Mortality risk factors among critically ill children with MIS-C in PICUs: a multicenter study.

BACKGROUND: This study evaluated of clinical characteristics, outcomes, and mortality risk factors of a severe multisystem inflammatory syndrome in children admitted to a the pediatric intensive care unit. METHODS: A retrospective multicenter cohort study was conducted between March 2020 and April 2021 at 41 PICUs in Turkey. The study population comprised 322 children diagnosed with multisystem inflammatory syndrome. RESULTS: The organ systems most commonly involved were the cardiovascular and hematological systems. Intravenous immunoglobulin was used in 294 (91.3%) patients and corticosteroids in 266 (82.6%). Seventy-five (23.3%) children received therapeutic plasma exchange treatment. Patients with a longer duration of the PICU stay had more frequent respiratory, hematological, or renal involvement, and also had higher D-dimer, CK-MB, and procalcitonin levels. A total of 16 patients died, with mortality higher in patients with renal, respiratory, or neurological involvement, with severe cardiac impairment or shock. The non-surviving group also had higher leukocyte counts, lactate and ferritin levels, and a need for mechanical ventilation. CONCLUSIONS: In cases of MIS-C, high levels of D-dimer and CK-MB are associated with a longer duration of PICU stay. Non-survival correlates with elevated leukocyte counts and lactate and ferritin levels. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality. IMPACT: MIS-C is a life-threatening condition. Patients need to be followed up in the intensive care unit. Early detection of factors associated with mortality can improve outcomes. Determining the factors associated with mortality and length of stay will help clinicians in patient management. High D-dimer and CK-MB levels were associated with longer PICU stay, and higher leukocyte counts, ferritin and lactate levels, and mechanical ventilation were associated with mortality in MIS-C patients. We were unable to show any positive effect of therapeutic plasma exchange therapy on mortality.

Epidemiology of pediatric severe sepsis and septic shock in Turkey: Prevalence, Results and Treatments Study.

AIM: This study was aimed at characterizing the prevalence, management, and outcomes of pediatric severe sepsis and septic shock in tertiary pediatric intensive care units (PICUs) in Turkey. METHODS: A point prevalence study was conducted on five days over the course of one year in 29 PICUs in Turkey. Outcomes included severe sepsis and septic shock point prevalence, therapies used, duration of PICU stay, and mortality at day 28. RESULTS: Of the 1757 children who were admitted to the PICU during the study period, 141 (8.0%) children met the consensus criteria for severe sepsis and 23 (1.3%) children met the criteria for septic shock. Pediatric severe sepsis and septic shock accounted for 8% and 1.3% of all PICU admissions, respectively. The median age of the patients was 2.6 years (interquartile range (IQR), 0.7-8.6 years). Enteral nutrition (79.3%) was preferred compared to parenteral nutrition (31.1%) for the first 3 days after PICU admission. A total of 39 patients died while in the PICU, for a 23.8% mortality rate, which did not vary by age. CONCLUSION: The mortality rate was similar to that in other studies. Hematologic-immunologic comorbidity, parenteral nutrition and the use of vasoactive drugs were independently associated with mortality.

Daily Practice of Mechanical Ventilation and Weaning in Turkish PICUs: A Multicenter Prospective Survey.

