Bradicardia sinusal inducida por corticoesteroides en un niño con insuficiencia suprarrenal y septicemia / Corticosteroid-induced sinus bradycardia in a young boy with adrenal insufficiency and sepsis

La bibliografía no incluye frecuentemente alteraciones en el ritmo cardíaco de los pacientes que reciben corticoesteroides; se desconoce su mecanismo exacto. En este artículo, presentamos el caso de un paciente con bradicardia sinusal asociada con una dosis de estrés de corticoesteroides. Se ingresó a un niño de 9 años con antecedentes de panhipopituitarismo con gastroenteritis y neumonía y presentó choque septicémico el día de la hospitalización. El tratamiento con líquidos intravenosos, dosis de estrés de hidrocortisona y antibióticos permitió la recuperación. Sin embargo, luego se documentó bradicardia sinusal con una frecuencia cardíaca de 45 latidos por minuto. Esta se resolvió después de reducir gradualmente la hidrocortisona. La bradicardia sinusal inducida por corticoesteroides es un efecto adverso que suele resolverse tras interrumpir el tratamiento. Se debe considerar el monitoreo hemodinámico en estos casos. Este es el primer informe de bradicardia sinusal posterior al uso de hidrocortisona en niños con insuficiencia suprarrenal

The literature does not commonly describe cardiac rhythm disturbances, including bradycardia, in patients who are receiving corticosteroids, and the exact mechanism of such disturbances remains unknown. Herein, we present a case of sinus bradycardia associated with stress-dose corticosteroid therapy. A nine-year-old boy with a history of panhypopituitarism was admitted with gastroenteritis and pneumonia and developed septic shock on the day of admission. Management using intravenous fluids, stress doses of hydrocortisone, and antibiotics resulted in full recovery. However, within 24 hours following treatment, sinus bradycardia was documented, with a heart rate of 45 beats per minute (BPM). The bradycardia resolved after the dose of hydrocortisone was decreased gradually. Corticosteroidinduced sinus bradycardia is an adverse effect that usually resolves after corticosteroid treatment is discontinued. During stress-dose corticosteroid therapy, hemodynamic monitoring should be considered. To our knowledge, this is the first report of sinus bradycardia following the use of hydrocortisone in children who have adrenal insufficiency.

Fetal cardiac Doppler changes in gestational diabetic pregnancies and its relationship with perinatal outcomes.

AIM: To examine the structural and functional changes of the fetal heart in gestational diabetes mellitus (GDM) and to evaluate the power of fetal cardiac Doppler parameters in predicting adverse perinatal outcomes in this group of pregnancy. METHODS: Within the study's scope, 36 cases in the A1 GDM group, 33 cases in the A2 GDM group, and 124 cases in the control group were evaluated. The relationship between structural and functional fetal cardiac parameters and perinatal outcomes was evaluated via fetal echocardiography. RESULTS: Fetal left ventricular myocardial performance index (MPI) values were found to be statistically significantly higher when compared between the A1 GDM and A2 GDM groups and the control group (p = 0.000 and p = 0.000, respectively), while the E/A ratio was found to be significantly lower (p = 0.000 and p = 0.000, respectively). It was determined that the maternal blood HbA1c level showed a significant negative correlation with the fetal cardiac E/A ratio and a significant positive correlation with isovolumetric relaxation time and MPI (p = 0.000, p = 0.000, and p = 0.000, respectively). Adverse perinatal outcome rate was higher in the diabetic group (46.4%-22.6%). When the cases with GDM were examined in terms of perinatal outcomes, it was observed that there was a significant difference in HbA1c levels, E/A ratio, and MPI values between the cases in the group with adverse perinatal outcomes and the group with normal results (p = 0.001, p = 0.000, and p = 0.000, respectively). CONCLUSIONS: The strong relationship between abnormal cardiac function and adverse perinatal outcomes suggest that cardiac Doppler may be a valuable tool for fetal monitoring and management for the GDM patient group.

