Efficacy of Prednisone in Children with Acute Nonspecific Mesenteric Lymphadenitis: A Pilot Study.

BACKGROUND: Acute nonspecific mesenteric lymphadenitis (ANML) is a common cause of acute abdominal pain in children with no specific treatment. METHODS: A total of 13 patients (6 boys, 7 girls) aged 7.3 (5-13.5) years with severe acute abdominal pain were evaluated using ultrasonography and laboratory tests to establish the diagnosis of ANML. They were treated with prednisone 1 mg/kg (max 40 mg daily) for a maximum of 5 days. The intensity of abdominal pain was evaluated before and after treatment using a numeric rating scale. RESULTS: All patients had pain scores above 6/10 before, and below 4/10 after treatment with prednisone. Intensity of abdominal pain after treatment for 1-5 days decreased significantly (p < 0.001), with no recurrence at follow-up within 3 months. All other pre-existing signs and symptoms, such as nausea, vomiting, anorexia, fever, diarrhea, and constipation were found to disappear with no adverse effects of corticosteroid therapy. CONCLUSION: These results suggest that the treatment with prednisone in selective patients with ANML can reduce the duration of abdominal pain.

Screening of celiac disease in Down syndrome - Old and new dilemmas.

Celiac disease (CD) is a common and well defined autoimmune disorder caused by gliadin and related proteins of wheat, rye, and barley. Epidemiologic studies confirmed that CD is highly associated with other autoimmune diseases and with Down syndrome (DS). The symptomatic form of CD in patients with DS is more frequent than asymptomatic forms. However, growth impairment, anemia, intermittent diarrhea, and constipation are symptoms and signs typically of children with DS without CD. Late identification of the disease can lead to various complications, sometimes even very severe. Therefore, systematic screening for CD is essential in the management of children and adolescents with DS. Many medical organizations recommend screening in this group of patients. However, current policy statements vary in their recommendations for screening and there is still a need for establishing uniform diagnostic criteria.

[The founding of Zemun Hospital].

This year Zemun Hospital--Clinical Hospital Center Zemun celebrates 230th anniversary of continuous work, thus becoming the oldest medical facility in Serbia.The exact date of the hospital founding has been often questioned in history. Various dates appeared in the literature, but the most frequent one was 25th of February 1784. Until now, the document which confirms this has never been published. This article represents the first official publication of the document which confirms that Zemun Hospital was indeed founded on this date. The first hospitals started emerging in Zemun when the town became a part of the Habsburg Monarchy. The first sanitary facility ever formed was the"Kontumac"--a quarantine established in 1730. Soon after, two more confessional hospitals were opened.The Serbian (Orthodox) Hospital was founded before 1769, whereas the German (Catholic) Hospital started working in 1758. Both hospitals were financed, amongst others, by the Town Hall--the Magistrate. In order to improve efficiency of these hospitals, a decision was made to merge them into a single City Hospital. It was founded on 25th February 1784, when the General Command ordered the Magistrate of Zemun to merge the financess of all existing hospitals and initiate the construction of a new building. Although financially united, the hospitals continued working in separate buildings over a certain period of time.The final, physical merging of these hospitals was completed in 1795.

A case of human monocytic ehrlichiosis in Serbia.

INTRODUCTION: Ehrlichiosis is a bacterial zoonosis transmitted by hematophagous arthropods--ticks. In humans, it occurs as monocytic, granulocytic, and ewingii ehrlichiosis. Pathological process is based on parasitic presence of Ehrlichia organisms within peripheral blood cells--monocytes and granulocytes. CASE OUTLINE: Fifty-two year old patient was admitted to hospital due to high fever of over 40 degrees C that lasted two days, accompanied with chills, muscle aches, malaise, loss of appetite, headache, confusion, breathing difficulties, and mild dry cough. The history suggested tick bite that occurred seven days before the onset of disease. Doxycycline was introduced and administered for 14 days, causing the disease to subside. Indirect immunofluorescence assay was used to analyze three serum samples obtained from this patient for Ehrlichia chaffeensis antibodies, and peripheral blood smear was evaluated for the presence of Ehrlichia and Ehrlichia aggregation into morulae. CONCLUSION: Ehrlichiosis should be considered in each case where there is a history of tick bite together with the clinical picture (high fever, chills, muscle aches, headache, generalized weakness and malaise, and possible maculopapular rash). The presence of Ehrlichia chaffeensis antibodies was confirmed in a patient with the history of tick bite, appropriate clinical picture and indirect immunofluorescence assay. This confirmed the presence of human monocytotropic ehrlichiosis, a disease that is uncommonly identified in our country.

