Acute acalculous cholecystitis of viral etiology--a rare condition in children?

Acute acalculous cholecystitis (AAC) comprises 5% to 10% of all cases of acute cholecystitis in adults and appears to be even less frequently diagnosed in children. The diagnosis of AAC is established upon some clinical, laboratory, and ultrasonographic findings, which may sometimes be ambiguous and confusing especially in children. Diagnostic difficulties may result in either delayed diagnosis or unnecessary surgical intervention. Acute cholecystitis owing to viral infectious factors is reported to be extremely rare. The aim of the article is to demonstrate 2 cases of AAC as a clinical presentation of both Epstein-Barr virus and cytomegalovirus infection in children.

[Chronic hepatitis B in children--is it still a real problem?]. / Przewlekle zapalenie watroby typu B u dzieci--problem nadal aktualny?

Over one million people all over the world die every year due to the complications of HBV infections. This problem is particularly important in Asia, Africa and in the West Pacific region where HBV infection is widely spread (from 5-20% up to 80% of all infected people in the world). In these regions HBV infections are transmitted mostly perinatally or during early childhood. In North America and in West Europe where after introducing anti-HBV vaccinations less than 2% of the population is affected, infections are usually transmitted by intravenous drug abuse, sexual intercourse, or much less frequently by blood transfusions. The immaturity of immune system in young children is responsible for the fact that nearly 90% of HBV infections acquired in infancy and 40-70% of HBV infections before the age of 3 years, result in chronic viral hepatitis. Therefore, the choice of an efficient and safe therapy is one of the most important problems. In this paper current data concerning indications for treatment and side-effects of interferon-alpha and lamivudine therapy in children with chronic viral hepatitis type B are presented.

[Therapy of chronic viral hepatitis type B in children after previous ineffective interferon-alpha treatment]. / Terapia przewleklego wirusowego zapalenia watroby typu B u dzieci po uprzednim, nieskutecznym leczeniu interferonem alfa.

UNLABELLED: THE AIM of this study was to estimate the efficacy of nucleoside analogue (lamivudine) in the therapy of chronic viral hepatitis type B in children, after previous, ineffective treatment with interferon-alpha. PATIENTS AND METHODS: we analyzed 53 children with chronic viral hepatitis type B, who had not responded to Interferon-alpha treatment conducted 1-7,5 years before this study (mean 4,0 +/- 7,5; median 4 years). Inclusive criteria to re-therapy with lamivudine were as follows: increased serum alanine aminotransferase activity, detected at least three times during 6 months before treatment, HBsAg and HBeAg present in the blood, viral HBV DNA detected for at least 6 months before the beginning of lamivudine therapy (above 200 genome copies per mL) and inflammation activity observed in liver biopsy specimen (biopsy performed within previous 24 months). Evaluation of side-effects of lamivudine therapy was based on anamnesis (subjective data) and laboratory tests performed regularly in the time of clinical visits during and after the end of the treatment. RESULTS: all the children concluded the treatment. Before lamivudine therapy, serum alanine aminotransferase activity ranged between 20-590 IU/L. In 28,4% of children it was less than 100 IU/L. In almost all the children moderate staging and grading were observed in liver biopsy specimens. HBV DNA in serum ranged between 200-200000 copies/mL: in 31 children (58,4%) HBV DNA exceeded 200000 copies/mL, in 5 (28,3%) was between 10000 and 200000 copies/mL, and in 7 (13,2% ) was below 10000 copies/mL. Applied treatment resulted in alanine aminotransferase activity normalization in 79,2% of children, mostly after 2-11 months (mean 3,9 +/- 2,7; median 3,8 months). HBeAg/HBeAb seroconversion was achieved in 28,3% of children, usually at the end of lamivudine therapy (approximately after 12 months). Sustained viral response was observed in 24,5% of treated children. There were no undesirable effects of therapy noted. Serum alanine aminotransferase activity increased slightly and temporarily in 4 children between 3rd and 12th month of therapy. In 2 of these children YMDD mutation was detected. CONCLUSIONS: lamivudine is effective, safe and well tolerated in treatment of chronic viral hepatitis type B, following unsuccessful interferon-alpha therapy. Serum alanine aminotransferase activity normalized in most of the patients. HBeAg/HBeAb seroconversion as well as positive viral response is mostly connected with low level of HBV DNA before therapy.