Corticosteroid-induced sinus bradycardia in a young boy with adrenal insufficiency and sepsis. / Bradicardia sinusal inducida por corticoesteroides en un niño con insuficiencia suprarrenal y septicemia.

The literature does not commonly describe cardiac rhythm disturbances, including bradycardia, in patients who are receiving corticosteroids, and the exact mechanism of such disturbances remains unknown. Herein, we present a case of sinus bradycardia associated with stress-dose corticosteroid therapy. A nine-year-old boy with a history of panhypopituitarism was admitted with gastroenteritis and pneumonia and developed septic shock on the day of admission. Management using intravenous fluids, stress doses of hydrocortisone, and antibiotics resulted in full recovery. However, within 24 hours following treatment, sinus bradycardia was documented, with a heart rate of 45 beats per minute (BPM). The bradycardia resolved after the dose of hydrocortisone was decreased gradually. Corticosteroidinduced sinus bradycardia is an adverse effect that usually resolves after corticosteroid treatment is discontinued. During stress-dose corticosteroid therapy, hemodynamic monitoring should be considered. To our knowledge, this is the first report of sinus bradycardia following the use of hydrocortisone in children who have adrenal insufficiency.

La bibliografía no incluye frecuentemente alteraciones en el ritmo cardíaco de los pacientes que reciben corticoesteroides; se desconoce su mecanismo exacto. En este artículo, presentamos el caso de un paciente con bradicardia sinusal asociada con una dosis de estrés de corticoesteroides. Se ingresó a un niño de 9 años con antecedentes de panhipopituitarismo con gastroenteritis y neumonía y presentó choque septicémico el día de la hospitalización. El tratamiento con líquidos intravenosos, dosis de estrés de hidrocortisona y antibióticos permitió la recuperación. Sin embargo, luego se documentó bradicardia sinusal con una frecuencia cardíaca de 45 latidos por minuto. Esta se resolvió después de reducir gradualmente la hidrocortisona. La bradicardia sinusal inducida por corticoesteroides es un efecto adverso que suele resolverse tras interrumpir el tratamiento. Se debe considerar el monitoreo hemodinámico en estos casos. Este es el primer informe de bradicardia sinusal posterior al uso de hidrocortisona en niños con insuficiencia suprarrenal.

Amitriptyline Intoxication in Children: Twenty Years' Experience in a Tertiary Care Center in Turkey.

BACKGROUND: Amitriptyline ingestion is an important cause of poisoning morbidity and mortality in Turkey and other countries. In contrast to adults, data concerning amitriptyline intoxication in children are limited. The purpose of this study was to investigate amitriptyline intoxication findings in the pediatric population, based on age groups and reported dosages. METHODS: The medical records of 192 patients admitted to the Karadeniz Technical University Medical Faculty Farabi Hospital Pediatric Emergency Department, Turkey, due to amitriptyline intoxication in 1997-2017 were examined retrospectively. Patients were divided into 6 groups based on amitriptyline doses and 4 groups based on age. Complete blood count, blood glucose, serum electrolytes, renal and liver function tests, coagulation tests (prothrombin time and partial thromboplastin time), and blood gas analysis were studied in all patients. Electrocardiography was performed on all children, and chest radiography and electroencephalography on those with respiratory or central nervous system symptoms. RESULTS: Amitriptyline intoxication was most frequently observed between the ages of 1 and 4 years. The most common signs and symptoms observed at time of hospital admission were lethargy and drowsiness (45.3%), sinus tachycardia (19.2%), and nausea and vomiting (13%). The most common laboratory finding was hyperglycemia (17.7). Six patients were intubated because of respiratory failure, and mechanical ventilation was initiated in these cases. One patient with amitriptyline overdose had persistent supraventricular tachycardia. Four children died due to amitriptyline intoxication. CONCLUSIONS: Tricyclic antidepressant intoxication is a leading cause of mortality and morbidity in children. It is therefore particularly important to identify the clinical and laboratory findings that develop with high-dose consumption.