When to screen children with Down syndrome for celiac disease?

The coexistence of Down syndrome (DS) and celiac disease (CD) has been reported in many studies. In our study, we examined 82 children with DS aged 8 months to 8.6 years for the existence of CD using serological markers immunoglobulin A (IgA) and immunoglobulin G (IgG) transglutaminase antibodies, followed by follow-up determination of total IgA levels. In four children who were positive for one of the above-mentioned antibodies, enteric biopsy has been performed that showed absence of CD. Our findings raise doubt about the need for obligatory serological screening of children with DS aged <8 years.

Coeliac disease as the cause of resistant sideropenic anaemia in children with Down's syndrome: case report.

INTRODUCTION: Coeliac disease (CD) is a permanent intolerance of gluten, i.e., of gliadin and related proteins found in the endosperm of wheat, rye and barley. It is characterized by polygenic predisposition, autoimmune nature, predominantly asymptomatic or atypical clinical course, as well as by high prevalence in patients with Down's syndrome (DS) and some other diseases. OUTLINE OF CASES: We are presenting a girl and two boys, aged 6-7 (x = 6.33) years with DS and CD recognized under the feature of sideropenic anaemia resistant to oral therapy with iron. Beside mental retardation, low stature and the morphological features characteristic of DS, two patients had a congenital heart disease; one ventricular septal defect and the other atrioventricular canal. In two patients, trisomy on the 21st chromosome pair (trisomy 21) was disclosed in all cells, while one had a mosaic karyotype. All three patients had classical laboratory parameters of sideropenic anaemia: blood Hb 77-89 g/l (x = 81.67), HCT 0.26-0.29% (x = 0.28), MCV 69-80 fl (x = 73), MCH 24.3-30 pg (x = 26.77) and serum iron 2-5 micromol/L (x = 4.0). Beside anaemia and in one patient a mild isolated hypertransaminasemia (AST 67 U/l, ALT 62 U/l), other indicators of CD were not registered in any of the children. In addition, in all three patients, we also detected an increased level of antibodies to tissue transglutaminase (atTG) of IgA class (45-88 U/I) so that we performed endoscopic enterobiopsy in order to reliably confirm the diagnosis of CD. In all three patients, the pathohistological finding of the duodenal mucosa specimen showed mild to moderate destructive enteropathy associated with high intraepithelial lymphocyte infiltration, cryptic hyperplasia and lympho-plasmocytic infiltration of the stroma. In all three patients, the treatment with a strict gluten-free diet and iron therapy applied orally for 3-4 months resulted in blood count normalization and the correction of sideropenia. Serum level of the atTG-IgA, repeated after a 12-month diet, was also normal. CONCLUSION: CD should be taken into consideration in all cases of sideropenic anaemia resistant to iron oral therapy in children with DS.The diagnosis of CD implicates corresponding pathohistological confirmation, while the treatment of sideropenic anaemia and its complications, beside iron preparations, also requires compliance with a gluten-free diet.

Lactose intolerance in infants with gluten-sensitive enteropathy: frequency and clinical characteristics.

INTRODUCTION: Secondary lactose intolerance (SLI) belongs to the rarer manifestations of gluten-sensitive enteropathy (GSE). It occurs in more severe forms of the disease and its presence contributes significantly to the degree of its expression. OBJECTIVE: The goal of the study was to determine the frequency of SLI in infants with clinically classic form of GSE, as well as its relationship with the duration, severity and age at the diagnosis of the basic disease and the degree of small bowel mucosa damage. METHODS: The study was based on a sample of 42 infants, 30 female and 12 male, aged 7-12 months (x = 9.98 +/- 1.69), with a clinically classic form of GSE. The diagnosis of GSE was established based on the characteristic pathohistological appearance of small bowel mucosa and clinical improvement of patients on gluten-free diet, while SLI on pathological lactose or milk tolerance test. The assessment of basic disease severity was based on body mass divergence in relation to the standard value, as well as on Hb and serum iron levels, while the degree of small bowel mucosa damage was determined according to the modified Marsh criteria. RESULTS: SLI was verified in 8/42 or 19.05% of patients. In addition to the symptoms and clinical signs of GSE, all the patients with SLI also featured the problems characteristic of lactose tolerance disorders, i.e. watery diarrhoea, borborygmus and meteorism occurring after milk meals. In addition, all had perianal erythema (6 with erosive changes), as well as destructive enteropathy (5 subtotal and 3 total). The difference in the duration of the basic disease, age at diagnosis, as well as in the degree of body mass deviation from the standard value between the lactose-tolerant and lactose-intolerant infants was not found. In addition, no difference in Hb and serum iron levels or in the degree of small bowel mucosa damage was found between the two groups. CONCLUSION: Our findings indicate that SLI presents a relatively frequent occurrence in infants with clinically classic GSE, as well as that it occurs independently to the duration, severity and age at diagnosis of the basic disease and the degree of small bowel mucosa damage.