[Vasculitis in children]. / Zapalenia naczyn u dzieci.

Vasculitis is a group of rare diseases of unknown etiology, characterised by inflammation and necrosis of blood vessels, contributing to various clinical consequences. The variety of clinical symptoms and presence of symptoms from various syndromes often make the diagnosis difficult. Until now no causal treatment has been established. In order to achieve a remission of the disease, corticosteroids and immunosuppressive therapy are recommended.

[Congenital extrahepatic biliary atresia as a cause of cholestasis in newborns and infants]. / Wrodzona atrezja dróg zólciowych zewnatrzwatrobowych jako pryczyna cholestazy u noworodków i niemowlat.

UNLABELLED: Congenital extrahepatic biliary atresia (CEBA) is one of the most common causes of cholestasis in newborns and infants. THE AIM OF THE STUDY: was the analysis of clinical presentation, results of laboratory and imaging investigations as well as clinical outcome of children with extrahepatic cholestasis caused by CEBA. MATERIALS AND METHODS: the analyzed group included 15 children aged from 2 weeks to 4 months. Data concerning: pregnancy and delivery, newborn's health condition, faeces color; jaundice onset, manifestation of coagulation disorders coexisting malformations and disorders of other systems were obtained. The following investigations were performed: biochemical tests evaluating the function of the liver and cholestasis (serum bilirubin concentration and fractions, bile acids in serum, AlAT, AspAT, GGTP, FALK activities, serum electrophoresis, prothrombin index). We also performed tests focusing on hepatotropic infections, - metabolic disorders tests and in all children - ultrasound of the abdomen, scintigraphy of the bile ducts - HEPIDA. 14 children had undergone hepatoportoenterostomy, modo Kasai. RESULTS: jaundice, acholic stools and hepatomegaly were present in all children. The serum concentration of bilirubin and its conjugated fraction and bile acids in all children were increased. GGTP and FALK activities were markedly elevated in all children. Aminotransferases activities elevations were observed, more distinctively for AST. Active cytomagalovirus infection was detected in 3 children. Abdominal ultrasound revealed gallbladder in 7 children, whereas intrahepatic bile ducts were described as normal in 12 cases. In all cases the HEPIDA scintigraphy showed no passage of the tracer to the GI tract even after 24 hours delay. Hepatoportoenterostomy was performed in 14 children, 5 of them had liver transplantation. CONCLUSIONS: 1. There is still not one effective and specific diagnostic method in differentiating between the causes of cholestasis in the newborns and infants. Thus many investigation methods should be run simultaneously. 2. Congenital atresia must be definitely excluded before cholestasis with other background is finally diagnosed. 3. The hepatoportoenterostomy should be considered as the first line treatment in children with CEBA. Most cases will need liver transplantation in the future.

[Mesenteric lymphadenopathy - a valid health problem in children]. / Limafadenopatia krezkowa- czesty problem kliniczny wieku dzieciecego.