OBJECTIVES: To investigate conventional mechanical ventilation weaning characteristics of patients requiring conventional mechanical ventilation support for greater than 48 hours within the PICU. DESIGN: The prospective observational multicenter cohort study was conducted at 15 hospitals. Data were being collected from November 2013 to June 2014, with two designated researchers from each center responsible for follow-up and data entry. SETTING: Fifteen tertiary PICUs in Turkey. PATIENTS: Patients between 1 month and 18 years old requiring conventional mechanical ventilation for greater than 48 hours were included. A single-center was not permitted to surpass 20% of the total sample size. Patients with no plans for conventional mechanical ventilation weaning were excluded. INTERVENTIONS: Conventional mechanical ventilation MEASUREMENTS AND MAIN RESULTS:: Pertinent variables included PICU and patient demographics, including clinical data, chronic diseases, comorbid conditions, and reasons for intubation. Conventional mechanical ventilation mode and weaning data were characterized by daily ventilator parameters and blood gases. Patients were monitored until hospital discharge. Of the 410 recruited patients, 320 were included for analyses. A diagnosis of sepsis requiring intubation and high initial peak inspiratory pressures correlated with a longer weaning period (mean, 3.65 vs 1.05-2.17 d; p < 0.001). Conversely, age, admission Pediatric Risk of Mortality III scores, days of conventional mechanical ventilation before weaning, ventilator mode, and chronic disease were not related to weaning duration. CONCLUSIONS: Pediatric patients requiring conventional mechanical ventilation with a diagnosis of sepsis and high initial peak inspiratory pressures may require longer conventional mechanical ventilation weaning prior to extubation. Causative factors and optimal weaning for this cohort needs further consideration.

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey.

OBJECTIVES: To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey. MATERIALS AND METHODS: It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions. RESULTS: Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO2 ≥60 mm Hg. CONCLUSION: Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them. HOW TO CITE THIS ARTICLE: Kockuzu E, Bayrakci B, Kesici S, Citak A, Karapinar K, Emeksiz S, et al. Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs During the Winter Season in Turkey. Indian J Crit Care Med 2019;23(6):263-269.

Continuous Venovenous Hemodiafiltration in the Treatment of Maple Syrup Urine Disease.

BACKGROUND: The study aims to define the efficacy of continuous renal replacement therapy in acute metabolic decompensation treatment of maple syrup urine disease (MSUD). METHODS: All the neonates, infants and children who have had life threatening conditions due to MSUD and were treated with continuous venovenous hemodiafiltration (CVVHDF) were analyzed retrospectively. RESULTS: Fourteen patients underwent 15 sessions of CVVHDF (age range 15 days to 87 months, mean 40.8 ± 31.4 months). One patient required additional CVVHDF 1 week after cessation of CVVHDF. Twenty seven percent (n = 4) of the patients were intubated and mechanically ventilated. Twelve patients responded to treatment and dramatic neurological improvement was observed within 24 h. Two of the 14 patients required 36 h of CVVHDF for neurological improvement. The mean duration of CVVHDF was 20.2 ± 8.6 (9-36) h. The mean leucine level was 1,648 ± 623.8 (714-2,768) µmol/l before and was 256.5 ± 150.6 (117-646) µmol/l at the end of treatment. No mortality was observed. CONCLUSION: Continuous hemodiafiltration is an effective and safe method in correcting metabolic disturbances in MSUD.

Atypical presentation of human bocavirus: Severe respiratory tract infection complicated with encephalopathy.

Human bocavirus (HBOV) has been reported as a worldwide distributed respiratory pathogen. It has also been associated with encephalitis recently by detection of the virus in cerebrospinal fluid (CSF) of patients presented with encephalitis. This retrospective study aimed to present clinical features of HBOV infections in children with respiratory symptoms and describe unexplained encephalopathy in a subgroup of these patients. Results of 1,143 pediatric nasal samples from mid-December 2013 to July 2014 were reviewed for detection of HBOV. A multiplex real time polymerase chain reaction assay was used for viral detection. Medical records of the patients were retrospectively analyzed. HBOV was detected in 30 patients (2.6%). Median age was 14 months (5-80). Clinical diagnoses were upper respiratory tract infection (n = 10), bronchopneumonia (n = 9), acute bronchiolitis (n = 5), pneumonia (n = 4), acute bronchitis (n = 1), and asthma execarbation (n = 1). Hospitalization was required in 16 (53.3%) patients and 10 (62.5%) of them admitted to pediatric intensive care unit (PICU). Noninvasive mechanical ventilation modalities was applied to four patients and mechanical ventilation to four patients. Intractable seizures developed in four patients while mechanically ventilated on the 2nd-3rd days of PICU admission. No specific reason for encephalopathy was found after a thorough investigation. No mortality was observed, but two patients were discharged with neurological sequela. HBOV may lead to respiratory infections in a wide spectrum of severity. This report indicates its potential to cause severe respiratory infections requiring PICU admission and highlights possible clinical association of HBOV and encephalopathy, which developed during severe respiratory infection.