Effect of gluten-free diet on the growth and nutritional status of children with coeliac disease.

INTRODUCTION: Gluten-free diet (GFD) presents the basis of coeliac disease (CD) treatment. If strictly applied, the disorders of the small bowel mucosa and other disease signs rapidly resolve. OBJECTIVE: The goal of the study was to evaluate the effect of GFD on the growth and nutritional status of children with the classical form of CD. In addition, we analyzed the differences between these parameters with the duration and the patients' compliance with GFD. METHODS: The study goals were achieved on a sample of 90 children, 56 female and 34 male, aged 0.5-7.5 (1.53 +/- 1.05) years, with the classic CD diagnosed on the basis of typical pathohistological findings of the small bowel mucosa and clinical recovery of patients on GFD. The duration of the patients' follow-up was 1.08-8.75 (3.03 +/- 1.14) years, i.e. until the age of 2.5-15 (4.59 +/- 1.78) years. The initial and control values of body height (BH) in relation to matched values for age and gender were expressed in percentiles, while the deviation in body weight (BW) for the matched values of height and gender was expressed in percentages. The referent haemoglobin (Hb) rate in blood, as a laboratory indicator of nutritional status in children aged up to 5 years was > or = 110 g/L, and for those aged above 5 years it was > or = 115 g/L Compliance with GFD was based on the pathohistological findings of the small bowel mucosa or determination of tissue transglutaminase. RESULTS: Over the studied period, the effect of GFD was highly significant, both on the increase of BH percentiles (37.62 +/- 26.26 vs. 57.22 +/- 25.29; p < 0.001), and on the decrease of BW deficit 11.58 +/- 10.80 vs. 0.89 +/- 8.194; p < 0.001). After the treatment period, none of the children showed slowed growth rate or BW deficit above 20%, while BW deviation ranging between 10-20% in relation to the referent values was registered in 17 (18.19%) and the excess of over 20% in 2 patients. In 86 (95.56%) patients, control Hb values in blood were normal, while mild anaemia was registered in 4 patients, all compliant with GFD. The difference between the compliant and non-compliant patients with GFD was not detected either in BH percentiles (p = 0.586) or in BW percentage deviation as compared to standard values (p = 0.516) or in blood Hb values (p = 0.445). In addition, differences between the children on GFD lasting over and below 3 years were not detected either in BH percentiles (p = 0.915) or in BW deviation percentages in relation to the ideal rate (p = 0.476). CONCLUSION: GFD applied for 1-3 years has a highly significant effect on the growth rate and nutritional status of children with the classical form of CD. Significant differences in these parameters of the disease were not detected between strictly compliant and non-compliant patients on GFD.

[Comparison of different methods of temperature measurment in children].

INTRODUCTION: The consequences of failing to notice fever in children can be serious. On the other hand, false positive reading can result in unnecesery investigation or diagnostic approach. The aim of this study was to compare different ways of body temperature measurement. MATERIAL AND METHODS: This prospective study was carried out on Pediatric Department of General Hospital in Subotica during 10 months (March-December 2006). In 263 children aged 1 month to 18 years of age, the body temperature was obtained from 4 measurement sites: tactile assesment, forehead and ear by electronic thermometer, rectal temperature in small children (up to 2 years of age) or axillar temperature in older children by mercury thermometer. Tympanic thermometry was considered as a standard for fever detection. RESULTS: The sensitivity of rectal temperature to detect fever is 46.67%, while specificity is 92.19%. The sensitivity of fever detection by electronic thermometry on the forehead is lower according to rectal thermometry - 36.08%, while specificity is 95.18%. The lowest values ofsensitivity are recorded in axillar thermometry (35.82%), specificity is 90.20%. The correlation coefficient is higher between tympanic and rectal temperature measurement (r=0.5076, p<0.0005), than between tympanic and forehead measurements (r=0.5076, p<0,0005), while the lowest was between tympanic and axillar mesurement sites (r=0.4933, p<0.0005). CONCLUSIONS: The results of our study and literature data show that the most accurate methods of thermometry are rectal measurement of body temperature in small children and tympanic thermometry in children over 2 years of age.