THE AIM: of the study is to evaluate the reasons of mesenteric lymphadenopathy and its clinical picture in hospitalized children. MATERIAL AND METHODS: the study was performed on 127 children (49 girls and 78 boys age of 8 months to 18 years; mean age 9 years and 3 months) hospitalized in the Department of Paediatrics, and Paediatric Gastroenterology and Oncology, Medical University of Gdansk. Ultrasonography showed enlarged abdominal lymph nodes in all children. According to definition of mesenteric lymphadenopathy, the clinical course of disease was analyzed in children, in whom there were at least three lymph nodes in ultrasonography with the peroneal diameter of 5 mm or more. Inflammatory parameters were examined in all children. In selected cases culture, viral and parasitic, as well as endoscopic examination, were also performed. RESULTS: analyzing accompanying clinical symptoms, it was found, that abdominal pain was the most dominant complaint in children with mesenteric lymphadenopathy; it was observed in 63 children (49.6%). In 33 (26%) of them the pain was the sole complaint, while in the rest vomiting and fever were present. 8 children (6.3%) with generalized lymphadenopathy were diagnosed. Ultrasonographic evaluation demonstrated that numerous enlarged lymph nodes were present the most frequently, in 65 (51.2%), less numerous, in 42 (33.1%), while sparse lymph nodes were seen only in 20 (15.7%) children. In 85 patients (66.9%) long axis of the lymph nodes reached min. 10 mm, in 39 (30.1%) was smaller than 10 mm, in 3 (2.4%) exceed 20 mm. Conglomerates of lymph nodes were described in 9 (7.1%) patients with various diagnosis (acute diarrhea - 3 children, ulcerative colitis - 3 children, celiac disease, cytomegaly, lambliosis). Tendency to invagination was observed in 5 (3.9%) children. In 4 of them acute infection (acute diarrhea, pneumonia) with high inflammatory parameters was diagnosed. Elevated inflammatory parameters were present in 42 (33.1%) patients. Examining the reasons of the abdominal lymph nodes enlargement, it was found that primary mesenteric lymphadenopathy was the most frequent diagnosis; it was recognized in 27 (21.3%) children. In 20 (15.7%) lymphadenopathy was caused by acute diarrhea, in 19 (14.9%) patients - by respiratory tract infection. Cytomegaly was recognized in 4 (3.1%), toxoplasmosis in 3 (2.3%), lambliosis in 9 (7.0%) patients. Both gastritis and colitis were diagnosed in 12 (9.4%) children. In 7 (5.5%) patients generalized lymphadenopathy with unknown etiology was described. In single cases other diseases were diagnosed. CONCLUSIONS: the enlargement of mesenteric lymph nodes frequently causes abdominal pain in children, being an indication for laboratory investigations. Vomiting and fever are the most common other symptoms in these patients. Ultrasonographic examination usually shows large enlargement of lymph nodes, sometimes in conglomerates, with tendency to invagination. Acute diarrhea and respiratory tract infection are the most frequent reasons of the enlargement of abdominal lymph nodes. In about 20% of the children primary mesenteric lymphadenopathy is diagnosed.

[Giardiasis in children - clinical diversity and diagnostic problems based on own experience]. / Zakazenia giardia lamblia u dzieci- zmiennosc obrazu klinicznego i trudnosci diagnostyczne w swietle doswiadczen wlasnych.

UNLABELLED: Parasitosis still remains a significant pediatric health problem, despite improving hygienic conditions and social awareness. THE AIM OF THIS STUDY: was to analyze clinical manifestations of Giardia lamblia infection in children hospitalized in the Department of Pediatrics, Pediatric Gastroenterology and Oncology of Medical University of Gdansk. MATERIAL AND METHODS: studied children included 49 patients aged 2.2 - 17.3 years: group I children below and group II above 5 years of age. The patients were admitted for further diagnosis of unexplained clinical manifestations in outpatient care. Parasitosis was confirmed by immuno-enzymatic technique detecting protein GSA 65; only in one child parasites cysts were found by microscopic technique in faecal samples obtained from infected children. RESULTS: chronic abdominal pain was noted in 16 (72.7%) children in group I and in 22 (81.5%) patients in group II. Chronic diarrhea was observed in 20 (90.9%) children in group I and in 4 (14.8%) in group II. Ultrasound scans revealed mesenteric lymphadenopathy in 42 children (16 in group I and 26 in group II). CONCLUSIONS: chronic and recurrent abdominal pain was the main clinical complain and chronic diarrhea in children under 5 years of age. In few cases hepatobiliary involvement was observed, which might suggest a changing clinical course of giardiasis. Most of the children presented with mesenteric lymphadenopathy, which was confirmed by abdominal ultrasound scan. Thus, this method should be included in the diagnostic algorithm, if parasitosis is considered.

[Immune components of human milk]. / Skladniki mleka kobiecego wspomagajace uklad odpornosciowy dzieci karmionych piersia.

Many benefits of breast-feeding have been generally accepted. In the article the constituents of human milk supporting the immune system of breast fed babies are reviewed. The effect of maternal undernutrition on immunological properties of breast milk is also presented.

[Short bowel syndrome in children - own experience]. / Zespól krótkiego jelita u dzieci-obserwacje wlasne.