Rapid genome sequencing for critically ill infants: an inaugural pilot study from Turkey.

Introduction: Rare and ultra-rare genetic conditions significantly contribute to infant morbidity and mortality, often presenting with atypical features and genetic heterogeneity that complicate management. Rapid genome sequencing (RGS) offers a timely and cost-effective approach to diagnosis, aiding in early clinical management and reducing unnecessary interventions. This pilot study represents the inaugural use of next-generation sequencing (NGS) as a diagnostic instrument for critically ill neonatal and pediatric ICU patients in a Turkish hospital setting. Methods: Ten infants were enrolled based on predefined inclusion criteria, and trio RGS was performed. The mean age of the participants was 124 days, with congenital abnormalities being the most common indication for testing. Three patients had consanguineous parents. The mean turnaround time from enrollment to delivery of results was 169 h, with a diagnostic yield of 50%. Results: Three patients received a definitive molecular diagnosis, impacting their clinical management. Two patients benefited from the exclusion of Mendelian conditions, leading to alternative diagnoses. Discussion: This study demonstrates the feasibility and results of RGS in Turkish hospital settings, emphasizing the importance of timely genetic diagnosis in reducing the diagnostic odyssey for families and improving patient care. Further research is needed to evaluate the cost-effectiveness and applicability of RGS in the Turkish healthcare system for children with diseases of uncertain etiology.

Increased Severe Cases and New-Onset Type 1 Diabetes Among Children Presenting With Diabetic Ketoacidosis During First Year of COVID-19 Pandemic in Turkey.

Introduction: There have been some significant changes regarding healthcare utilization during the COVID-19 pandemic. Majority of the reports about the impact of the COVID-19 pandemic on diabetes care are from the first wave of the pandemic. We aim to evaluate the potential effects of the COVID-19 pandemic on the severity of diabetic ketoacidosis (DKA) and new onset Type 1 diabetes presenting with DKA, and also evaluate children with DKA and acute COVID-19 infection. Methods: This is a retrospective multi-center study among 997 children and adolescents with type 1 diabetes who were admitted with DKA to 27 pediatric intensive care units in Turkey between the first year of pandemic and pre-pandemic year. Results: The percentage of children with new-onset Type 1 diabetes presenting with DKA was higher during the COVID-19 pandemic (p < 0.0001). The incidence of severe DKA was also higher during the COVID-19 pandemic (p < 0.0001) and also higher among children with new onset Type 1 diabetes (p < 0.0001). HbA1c levels, duration of insulin infusion, and length of PICU stay were significantly higher/longer during the pandemic period. Eleven patients tested positive for SARS-CoV-2, eight were positive for new onset Type 1 diabetes, and nine tested positive for severe DKA at admission. Discussion: The frequency of new onset of Type 1 diabetes and severe cases among children with DKA during the first year of the COVID-19 pandemic. Furthermore, the cause of the increased severe presentation might be related to restrictions related to the pandemic; however, need to evaluate the potential effects of SARS-CoV-2 on the increased percentage of new onset Type 1 diabetes.

Regional citrate versus systemic heparin anticoagulation for continuous renal replacement therapy in critically ill children.

