Apparent cyclic vaginal bleeding in a child: factitious disorder.

A 20-mo-old girl was brought to our department by her mother because of breast enlargement. She was diagnosed with premature thelarche. One month later, she returned to our hospital with a complaint of vaginal bleeding. During the subsequent 6 mo, her vaginal bleeding recurred every month while her breast development disappeared. We performed laboratory tests and imaging. At the end of 6 mo, we realized that her mother's menstrual bleeding and the patient's blood staining were concurrent. The mother confessed applying her vaginal flow to her daughter's underwear. Factitious disorder should be included in the differential diagnosis of unexplained vaginal bleeding in childhood.

Transient Congenital Hypothyroidism in Turkey: An Analysis on Frequency and Natural Course.

OBJECTIVE: Prevalence of congenital hypothyroidism (CH) in Turkey at birth was reported to be as high as 1:650 in 2008-2010. Incidence rates of permanent and transient CH separately are unknown due to lack of follow-up data. We aimed to evaluate the impact of transient hypothyroidism on increasing incidence of CH and to determine the natural course and the clinical, biochemical, and imaging characteristics of transient CH. METHODS: Baseline and follow-up data of the infants with CH detected at screening in six provinces in the Black Sea Region were analyzed retrospectively during a time period covering the years 2008-2010. RESULTS: Among 138 cases (48% female), 16 (12%) showed transient hyperthyrotropinemia which resolved without intervention. Of the treated 122 cases, 63 (52%) had transient CH. While its frequency was 35% in 2008, it increased to 56% in 2009-2010, following a lowering of the thyroid stimulating hormone cutoff value. The frequency was higher in inland provinces than in coast (67% vs. 43%; p=0.01).Clinical characteristics of permanent and transient cases were similar except female-to-male sex ratios (1.5:1 vs. 0.6:1; p=0.02). L-thyroxine was discontinued in 70% of transient cases before 3 years of age at a median age of 19 (2-36) months. The only indication for early discontinuation of treatment was a low L-thyroxine dose, which was 1.25±0.27 µg/kg/day at withdrawal time. CONCLUSION: Our regional follow-up data showed that more than half of newborns with primary CH had transient thyroid dysfunction. In the majority of cases, discrimination between transient and permanent CH can be made before age 3 years, as indicated by cessation of L-thyroxine treatment.

Clinical features of extrapulmonary tuberculosis in children.

OBJECTIVE: To review the clinical features of the extrapulmonary tuberculosis (TB) in children. METHODS: Sixty-four children with extrapulmonary TB followed in Ankara Social Security Children's Hospital between June 1995 and May 2003 were reviewed. RESULTS: The mean age was 7.5 +/- 4.1 years. The most commonly involved sites were the central nervous system [(CNS) 16 cases] and pleura (14 cases). Aside from this, 10 children had a diagnosis of miliary TB. Abdominal TB (median age of 12 years) and pleural effusion (median age of 10.9 years) were mostly seen in older children while miliary TB was encountered more frequently in younger children (median age 2.5 years). A positive family history of active TB was detected in 39% of the cases. There was consanguinity between parents in 23 (35.9%) of the cases. Twenty-five (39%) cases had no Bacillus Calmette-Guerin vaccination scar. One case with CNS TB expired. Sequelae observed during the follow up were; motor-mental retardation in 3 cases, hemiparesis in 2 cases, strabismus in one case with CNS TB and vertebral deformation in 2 cases with Pott's disease. CONCLUSION: Severe forms such as CNS and miliary TB constituted an important percentage of childhood extrapulmonary TB cases.

Vitamin D intoxication due to an erroneously manufactured dietary supplement in seven children.

Pediatric cases of vitamin D intoxication (VDI) with dietary supplements have not been previously reported. We report on 7 children with VDI caused by consumption of a fish oil supplement containing an excessively high dose of vitamin D due to a manufacturing error. Seven children aged between 0.7 and 4.2 years were admitted with symptoms of hypercalcemia. Initial median (range) serum concentrations of calcium and 25-hydroxyvitamin D were 16.5 (13.4-18.8) mg/dL and 620 (340-962) ng/mL, respectively. Repeated questioning of the parents revealed use of a fish oil that was produced recently by a local manufacturer. Analysis of the fish oil by gas chromatography/mass spectrometry revealed that the vitamin D3 content was ~4000 times the labeled concentration. Estimated daily amounts of vitamin D3 intake varied between 266,000 and 800,000 IU. Patients were successfully treated with intravenous hydration, furosemide, and pamidronate infusions. With treatment, serum calcium returned to the normal range within 3 days (range: 2-7 days). Serum 25-hydroxyvitamin D levels normalized within 2 to 3 months. Complications, including nephrocalcinosis, were not observed throughout the 1-year follow-up. In conclusion, errors in manufacturing of dietary supplements may be a cause of VDI in children. Physicians should be aware of this possibility in unexplained VDI cases and repeatedly question the families about dietary supplement use. To prevent the occurrence of such unintentional incidents, manufacturers must always monitor the levels of ingredients of their products and should be rigorously overseen by governmental regulatory agencies, as is done in the pharmaceutical industry.