[A right-sided congenital diaphragmatic hernia masked by pneumonia]

A 1-day-old premature newborn (34 weeks and 6 days) presented with respiratory insufficiency due to a group B haemolytic streptococcal (GBS) pneumonia. She recovered after temporary treatment with mechanical ventilation and antibiotics. At the time of discharge there was a slight increased fogging on the right side of the chest X-ray, interpreted as residual pleural effusion. Three days later the patient was readmitted with respiratory failure and a need for respiratory support. A chest CT scan revealed a right-sided congenital diaphragmatic hernia (CDH) with a large part of the liver and intestine in the chest. The diaphragmatic defect was closed during a surgical procedure. After an uneventful recovery the patient was discharged in good clinical condition. The combination of delayed presentation of right-sided CDH and neonatal GBS infection occurs rarely but has been described. Its pathogenesis is still unclear.

[Arthralgia and urticaria as immune-complex mediated complications after meningitis with meningococci group B]

A 4-year-old boy was treated for an infection with a meningococcus type B. After a few days of recovery, he felt ill again on day 6. The patient had urticaria and arthralgia without arthritis. The infection parameters did not normalize or increase in severity. No abnormalities other than a lowered CH50 value were found in the extensive diagnostic tests performed. The diagnosis of immune-complex mediated complications following a meningococcal infection was made. The patient was sent home where he continued pain relief and physiotherapy treatment. After 2 months at outpatient follow-up, he showed complete recovery and the CH50 value had returned to normal. Other immune-complex mediated complications of meningococcal infection are arthritis, episcleritis, pericarditis, myocarditis and pleuritis. These occur in 6-15% of the patients with a meningococcal infection. Early recognition prevents unnecessary extensive and costly diagnostic testing as well as a longer than necessary hospital stay.

[Rituximab instead of splenectomy in 4 children with chronic or refractory autoimmune haemolytic anaemia]

4 children, a boy aged 10 years and 3 girls aged 3, 3, and 16 years, suffering from chronic or refractory autoimmune haemolytic anaemia (AIHA), who were dependent on high doses of steroids and were refractory to immunosuppressants, were treated with rituximab at a dose of 375 mg/m2 once a week for 3 or 4 weeks as an alternative to splenectomy. Rituximab is a monoclonal anti-CD20 antibody that prevents the production ofautoantibodies by selective destruction of B-lymphocytes. Haemoglobin levels increased and the parameters of chronic haemolysis (reticulocyte count, lactate dehydrogenase activity, bilirubin concentration) decreased to normal values. 3 patients were taken off corticosteroids completely; 1 of these was also no longer dependent on blood transfusions. Circulating B-lymphocytes were absent for 6 to 15 months after the treatment and the rituximab was well-tolerated. During the treatment, immunoglobulins were substituted and infectious complications were not seen. Rituximab was valuable in the treatment of chronic or refractory AIHA and eliminated the need for splenectomy. 1 patient did not respond to rituximab.