OBJECTIVES: Anticoagulation is used to prevent filter clotting in patients undergoing continuous renal replacement therapy. Regional citrate anticoagulation is associated with lower rates of bleeding complications and prolongs the filter life span; however, a number of metabolic side effects had been associated with this therapy. The aim of this study was to evaluate the effect and safety of citrate versus heparin anticoagulation for continuous renal replacement therapy in critically ill children. METHODS: A retrospective comparative cohort study. Department of Pediatric Intensive Care, Acibadem Mehmet Ali Aydinlar University School of Medicine. RESULTS: From August 2016 to August 2018, 45 patients (19 in the citrate group and 26 in the heparin group) were included. A total of 101 hemofilters were used in all therapies: 44 in the citrate group (total continuous renal replacement therapy time: 2699 h) and 57 in the heparin group (total continuous renal replacement therapy time: 2383 h). The median circuit lifetime was significantly longer for regional citrate anticoagulation (53.0; interquartile range, 40-70 h) than for heparin anticoagulation (40.25; interquartile range, 22.75-53.5 h; p = 0.025). Mortality rates were similar in both groups (31.58% vs 30.77%). The most common indication for dialysis was hypervolemia in both groups. Transfusion rates were 1.65 units (interquartile range, 0.5-2.38) with heparin and 0.8 units (interquartile range, 0.3-2.0) with citrate (p = 0.32). Clotting-related hemofilter failure occurred in 11.36% of filters in the citrate group compared with 26.31% of filters in the heparin group. CONCLUSION: Our study showed that citrate is superior in terms of safety and efficacy, with longer filter life span. Regional citrate should be considered as a better anticoagulation method than heparin for continuous renal replacement therapy in critically ill children.

The clinical characteristics and prognosis of pertussis among unvaccinated infants in the pediatric intensive care unit.

AIM: To evaluate the clinical characteristics, risk factors, and prognosis of pertussis in the pediatric intensive care unit. MATERIAL AND METHODS: Patients who were hospitalized in pediatric intensive care unit between January 2017 and January 2019 and diagnosed as having pertussis were retrospectively evaluated. Samples were taken from tracheal aspirate material in intubated patients and nasopharyngeal swabs in the other patients. Samples for Bordetella pertussis were studied using multiplex real-time polymerase chain reaction. RESULTS: Eighteen patients were admitted to our pediatric intensive care unit with a diagnosis of pertussis. Ten patients were female (55.5%), and all patients were unvaccinated. The median age was 40 (range, 38-47.5) days and the median intensive care unit stay was 9 (range, 5-14) days. All patients had respiratory distress, 14 patients had cough (77.7%), four patients had fever (22.2%), and three patients had convulsions (16.6%). Seven patients were intubated. Three patients died of multiple organ failure and cardiogenic shock despite extracorporeal treatment. Respiratory syncytial virus was found in two patients and rhinovirus was found in one patient. The median leukocyte count was significantly higher in non-survivors than in survivors. Blood exchange was performed in three patients due to hyperleukocytosis. Pulmonary hypertension was the most common cardiac pathology detected in echocardiographic examinations. CONCLUSION: We found that high leukocyte count, viral co-infection, and severe pulmonary hypertension were associated with mortality and morbidity in pertussis.

Therapeutic plasma exchange in pediatric intensive care: Indications, results and complications.

Therapeutic plasma exchange (TPE) is an effective treatment method in selective indications. Secondary to access and technical features, it is more difficult to apply in pediatric population than adults. The aim of this study is investigate safety, clinical indications, and results of this method in critically ill pediatric patients who need TPE treatment. All of the TPE procedures performed in a pediatric intensive care unit providing tertiary care during 4 years (2015-2019) were evaluated retrospectively. TPE procedures (635) were performed for 135 patients. Median age was 34 months (10-108). Ninety-seven patients had mechanical ventilation support. Sepsis with multiple organ failure was the most frequent indication and accounted for 44.4% (n = 60) of the indications followed by hematological and neurological diseases (19.2% and 9.6% respectively). TPE was performed alone in 469 cases (73.9%), in combination with continuous renal replacement therapy in 154 cases (24.2%), and additional to extracorporeal membrane oxygenation in 12 cases (1.9%). Hematological disease and sepsis subgroups had the highest intubation rate, mechanical ventilation period, PRISM score, organ failure count, and mortality. Fresh frozen plasma (FFP) was the most frequently used replacement fluid in 90.4% of the procedures. The most frequent anticoagulant used in TPE was acid citrate dextrose solution (79.3%). Procedural complications were detected in 104 cases (16.3%) and occurred during TPE sessions. Overall survival rate was 78.5%. We found that the non-survivor group had significantly higher rates of organ failures (P = 0.0001), higher PRISM scores on admission (P = 0.0001), and higher rates of invasive ventilation support needed (P = 0.012). TPE is a treatment method which can be safely provided in healthcare facilities with necessary medical and technical requirements. Although it is riskier to provide such treatment to critically ill children, complications can be minimized in experienced healthcare facilities. Overall results are good and can vary depending on indication.