A case of Kawasaki disease presenting with atypical cutaneous involvement and mimicking Stevens-Johnson syndrome.

Kawasaki disease is the second most common cause of childhood vasculitis. Cutaneous manifestation, which is the diagnostic criteria of Kawasaki disease, may show atypical course and causes conflict in diagnosis for physicians. A 14-month-old girl treated with intravenous immunoglobulin after diagnosed with KD. Target lesions and a vesicular rash developed on the whole body during the course of the disease. Methylprednisolone was added to the treatment. All atypical skin lesions and disease findings were improved using IVIG and subsequent methylprednisolone therapy. Cutaneous signs of KD may show atypical course. Thus, it may lead to confusion in diagnosis with Stevens-Johnson syndrome.

Clinical signs and symptoms of toxic serum digoxin levels in neonates.

Mutlu M, Aslan Y, Kader S, Aktürk-Acar F, Dilber E. Clinical signs and symptoms of toxic serum digoxin levels in neonates. Turk J Pediatr 2019; 61: 244-249. Digoxin is widely used in the treatment of congestive heart failure and some arrhythmias. Digoxin toxicity may occur easily because digoxin has a narrow therapeutic index. This retrospective study was conducted to evaluate the clinical signs and symptoms of toxic serum digoxin levels in neonates. Medical reports of the neonates who had serum digoxin concentrations > 2 nanogram/milliliter (ng/ml) were reviewed in terms of patient demographics, serum digoxin concentrations, signs and symptoms of digoxin toxicity, serum digoxin and electrolyte levels, renal function tests, electrocardiograms, echocardiography, and treatments applied. Digoxin toxic levels were identified in the 13 neonates. Of the 13 neonates with digoxin toxic level, 9 (69%) were term and 8 (62%) were female. Twenty-three percent (3/13) of newborn infants were symptomatic. Symptomatic patients had statistically significantly higher serum digoxin levels, at 7.76±2.76 (5.4-10.8) ng/ml, than asymptomatic patients, at 3.31±1.09 (2.02-4.95) (p=0.036). Symptoms related to toxic digoxin levels were observed in the three neonates with plasma digoxin levels > 5 ng/ml. Gastrointestinal and central nervous system symptoms were the major clinic findings. Despite high digoxin levels, no digoxin-related arrhythmia was observed on electrocardiography, other than sinus bradycardia. Two premature neonates were treated with digoxin-specific antibody Fab fragments (DigiFab®) and hypokalemia developed in both of them. Our data suggests that symptoms related with digoxin toxic levels were observed in neonates with plasma digoxin levels > 5 ng/ml. Serum digoxin levels should be measured in case of signs and symptoms of digoxin toxicity or risk factors for such toxicity.

Effects of chronic amiodarone treatment on rat testis.

Amiodarone is a potent agent used to treat tachyarrhythmias, which are especially refractory to other medications, in both adults and children. Although widely used as an antiarrhythmic drug, amiodarone causes many serious adverse effects that limit its use. This study investigated the possible morphological and apoptotic effects of amiodarone on rat testes. Amiodarone was administered to male Sprague-Dawley rats at doses of 20 or 200mg/kg/day for 14 days. A histopathological examination of testicular tissue revealed the presence of inflammatory cells in the seminiferous tubule lumen together with swelling and vacuolization in the cytoplasm of some spermatogonia; these effects occured in a dose-dependent manner. Immunohistochemical staining showed evidence of apoptosis, including caspase-3, caspase-9, Bax and increased DNA fragmentation was detected via a terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. In conclusion, the results show that chronic amiodarone treatment causes dose-dependent degenerative and apoptotic effects on rat testes.

Pyloric atresia-junctional epidermolysis bullosa syndrome showing novel c.4505-4508insACTC mutations in integrin b4 gene (ITGB4).