[Corticosteroid therapy in Henoch-Schönlein gastritis].

INTRODUCTION: Henoch-Schönlein purpura (HSP) is the most common vascular disease of childhood. It is a multisystem disease most commonly affecting the skin,joints, gastrointestinal tract, and kidneys, but other organs may be affected, too. Gastrointestinal involvement occurs in approximately 65-90% of patients, ranging from mild symptoms such as abdominal pain, nausea, and vomiting, to more severe manifestations such as gastrointestinal bleeding and intussusception. In most cases, HSP spontaneously resolves without treatment. The use of corticosteroids is controversial and usually reserved for severe systemic manifestations. Some authors suggest that the abdominal pain and gastrointestinal hemorrhage of HSP may respond to steroids, with some suggesting that there is a benefit in their use and describing a regimen. CASE OUTLINE: This is a case report of HSP in a fourteen-year-old boy with abdominal pain and hematemesis. Upper endoscopy showed an edematous and erythematous change in the body of the stomach and purpuric lesions in the duodenum, while multiple erosions were found in the antral area. Parenteral corticosteroid therapy with gastric acid secretion inhibitor administration led to regression of gastrointestinal symptoms on the seventh day, with relapses on the fourth and sixth day. Peroral administration of corticosteroids and gradual decrease of daily doses started on the eighth day of abdominal symptoms. New purpuric skin rashes appeared during six weeks. CONCLUSION: Corticosteroid therapy with gastric acid secretion inhibitors showed a positive effect in our patient with a severe form of HSP accompanied by abdominal pain and gastrointestinal hemorrhage.

[Erythromycin in therapy of cyclic vomiting syndrome].

Cyclic vomiting syndrome is an insufficiently understood disorder which manifests itself in stereotypical episodes of vomiting with no detectable organic cause. Considering its unknown aetiology, drugs borrowed from various medication classes are applied in the therapy of this disorder, with variable success. Among other medicaments, erythromycin is also used in treatment of cyclic vomiting syndrome. This is a case study in which the application of erythromycin led to the prevention of attacks of cyclic vomiting syndrome. Our case report presents how periodical erythromycin therapy in two-week intervals at expected attack periods in a girl led to disappearance of cyclic vomiting. Adverse effects of erythromycin did not show up.

[Arias icterus--prolonged unconjugated hyperbilirubinemia caused by breast milk].

INTRODUCTION: Breast milk jaundice occurs in 1-2% of healthy breast-fed newborns and young infants. It develops as the result of liver immaturity and the inhibitory effect of mother's milk to the clearance of unconjugated bilirubin. OBJECTIVE: The paper analyzes variations in the level and length of unconjugated hyperbilirubinemia in breast-fed infants. METHOD: The study was conducted on a sample of 29 young infants (19 male) with breast milk jaundice. All infants were born on time, by natural delivery and without complications. All were on breast-feeding only and developed optimally. None of the infants had either haemolysis or any other disease associated with unconjugated hyperbilirubinemia. RESULTS: All infants had physiological jaundice in the first week after birth, with unconjugated bilirubin level of 166-260 micromol (201.50 +/- 36.37 micromol). In the postneonatal period the highest bilirubin level was recorded in the fifth week of life and was 87-273 micromol (166.82 +/- 45.06 micromol), which then spontaneously, without interruption of breast-feeding, gradually declined. The decrease of the unconjugated fraction of serum bilirubin between the fourth and fifth week was significant, and after that highly significant. The normalization of serum bilirubin occurred in the seventh and thirteenth week (10.41 +/- 1.68 micromol). Negative consequences of hyperbilirubinemia were not noted in any of the infants. CONCLUSION: Breast milk jaundice presents a harmless and transitory disorder of bilirubin metabolism. It occurs in healthy breast-fed neonates and young infants. Jaundice is most marked in early neonatal period, and then it gradually declines and disappears between the seventh and thirteenth week.