Double Aortic Arch Mimics the Clinical Characteristics of Severe Reactive Airway Disease in a Pediatric Patient.

Reactive airway disease is a prevalent condition that can be detected in the early infancy period. The condition might also deteriorate into asthma in some cases. If infants do not respond to the treatment of persistent wheeze and coughing, other rare causes should be investigated. The complete form of vascular ring is an extremely uncommon congenital cardiovascular abnormality. Double aortic arch constitutes the most significant portion of the complete vascular ring anomalies. Clinical manifestations of the anomaly are mainly respiratory due to the tracheal compression and mimicking the conditions of asthma. There have not been many reports about the clinical presentations of double aortic arch being remarkably similar to the same clinical manifestations of asthma in the literature. As far as we can be sure, there have not been any reported cases about severe reactive airway disease that caused a patient to have a life-threatening condition in the pediatric intensive care unit. Herein, we present a 5-month-old girl who had double aortic arch. Her anatomical aberration was diagnosed by three-dimensional computed tomography angiography of thorax, and the anomaly mimicked the clinical characteristics of life-threatening severe reactive airway disease.

Clinical and laboratory predictors of survival for pediatric patients on non-postcardiotomy extracorporeal membrane oxygenation (ECMO).

Extracorporeal membrane oxygenation (ECMO) is used in pediatric patients with severe cardiopulmonary failure who do not respond to conventional therapy; only a few studies have been conducted in Turkey. We present the experience of pediatric ECMO with the aim of showing factors affecting mortality. We retrospectively reviewed our ECMO database to identify patients who received ECMO from October 2015 to March 2018. Our population comprised 30 pediatric patients. The mean patient age was 41.31±53.35 months and 17 (56.7%) patients were male. The median duration of ECMO support was 8.9 (6.6-10.8) days. The rates of successful ECMO weaning and survival to discharge were 70.0% (n=21) and 66.7% (n=20), respectively. Indications for ECMO were respiratory failure (40.0%), cardiac failure (33.3%), and sepsis (26.7%). We found that pre-cannulation values of pH (p=0.034), leukocytes (p=0.029), C-reactive protein (p=0.045), creatinine (p=0.047), chloride (p=0.001) and post-cannulation pH (p=0.0001), bicarbonate (p=0.014), lactate (p=0.002), chloride (p=0.0001) were associated with mortality. The results showed that preexisting sepsis and renal conditions contributed to poor outcomes. Indications, ECMO onset time, and pre- and post-cannulation laboratory values such as leukocytes, CRP, creatinine, bicarbonate, lactate, and chloride are factors that affect outcomes.

Intrathecal baclofen use in the management of tetanus related spasm: A case report.

Sik G, Aydoseli A, Çitak A. Intrathecal baclofen use in the management of tetanus related spasm: A case report. Turk J Pediatr 2019; 61: 126-129. Tetanus is an infectious disease of the central nervous system with high mortality rates characterized with respiratory distress and tonic muscle spasms. The most common cause of mortality is cardiovascular complications (40%) and respiratory distress (15%). Despite vaccination programs, tetanus remains to be a significant healthcare issue in developing nations. Prolonged sedation and administration of muscle relaxants prolongs the period on mechanical ventilation and duration of hospitalization in severe tetanus cases. However, intrathecal baclofen (ITB) therapy might shorten the duration of stay at intensive care units, improve patient outcomes, and constitute a treatment option alternative to paralytic agents and sedation. In this manuscript, we present a 12-years-old case diagnosed with tetanus and treated with ITB upon observation of spasms refractory to high dose sedation and muscle relaxants.