Epidermolysis bullosa (EB) is a group of inherited blistering skin diseases that vary widely in their pathogenesis and severity. It has been divided into distinct subtypes depending on the level of tissue separation in the dermal- epidermal basement membrane zone. There are four main categories of EB: simplex, junctional, dystrophic and Kindler syndrome. Junctional epidermolysis bullosa with pyloric atresia (JEB-PA) is a rare autosomal recessive form and characterized by severe mucocutaneous blisters and gastric outlet obstruction. Most of the mutations in JEP-PA are associated with the α6ß4 integrin genes (ITGA6, ITGB4,). Herein, we present a female newborn with lethal JEB-PA caused by a novel beta4 integrin mutation.

Charcoal hemoperfusion in an infant with supraventricular tachycardia and seizures secondary to amitriptyline intoxication.

Tricyclic antidepressant (TCA) overdose is one of the common causes of drug poisoning and it has cardiovascular, respiratory and neurological side effects. An 18-month male infant was admitted to our pediatric emergency service due to poisoning with amitriptyline. The infant was unconscious. Tachycardia, irregular and shallow breathing, and tonic-clonic seizures were observed on physical examination. An electrocardiogram displayed a narrow complex tachycardia that was consistent with re-entrant supraventricular tachycardia (SVT). Although antiarrhythmic and anticonvulsive agents were administrated, SVT and seizures persisted. Charcoal hemoperfusion (HP) was performed for 4 hours. The infant's clinical condition has improved after the charcoal HP, seizures and SVT were not observed. It is concluded that charcoal HP can be used efficiently in patients with severe amitriptyline intoxication.

A Turner syndrome case associated with anal atresia, interrupted aortic arch and multicystic dysplastic kidney.

Although renal and cardiac malformations are commonly seen in Turner syndrome (TS), anorectal malformations, multicystic dysplastic kidney and interrupted aortic arch are quite rare in TS. A newborn with TS with three quite rare congenital malformations (imperforate anus/anal atresia associated with rectovestibular fistula, interrupted aortic arch, and multicystic dysplastic kidney) is presented.

High-dose methylprednisolone in children with Crimean-Congo haemorrhagic fever.

Treatment options for Crimean-Congo haemorrhagic fever (CCHF) are limited and based on general supportive managements. Thrombocytopenia is the major risk factor of CCHF. We report our experience with high-dose methylprednisolone (HDMP). This study included five patients with CCHF. Patients were given HDMP if there were findings compatible with virus-associated haemophagocytic syndrome and the effects of HDMP were evaluated. Following this, HDMP fever subsided and platelet counts increased within 24 hours. Leukocyte counts began to increase and visceral bleedings were improved. HDMP treatment was discontinued within approximately five days. After HDMP, only one patient required blood products. HDMP is effective in CCHF, especially on fever and platelet counts. Dependency on blood products was decreased. Further controlled randomized studies with large series are needed in order to analyse the timing and duration of HDMP treatment and its effect on outcome.

Intravenous amiodarone used alone or in combination with digoxin for life-threatening supraventricular tachyarrhythmia in neonates and small infants.

OBJECTIVES: The purpose of this study was to report the efficacy of intravenous amiodarone alone or in combination with digoxin in neonates and small infants with life-threatening supraventricular tachyarrhythmia (SVT). METHODS: We retrospectively analyzed 9 neonates and small infants with life-threatening or resistant SVT who were treated with intravenous amiodarone alone or in combination with digoxin. RESULTS: This report consists of 8 patients with reentrant SVT and 1 with atrial flutter. On admission, 7 patients had a congestive heart failure and 3 of whom had cardiovascular collapse. Intravenous rapid bolus of adenosine caused a sustained sinus rhythm in 4 patients. These patients were given digoxin initially, but recurrence of persistent tachyarrhythmia necessitated the use of intravenous amiodarone in all these patients. Amiodarone was given initially to the other 4 patients in whom adenosine caused only temporary conversion to the sinus rhythm. It was effective in 2 patients. In the other 2, digoxin was added to therapy for tachycardia control. Amiodarone alone or in combination with digoxin effectively controlled reentrant SVT in all patients. This combined treatment caused ventricular rate control in patient with atrial flutter, and conversion to the stable sinus rhythm was achieved at approximately 8 months. CONCLUSIONS: Intravenous amiodarone alone or in combination with digoxin was found to be safe and effective in controlling refractory and life-threatening SVT in neonates and small infants.

