose of 90 microg/kg i.m. every 28 days. Nine patients initially received buserelin (at a mean initial dose of 53.4 microg/kg/day i.n. divided into 3-6 equal doses) or buserelin (at a mean dose of 36.7 microg/kg/day s.c.) and were subsequently switched to triptorelin. The GnRHa therapy was continued for 4.1 +/- 0.6 yr (range 2.9-5.4). The mean predicted adult height increased from 169.9 +/- 4.2 cm at diagnosis to 180.7 +/- 6.0 cm at the end of treatment. Mean FH was 176.1 +/- 6.1 cm (170.1-190.7), corresponding to mean SDS(CA) 0.4 +/- 0.8 (-0.6/2.5), mean SDSBA 0.2 +/- 0.9 (-0.6/2.4) and mean corrected SDS for target height of 0.4 +/- 0.6 (-0.8/1.2). Multiple regression analysis revealed that FH was mainly influenced by target height and height at discontinuation of GnRHa therapy. The present data indicate that GnRHa therapy significantly improves growth prognosis in boys with CPP and fully restores genetic height potential.

[Endocrinologic problems of the male adolescent]

The male adolescent may present several endocrinological problems, the most frequent of which is the retardation or absence of puberty due to constitutional delay of growth and development. This form does not require therapy and must be distinguished from other forms of hypogonadism (primitive or secondary) by endocrine tests (LHRH test, nightly pulses LH secretion, plasmatic basal level of testosterone and after HCG, cerebral NMR). Hypogonadism treatment consists of replacement therapy with testosterone or testes stimulation with HCG or LHRH. Another frequent disease is gynecomastia, usually due to physiological enlargement of mammary gland during pubertal development, sometimes it may be secondary to hypogonadism, tumors, liver function abnormalities. Severe or psychologically disturbing gynecomastia can be corrected by reductive mammoplasty. Very often, adolescents may present diseases related to incorrect food habits. Obesity is common and anorexia is becoming an important problem also in males.

[Endocrinological problems in male adolescents]

The male adolescent may present several endocrinological problems, the most frequent of which is the retardation or absence of puberty due to constitutional delay of growth and development. This form does not require therapy and must be distinguished from other forms of hypogonadism (primitive or secondary) by endocrine tests (LHRH test, nightly pulses LH secretion, plasmatic basal level of testosterone and after HCG, cerebral NMR). Hypogonadism treatment consists of replacement therapy with testosterone or testes stimulation with HCG or LHRH. Another frequent disease is gynecomastia, usually due to physiological enlargement of mammary gland during pubertal development, sometimes it may be secondary to hypogonadism, tumors, liver function abnormalities. Severe or psychologically disturbing gynecomastia can be corrected by reductive mammoplasty. Very often, adolescents may present diseases related to incorrect food habits. Obesity is common and anorexia is becoming an important problem also in males.

Effect of insulin treatment on osteocalcin levels in diabetic children and adolescents

To investigate bone mineral metabolism in insulin-dependent diabetes mellitus, serum osteocalcin, a marker of bone formation, was measured in 31 diabetic children at onset of disease and 15 days after metabolic improvement by insulin therapy. As a control group for osteocalcin levels we studied 31 healthy sex- and age-matched children. Mean values of serum osteocalcin at onset of diabetes were significantly lower than in control group (p < 0.001), but we did not find any difference after 15 days of insulin therapy. Osteocalcin and parathyroid hormone concentrations were significantly greater after 15 days of insulin treatment than at onset of disease (p < 0.001 and p < 0.01, respectively). The osteocalcin levels were negatively correlated both with fructosamine and with glycosylated hemoglobin (p < 0.01 and p < 0.001, respectively), and positively correlated with the degree of metabolic acidosis at onset (p < 0.05). Therefore we postulate that during glycometabolic imbalance there is a decrease in bone turnover that could be one of the etiological factors of diabetic osteopenia.

Effect of estrogen replacement therapy on bone mineral content in girls with Turner syndrome

Because a close relationship between estrogen deficiency and osteoporosis has been proven, it is possible that lifelong estrogen deficiency might be the cause of osteopenia in Turner syndrome. This study was done to characterize the effect of estrogen therapy on bone mineralization in girls with Turner syndrome. Radial bone mineral content values were found to be below the 95% normal confidence interval in 44 of 49 untreated patients, aged 10.82 +/- 3.45 years. An inverse correlation was found between the patients' ages and their delta bone mineral content values. The effect of beginning estrogen treatment early or late was studied in 16 girls who started the treatment before and 11 who started after age 12. Although they were still deficient compared with controls, the first group had better mineralization than the second (P = .0005). Finally, nine patients were followed prospectively during replacement therapy; their bone mineral content delta values changed significantly (P = .02) during the follow-up period (3.17 +/- 0.33 years), but the bone mineral content did not normalize. Our data show that estrogen deficiency per se does not cause osteoporosis in young girls with Turner syndrome. In fact, estrogen therapy prevented bone loss but failed to normalize the low bone mineral content values. Early treatment is preferable because it reduces the bone density deficit present in untreated patients.

[Changes in dynamic respiratory volumes in obese children and adolescents related to weight loss and sex]

Obesity is associated with various alterations in lung function in adults. These alterations appear to be proportional to the degree of EP and the beneficial effect of weight loss on respiratory function has been reported. Therefore, in 35 children and adolescents affected by essential obesity of medium-severe degree, we have evaluated the following parameters: FVC (forced vital capacity), PEF (peak expiratory flow), FEV1 (forced expiratory volume), FEV75, FEV50, FEV25, before and after six months of dieting. Twelve subjects (34%) showed at least a pathologic value of PEF and/or FEV50 before dieting. All the female patients normalized their parameters after six months of dieting, whilst 5 out of 7 males still showed pathologic respiratory indexes, although a similar weight loss was obtained in the two groups of patients. Our study enhances the presence of respiratory functions derangements in a significant percentage of children with medium-severe degree of obesity. A careful monitoring of these subjects is therefore necessary, in order to prevent further progression of the lung function damage. After dieting the pulmonary function improved in female patients only, suggesting that factors other than the EP are involved in the pathogenesis of the respiratory alterations.

Bone mass in young patients with type I diabetes

We measured bone mineral content (BMC) with single photon absorptiometry in two groups of young patients with type I diabetes: the first group (prospective study) consists of 48 patients followed from onset to the third year of diabetes and the second group (cross-sectional study) consists of 66 long-term diabetics. Bone mineral content at onset of disease was lower than normal in only two cases. After 3 years of diabetes no male revealed BMC below the normal range but two females (6.6%) had low BMC values. In our cross-sectional study we found a BMC reduction in 12% of the cases. We did not find a relationship between bone deficit and duration of diabetes, or bone mass values and HbA1.

[Osteopenia in premature children: an emerging problem]

Osteopenia of preterm newborns is a condition of undermineralization which arises during the first years of life in very low birth-weight infants. The pathogenesis of disease is multifactorial, even if its main mechanism is the inadequate mineral intake (overall the inadequate phosphorus intake). A wide spectrum of signs and symptoms may be observed ranging from overt rickets to asymptomatic conditions. Diagnosis is usually based on either photon or biochemical findings (hypophosphoremia, hyper calciuria, hypophosphaturia). There is not agreement about the prevention and the treatment and about the benefit of any form of mineral supplementation. The aim of our study is a review of the recent studies concerning the osteopenia of prematurity to focus this new problem.