Clinical Features and Indications Associated with Mortality in Continuous Renal Replacement Therapy for Pediatric Patients.

OBJECTIVES: To identify prognostic factors and indications in patients receiving continuous renal replacement therapy (CRRT) in the pediatric intensive care unit (PICU), and to demonstrate their effect on mortality. METHODS: A total of 63 patients admitted between 2011 and 2014 were included in the study. The demographic information, pediatric risk of mortality (PRISM) scores, vasoactive-inotropic score, indication for CRRT, time of starting CRRT, presence of fluid overload, durations of CRRT, and pediatric intensive care unit (PICU) stay were compared between survivors and non-survivors. RESULTS: The overall rate of survival was 69,8%. The most common indication for CRRT was fluid overload (31.7%) followed by acute attacks of metabolic diseases (15.9%), and resistant metabolic acidosis (15.9%). The median duration of CRRT was 58 (IQR 24-96) h. The most common CRRT modality was continuous venovenous hemodiafiltration. The CRRT modality was not different between survivors and nonsurvivors. Sepsis, as the diagnosis for admission to intensive care unit was significantly related to decreased survival when compared to acute kidney injury and acute attacks of metabolic diseases. Patients with fluid overload had significantly increased rate of death, CRRT duration, use of mechanical ventilation, and PICU stay. CONCLUSIONS: The CRRT, can be effectively used for removal of fluid overload, treatment of acute attacks of metabolic diseases, and other indications in critically ill pediatric patients. It has a positive effect on mortality in high-risk PICU patients. This treatment modality can be used more frequently in pediatric intensive care unit with improved patient outcomes, and should be focused on starting therapy in early stages of fluid overload.

Extracorporeal membrane oxygenation for the support of pediatric patients with acute fulminant myocarditis.

Sik G, Annayev A, Demirbuga A, Deliceo E, Aydin S, Erek E, Demir HI, Çitak A. Extracorporeal membrane oxygenation for the support of pediatric patients with acute fulminant myocarditis. Turk J Pediatr 2019; 61: 867-872. Acute fulminant myocarditis, is a severe, rapidly progressive disease. The clinical outcomes of children with severe acute myocarditis who are resist to medical treatment is not well known. We studied the clinical courses of patients with acute fulminant myocarditis supported by extracorporeal membrane oxygenation (ECMO). We performed a retrospective chart review of six children with acute fulminant myocarditis who were treated with ECMO. Demographic information, clinical and vital signs, as well as laboratory results were investigated. The median age of 63 months (13-140 months), the mean ECMO duration was 164 hours (79-402 hours), and median intensive care unit stay was 24 days. The most common symptoms were chest pain (66%) and fever (66%). Severe arrhythmia were seen in two patients. One patient received extracorporeal cardiopulmonary resuscitation. In two patients, right femoral arteries and right femoral veins were used, in others, right common carotid artery and right internal jugular veins were used. Five patients (83.3 %) survived to discharge. ECMO can be used effectively in pediatric patients with acute fulminant myocarditis to support the circulation while awaiting myocardial recovery. Timely use of ECMO can improve the survival rate and may be associated with better outcomes.

Magnusiomyces capitatus Peritonitis in a Child With Acute Lymphocytic Leukemia as a Breakthrough Infection During Caspofungin Therapy.

Magnusiomyces capitatus is an emerging opportunistic fungal pathogen particularly in immunocompromised patients. We report a case of a M. capitatus peritonitis in child with acute lymphocytic leukemia as a breakthrough infection during caspofungin therapy. The possibility of breakthrough infections caused by M. capitatus must be taken into consideration, particularly in immunosupressed patients being treated for systemic fungal infections by caspofungin. Although there are no defined breakpoints for susceptibility testing of M.capitatus, minimal inhibitory concentration results can be helpful for therapy. Antifungal treatment with amphotericin B lipid complex plus flucytosine can be effective against infections caused by M. capitatus.