Lead extraction in children and young adults using different techniques.

OBJECTIVE: To describe our experience with removal of pacing lead in children using different techniques. PATIENTS AND METHODS: Between 1999 and 2006, removal of 39 leads was attempted in 30 patients: 21 males and 9 females aged 4-21 years (mean 12 +/- 5 years). Sixteen patients had previous corrective cardiac surgery. The leads had been implanted for 46 +/- 31 months (range 1-120 months). The reasons for removal included lead fracture in 14, upgrading in 8, infection in 7, dislodgment in 5, pacing system not needed in 2, and other reasons in 3. RESULTS: Of the 39 leads, 29 (74.3%) were completely removed. Twelve leads were removed with simple traction and rotation and 9 were removed using a locking stylet combined with simple traction and rotation; a laser extraction system was used in 10 cases in which 8 leads were successfully removed. Duration of implantation was the only important predictor for successful removal. Three patients necessitated surgical lead removal and had epicardial pacemaker implantation. CONCLUSION: Using currently available techniques, percutaneous pacemaker lead removal was possible in the majority of cases, although a significant number of cases were not successful. Attempted lead removal with simple traction and rotation resulted in the need for surgical removal in a significant number of patients. Newer techniques should be developed to increase the success rate.

Septated pericarditis associated with Kawasaki disease: a brief case report.

Kawasaki disease (KD) is primarily the systemic vasculitis of childhood that affects mainly the medium-sized arteries, such as the coronary arteries. KD is the leading cause of acquired heart disease, whereas the incidence of rheumatic fever has declined. The most serious complication is coronary artery involvement. Among the children with KD who developed cardiac complications, pericarditis is a rare complication, with an incidence of 0.07%. We report our experience in a 5.5-year-old child with KD complicated with aneurysm of the left anterior descendant coronary artery and septated pericardial effusion, which has not been reported in the literature. The pericardial effusion disappeared very dramatically with intravenous immunoglobulin (IVIG) therapy. We would like to point out that septated pericardial effusion in cases of KD do not need any further therapy other than IVIG and high-dose acetylsalicylic acid.

Environmental tobacco smoke exposure and respiratory morbidity in children.

Environmental tobacco smoke (ETS) contains carcinogenic and toxic agents. Smoking might have a more serious effect on children than adults. We aimed to examine the effects of passive smoking on pulmonary function and respiratory health in children and to assess the concordance between parental self-reported smoking habits and urinary cotinine levels in their children. This cross-sectional study was conducted in the winter with the participation of 131 children (9-12 yr old). The procedure for each subject consisted of administration of a questionnaire to the parents, and collection of a urine sample and measurement of lung function in each child. Cotinine level excreted into urine was analyzed with respect to parental self-reported smoking behavior. Working mothers and mothers with higher level of education tended to smoke more at home (p values, respectively, .002 and .005). There was a statistical difference between the urinary cotinine levels of children when divided into two groups according to their fathers' smoking behavior at home (p = .0001). No statistically significant difference was determined in the mean episodes of respiratory infections treated during the last 12 mo among the groups formed according to daily number of cigarettes smoked by the parents at home (1: not exposed; 2: < 5 cigarettes; 3: 5-10 cigarettes; 4: > 10 cigarettes), or among the groups formed according to urinary cotinine levels (1: < 10 ng/ml; 2: > or =10 ng/ml). No significant difference was demonstrated in any of the respiratory function parameters investigated between the groups considered. The reliability of the declarations of the parents in the estimation of ETS exposure of children was low. Children are unable to remove themselves from ETS exposure. It is better to reduce the percentage of parents who smoke rather than to isolate smokers or increase ventilation.