THE AIM: of this study was to analyze the clinical status of children with short bowel syndrome (SBS) shortly after the resection and during following years. MATERIAL AND METHODS: we reviewed retrospectively 5 children with SBS aged from 2 years and 7 months till 14 years and 5 months, who were on total parenteral nutrition due to intestinal resection. The resection was performed, when they were either newborns or infants. In the analysis we considered somatic development and laboratory tests results. In 4 cases the cause for extensive bowel resection were congenital anomalies of the intestine, in one case it was intestinal necrosis as result of invagination. RESULTS: in all children there was diarrhea, during postoperative period and when oral caloric intake was increased and when loss of weight was observed. Most common complications included hypochromic anaemia and cholestasis. Moreover, in 2 children with resection of distal region of the ileum and ascending colon, we observed vitamin B12 deficiency and recurrent lactic acidosis due to secondary biotin deficiency. Catheter complications were one of the main problems. 3 patients developed sepsis. Occlusion or mechanic damage of the catheter were also observed. Despite initial severe retardation in somatic development, final anthropometric evaluation in all children was found to be normal. CONCLUSIONS: 1. Congenital intestinal and mesenteric defects were the most common reasons for SBS in the youngest children. 2. Parenteral nutrition is the cardinal element in the management. It was crucial for survival and further normal somatic development, even in children after extensive intestinal resection. 3. Lactic acidosis due to biotin deficiency must be considered if acid-base balance restoration is complicated in children with SBS. 4 Children with SBS after resection need long-term and multi specialistic medical care.

[Etiology of community - acquired acute diarrhea in children]. / Etiologia ostrych biegunek pozaszpitalych u dzieci.

THE AIM: of the study was to analyse the etiology of home acute diarrhea in children. MATERIAL AND METHODS: 2636 children with community-acquired acute diarrhea were included in the study. Stool samples were analysed for the presence of Salmonella spp, Shigella spp, rotaviruses and adenoviruses. RESULTS: etiology of acute diarrhea was established in 1149 out of 2636 children (43.6%). Among the children with known etiology - rotaviral diarrhea was most frequently diagnosed (24.67%), whereas salmonellosis - in 7.06% of cases, EPEC C - 6.37%, EPEC B - 2.92%, EPEC A - 1.89%, adenoviral diarrhea in 0.68%. Mean age of children with bacterial acute diarrhea (Salmonella, EPEC A, B, C) was higher as compared to the mean age of children with rotaviral acute diarrhea (p < 0.002). Rotaviral acute diarrhea was more frequently diagnosed in girls (p < 0.025), whereas bacterial - in boys (p < 0.044). The highest prevalence of acute rotaviral diarrhea was found in winter/spring, with peak in April. CONCLUSIONS: commonly used diagnostic procedure does not allow to establish the etiology of acute home diarrhea in children in most cases. Rotavirus is found in the majority of diagnosed cases. It seems reasonable to expand the spectrum of diagnostic tests in cases of acute diarrhea in children.

The "sugar" clear cell tumor of the lung-clinical presentation and diagnostic difficulties of an unusual lung tumor in youth.

A case of the "sugar" clear cell tumor of the lung in a 16-year-old boy is presented. The course of the disease with general symptoms, never reported before, highlights diagnostic difficulties of an extremely rare lung tumor in youth. The boy presented with daily spikes of unexplained high fever of 6 weeks' duration with features of hypochromic microcytic anemia, elevated erythrocyte sedimentation rate, C-reactive protein, alpha(2)- and beta-globulins, and elevated platelet count. The lung tumor was a yellow, circumscribed mass confined to the sixth segment of the left lung. Histological examination revealed the tumor composed of cells with clear cytoplasm with large content of glycogen, with no signs of necrosis, and immunoreactive for HMB-45, but not for cytokeratin, LCA, CD34, and CD68. The performed thoracotomy and segmentectomy were both diagnostic and curative.

Lamivudine therapy for children with chronic hepatitis B.