Fatal paraphenylenediamine poisoning due to black henna.

Paraphenylenediamine (PPD) is an oxidative chemical allergen that can cause hypersensitivity reactions. PPD intoxication could cause severe systemic adverse effects like acute renal failure, rhabdomyolysis and multiple organ failure. In this text we present a 9 year-old female patient who developed multiple organ failure and cardiac arrhythmia as a result of extensive application of PPD added to henna to the skin. Plasma exchange (PE) and continuous venovenous hemodiafiltration (CVVHDF) were started. The patient died on day 4 after developing ventricular fibrillation that was resistant to antiarrhythmic treatment and defibrillation. In summary, the most commonly seen clinical signs in PPD intoxication are cervical, upper respiratory and muscle edema, intravascular hemolysis, rhabdomyolysis, severe cardiac arrhythmias and acute renal failure. These symptoms would be suggestive of PPD poisoning.

[Fournier's gangrene after anorectal surgery in infant: Two case reports]. / Süt çocugunda anorektal cerrahi sonrasi gelisen Fournier gangreni: Iki olgu sunumu.

Necrotizing fasciitis is a life-threatening soft tissue infection characterized by progressive necrosis of the skin, subcutaneous tissues and fascia. Fournier's gangrene (FG) is a serious and aggressive form of infective necrotizing fasciitis involving perineal region and genitalia. Presently described are 2 pediatric cases of FG with widespread necrosis of surrounding tissue following anorectal surgery, causing severe septic shock. Case 1: Six-month-old female patient with anal stenosis and duplication presented at emergency clinic with fever, somnolence, irritability, and feeding difficulty. Physical examination upon admission to Intensive Care Unit (ICU) with septic shock determined she had ecchymosis in anal region. At 12fth hour after admission, lesion had become necrotic and patient was started on broad-spectrum antibiotics after surgical debridement. Cultures were negative and patient had complete recovery 2 months after admission. Case 2: Nine-month-old male patient was admitted to ICU for convulsions and sepsis eight hours after fistulectomy. Scrotal, gluteal, and perianal edema and ecchymosis were observed on physical examination. Perianal debridement and colostomy were performed, and patient was given broad-spectrum antibiotics after basic life support strategies for septic shock. Complete recovery was achieved after hyperbaric oxygen treatment for perianal lesion and patient was discharged from the hospital in third month after admission. After anorectal surgery, every patient should be observed carefully for FG. Early debridement, proper antibiotics, and hyperbaric oxygen treatment can be life-saving.

Role of Autoantibodies to N-Methyl-d-Aspartate (NMDA) Receptor in Relapsing Herpes Simplex Encephalitis: A Retrospective, One-Center Experience.

Post-herpes simplex virus encephalitis relapses have been recently associated with autoimmunity driven by autoantibodies against N-methyl-d-aspartate (NMDA) receptors. Because it offers different treatment options, determination of this condition is important. Between 2011 and 2014, 7 children with proven diagnosis of herpes simplex virus encephalitis were identified in a university hospital of Istanbul. Two patients had neurologic relapse characterized mainly by movement disorders 2 to 3 weeks after initial encephalitis. The first patient received a second 14 days of acyclovir treatment together with antiepileptic drugs and left with severe neurologic sequelae. The second patient was found to be NMDA receptors antibody positive in the cerebrospinal fluid. She was treated with intravenous immunoglobulin and prednisolone. She showed substantial improvement, gradually regaining lost neurologic abilities. Post-herpes simplex virus encephalitis relapses may frequently be immune-mediated rather than a viral reactivation, particularly in children displaying movement disorders like choreoathetosis. Immunotherapy may provide benefit for this potentially devastating condition, like the case described in this report.