Rhythm abnormalities in children with isolated ventricular noncompaction.

BACKGROUND: Isolated ventricular noncompaction (IVNC) is a serious cardiomyopathy with a generally poor prognosis. It is characterized by the presence of prominent ventricular myocardial trabeculations and deep intertrabecular recesses, in the absence of other structural heart defects. This cardiomyopathy is usually associated with ventricular dysfunction, thromboembolic events, and rhythm problems. METHODS AND RESULTS: This article describes 11 children who have rhythm abnormalities associated with IVNC. On admission, eight children had complaints including palpitation, syncope, heart failure, and bradycardia. Ventricular arrhythmias were diagnosed in four children, sinus node and atrioventricular conductance disturbances in six children, and Wolff-Parkinson-White syndrome and associated tachycardia in one child. Three children with ventricular arrhythmias received an automatic implantable cardioverter defibrillator (ICD). Three patients died of cardiac problems during the follow-up period. CONCLUSION: Since many of rhythm abnormalities, including life-threatening ventricular arrhythmias, may be seen in patients with IVNC, children with IVNC should be screened for arrhythmias. An ICD may be the best treatment for some of these patients.

Transcatheter closure of patent ductus arteriosus with Nit-Occlud coils.

The detachable coils have been successfully used for transcatheter occlusion of small- to moderate-sized patent ductus arteriosus (PDA). We report our experience regarding the use of the Nit-Occlud coils (NOCs) for transcatheter PDA and major aortopulmonary collateral (MAPCA) occlusion. Single NOCs were used to close PDA in 26 patients, and one small and two large MAPCAs in two patients. Mean age and weight of the patients were 7.7 +/- 5.4 years and 20.6 +/- 11.6 kg. Mean minimum duct diameter was 2.8 +/- 0.8 mm; ampulla, 8.7 +/- 2.4 mm; and PDA length, 9.3 +/- 4.4 mm. Mean pulmonary artery pressure ranged from 9 to 51 mm Hg and pulmonary/systemic flow ratio from 1.1 to 5.8. Ductal shape was conical in 24 patients. Route of approach was venous in 23 and arterial in 3. Successful coil implantation was achieved in 24/26 (92.3%). Mean procedure and fluoroscopy time were 67.2 +/- 22.1 and 14.9 +/- 6.5 min. The three MAPCAs were also successfully occluded using NOC Medium and Flex. Postimplantation angiograms revealed no leak in 3, a trace or small leak in 17, and a medium leak in 4 patients. Mean follow-up was 7 +/- 5 months. Complete occlusion was achieved in 17/24 (71%) at 24 hr, 19/24 (79%) by 1 month, 13/15 (87%) by 3 months, 14/15 (93%) by 6 months, and 10/11 (90%) by 12 months postprocedure. Hemolysis, late embolization, duct recanalization, and flow disturbances were not observed. Transcatheter occlusion of moderate-sized PDAs and MAPCAs using NOCs seems to offer a safe, simple, and controlled method in pediatric patients.

Association of prothrombin gene mutation with sepsis in a preterm with multiple intracardiac thrombi.

We report for the first time, a premature infant with multiple intracardiac thrombi and sepsis, who was heterozygous for the G20210A prothrombin gene variant. Anticoagulant treatment with low molecular weight heparin resulted in the complete disappearance of the thrombi. It may be suggested that prothrombin gene variant associated with sepsis, respiratory distress syndrome, and perinatal asphyxia, as well as other thrombophilic disorders, could be a risk factor for the development of neonatal thrombus.