AIM: To assess the effectiveness and side-effects of lamivudine therapy for children with chronic hepatitis B (CHB) who fail to respond to or have contraindications to interferon-alpha (IFN-alpha) therapy. METHODS: Fifty-nine children with CHB were treated with 100 mg lamivudine tablets given orally once daily for 12 mo. Alanine aminotransferase (ALT) activity was evaluated monthly during the therapy and every 3 mo after its discontinuation. HBe antigen, anti-HBe antibodies, HBV DNA level in serum were evaluated at baseline and every six months during and after the lamivudine therapy. Sustained viral response (SVR) to lamivudine therapy was defined as permanent (not shorter than 6 mo after the end of the therapy), namely ALT activity normalization, seroconversion of HBeAg to anti-HBe antibodies, and undetectable viral HBV-DNA in serum (lower than 200 copies per mL). The analysis of the side-effects of the lamivudine treatment was based upon interviews with the patients and their parents using a questionnaire concerning subjective and objective symptoms, clinical examinations, and laboratory tests performed during clinical visits monthly during the therapy, and every 3 mo after the therapy. RESULTS: ALT normalisation occurred in 47 (79.7%) patients between the first and 11(th) mo of treatment (mean 4.4+/-2.95 mo, median 4.0 mo), and in 18 (30.5%) of them after 2 mo of the therapy. There was no correlation between the time of ALT normalization and the children's age, the age of HBV infection, the duration of HBV infection, inflammation activity score (grading), staging, ALT activity before treatment, serum HBV DNA level, and lamivudine dose per kg of body weight. HBeAg/anti HBe seroconversion was achieved in 27.1% of cases. The higher rate of seroconversion was connected with lower serum HBV DNA level and longer duration of HBV infection. There was no connection between HBeAg/anti HBeAb seroconversion and the children's age, age of HBV infection, grading, staging, ALT activity before treatment, and lamivudnie dose per kg of body weight. No complaints or clinical symptoms were observed during lamivudine therapy. Impairment of renal function or myelotoxic effect was noted in none of the patients. CONCLUSION: One year lamivudine therapy for children with chronic hepatitis B is effective and well tolerated. Seroconversion of HBeAg/HBeAb and SVR are connected with lower pre-treatment serum HBV DNA level.

[Fimbriae as virulence factors of uropathogenic strains of Escherichia coli]. / Fimbrie jako czynniki zjadliwosci uropatogennych szczepów Escherichia coli.

In this paper uropathogenic Escherichia coli strains are characterized. In particular, fimbrie as virulence factors are presented and their role in the clinical course of urinary tract infection is assessed.

[Gastroesophageal reflux disease presenting as severe bronchial asthma in an 18 months old child]. / Choroba refluksowa przelyku przebigajaca pod maska astmy oskrzelowej o ciezkim przebiegu u 18-miesiecznego dziecka.

It is known that gastro-esophageal reflux can trigger bronchospasm among children with asthma and cystic fibrosis as well as in children without chronic respiratory tract disorders. In our practice we have met only once with the case of a child misdiagnosed as having severe asthma in whom surgical treatment of gastro-esophageal reflux disease ended with full withdrawal of respiratory symptoms. On the basis of this case we conclude that the diagnostic procedures should be performed in cases of asthma resistant to typical treatment.

[Therapeutic difficulties in a patient with ulcerative colitis and concomitant HBV and HCV infection]. / Trudnosci terapeutyczne u dziewczynki chorujacej na colitis ulcerosa zakazonej wirusami: HBV i HCV.

The aim of the paper was to describe therapeutic difficulties in a patient with ulcerative colitis. In the long-term clinical course of the disease a concomitant infection with hepatotropic viruses (HBV, HCV) was diagnosed. Due to the different treatment of autoimmunological diseases and chronic viral hepatitis the necessity of further search of therapeutic schedules for this group of patients is still needed.

[Autoimmunity in children with chronic hepatitis C treated with interferon alpha and ribavirin]. / Reakcje autoimmunologiczne u dzieci z przewleklym wirusowym zapaleniem watroby typu C leczonych interferonem alfa i ribawiryna.

The role of interferon alpha or the virus itself in the pathogenesis and the risk of autoimmunological disorders in patients infected with HCV, still remain unknown, especially in children. The aim of the study was to evaluate the incidence of autoantibodies and the risk of autoimmunological disorders in children with chronic hepatitis C, treated with interferon alpha and ribavirin in the Department of Paediatrics, Paediatric Gastroenterology and Oncology in Gdansk. In the studied group of 12 patients, in 4 cases autoantibodies were present in low titers prior to the treatment and they had no prognostic value for the response to the therapy or the risk of autoimmunological disorders. Positive response for the treatment was achieved in 4 cases; in 3 cases indications for discontinuation of the therapy were established. During the therapy with interferon alpha and ribavirin, in 2 children elevation of serum titers of antibodies to liver-kidney microsome type 1 (anti-LKM1) (> 1:640) with normal gammaglobulin levels was noted. In none of the children autoimmunological disorders were observed.

Serum interleukin 6 and interleukin 12 levels in children with chronic hepatitis HBV treated with interferon alpha.

INTRODUCTION: The course of HBV infection and the outcome of interferon alpha (IFNalpha) therapy of patients with chronic hepatitis B, is determined by the antiviral immune response of the host. The aim of the study was to investigate 1) the correlation between IL-6 and IL-12 serum levels and biochemical and histopathological changes in children with chronic hepatitis B, 2) predictive value of pre-treatment serum levels of these cytokines in patients treated with interferon alpha and 3) changes in serum levels of these cytokines after interferon alpha treatment. METHODS: Serum levels of IL-6, IL-12 (heterodimer p70) and IL-12 (heterodimer p70 & p40 subunit) were determined by specific ELISA in 39 children with chronic hepatitis B on the first and the last day of IFNalpha therapy. RESULTS: Serum levels of IL-6, IL-12 (p70) and IL-12 (p70&p40) were respectively within the following ranges of values: 0-1.7 pg/mL, 3.0-85.1pg/mL, 93.7-442.7 pg/mL and they showed no correlation with biochemical and histopathological changes. The pre-treatment cytokines levels in patients who responded and those who did not respond to IFNa therapy did not differ statistically. There was no statistical difference between the end and pre-treatment cytokines levels in both groups. CONCLUSIONS: Serum levels of IL-6 and IL-12 do not reflect the inflammatory activity of hepatitis and have no predictive value of positive response to the IFNalpha therapy in children with chronic hepatitis B. Serum IL-6 and IL-12 levels at the end of INFalpha treatment do not inform of their role in immunological changes which take place while inhibition of HBV replication or virus clearance.

Cytomegalovirus disease in neonates and infants--clinical presentation, diagnostic and therapeutic problems--own experience.

BACKGROUND: The aim of the study was to present diagnostic problems, different clinical presentations and results of treatment of cytomegalovirus infections in neonates and infants. MATERIAL/METHODS: The study was carried out in a group of 31 children from 10 days to 12 months of age (17 boys, 14 girls). The diagnosis was based on serological investigations (presence of specific IgM antibodies and/or increasing titer of IgG antibodies), presence of intermediate or early CMV antigen in peripheral blood leukocytes or positive blood or urine PCR results. The treatment of 25 cases involved intravenous administration of gancyclovir at 5-7 mg/kg daily doses for 14-21 days. In 1 case, hyperimmunized anti-CMV serum - Cytotect was used. RESULTS: The most common clinical symptoms were jaundice, hepato- and splenomegaly. Clinical investigations demonstrated increased aminotransferese activity and the signs of cholestasis. Other frequent findings included anemia, leukocytosis with atypical lymphocyte forms present, as well as thrombocytopenia. In majority treated patients, rapid regression of the clinical symptoms and normalization of transaminases activity was observed. Good outcome of the therapy was confirmed by immunological investigations. The effects of the terapy were similar irrespective of the dose and duration of gancyclovir treatment. The tolerance of the drug was good - no indications for discontinuation of the treatment were observed in any of the patients. CONCLUSIONS: The clinical presentations of cytomegalovirus disease in infants are varied, the diagnosis of the disease should be considered in children with persistent jaundice, especially if it is accompanied by hepatomegaly and increased aminotransferase activity or signs of cholestasis. Despite relatively good tolerance of the drug by children, the patients should be monitored for possible side effects, especially myelo- and nephrotoxic.