Multisystem Inflammatory Syndrome in Children Presenting With Pseudotumor Cerebri and a Review of the Literature.

Multisystem inflammatory syndrome in children (MIS-C) is a rare but life-threatening inflammatory immune response associated with severe acute respiratory syndrome coronavirus 2 infection. The majority of patients have been presented with hypotension, shock, gastrointestinal, cardiovascular and mucocutaneous symptoms. The incidence of neurologic symptoms in MIS-C is of rising concern as they are not well described and reported in fewer patients. An 8-year-old boy was admitted to the hospital with headache, fever, conjunctivitis, and hyperinflammatory findings diagnosed as MIS-C. Fundus examination performed with complaints of headache, vomiting, and conjunctivitis showed bilateral papilledema. Pseudotumor cerebri is a rare manifestation of MIS-C that can lead to vision loss and may not only be resolved with the standard treatment for MIS-C. We report a case of MIS-C presented with neurologic symptoms due to pseudotumor cerebri and successfully treated with intravenous immunoglobulin and acetazolamide.

Three-Year Follow-up of 2-Dose Versus 3-Dose HPV Vaccine.

BACKGROUND AND OBJECTIVES: Human papillomavirus (HPV) antibody responses to the 9-valent human papillomavirus (9vHPV) vaccine among girls and boys (aged 9-14 years) receiving 2-dose regimens (months 0, 6 or 0, 12) were noninferior to a 3-dose regimen (months 0, 2, 6) in young women (aged 16-26 years) 4 weeks after last vaccination in an international, randomized, open-label trial (NCT01984697). We assessed response durability through month 36. METHODS: Girls received 2 (months 0 and 6 [0, 6]: n = 301; months 0 and 12 [0, 12]: n = 151) or 3 doses (months 0,2, and 6 [0, 2, 6]: n = 301); boys received 2 doses ([0, 6]: n = 301; [0, 12]: n = 150); and young women received 3 doses ([0, 2, 6]: n = 314) of 9vHPV vaccine. Anti-HPV geometric mean titers (GMTs) were assessed by competitive Luminex immunoassay (cLIA) and immunoglobulin G-Luminex immunoassay (IgG-LIA) through month 36. RESULTS: Anti-HPV GMTs were highest 1 month after the last 9vHPV vaccine regimen dose, decreased sharply during the subsequent 12 months, and then decreased more slowly. GMTs 2 to 2.5 years after the last regimen dose in girls and boys given 2 doses were generally similar to or greater than GMTs in young women given 3 doses. Across HPV types, most boys and girls who received 2 doses (cLIA: 81%-100%; IgG-LIA: 91%-100%) and young women who received 3 doses (cLIA: 78%-98%; IgG-LIA: 91%-100%) remained seropositive 2 to 2.5 years after the last regimen dose. CONCLUSIONS: Antibody responses persisted through 2 to 2.5 years after the last dose of a 2-dose 9vHPV vaccine regimen in girls and boys. In girls and boys, antibody responses generated by 2 doses administered 6 to 12 months apart may be sufficient to induce high-level protective efficacy through at least 2 years after the second dose.

Primary ovarian rhabdomyosarcoma coexisting with Pseudo-Meigs' syndrome in a young patient: a case report and brief literature review.

Primary rhabdomyosarcoma is one of the malignant soft tissue sarcomas of childhood originating from embryonic mesenchyme. The tumor can occur in the head, neck region, and limbs, and genitourinary system. Primary ovarian rhabdomyosarcoma is an extremely rare malignancy with a few documented pediatric patients in the literature. Pseudo-Meigs' syndrome is a type of Meigs' syndrome that is usually associated with other benign ovarian tumors or any other type of malignant tumors. It is a rare condition characterized by ascites, pleural effusion, benign ovarian tumors or fibroma-like tumors, and resolution of ascites and pleural effusion after the removal of the tumor. A patient of Asian origin came to our clinic with symptoms of mild dyspnea, and gradually increasing abdominal swelling. Magnetic resonance imaging scans indicated masses with solid cystic components on both ovaries with a suspicion of malignancy, showing bilateral pleural effusion and massive ascites. This is the first reported case of a pure primary ovarian rhabdomyosarcoma associated with a Pseudo-Meigs syndrome in a young girl.

Native valve endocarditis due to Candida albicans in two children: Two new case reports.

Candida endocarditis (CE) is a rare and serious complication of candidemia. Using current diagnostic tools a confirmed diagnosis is often delayed and outcomes remain poor. The majority of new cases occur following cardiac valvular surgery, and/or in patients with the following risk factors: intravenous drug use, cancer chemotherapy, prolonged presence of central venous catheters, and prior history of bacterial endocarditis. It is not a common complication in non-neutropenic patients particularly with the absence of a prosthetic valve, and very few reports in the literature are available. Attempting to add to the limited data, 211 candidemia episodes from 172 nonneutropenic pediatric cases between January 2008 and December 2017 were evaluated. All patients were considered asymptomatic for underlying heart disease. However, 2 (0.9%) patients with a central venous catheter were determined as having endocarditis following echocardiography.

Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey.

OBJECTIVES: The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey. METHODS: A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed. RESULTS: A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies. CONCLUSION: The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.

The prevalence, serogroup distribution and risk factors of meningococcal carriage in adolescents and young adults in Turkey.

The serogroup epidemiology of invasive meningococcal disease (IMD), which varies considerably by geographic region and immunization schedule, changes continuously. Meningococcal carriage data are crucial for assessing IMD epidemiology and designing f potential vaccination strategies. Meningococcal seroepidemiology in Turkey differs from that in other countries: serogroups W and B are the predominant strains for IMD during childhood, whereas no serogroup C cases were identified over the last 10 y and no adolescent peak for IMD was found. There is a lack of data on meningococcal carriage that represents the whole population. The aims of this multicenter study (12 cities in Turkey) were to evaluate the prevalence of Neisseria meningitidis carriage, the serogroup distribution and the related risk factors (educational status, living in a dormitory or student house, being a household contact with Hajj pilgrims, smoking, completion of military service, attending bars/clubs) in 1518 adolescents and young adults aged 10-24 y. The presence of N. meningitidis DNA was tested, and a serogroup analysis was performed using polymerase chain reaction. The overall meningococcal carriage rate was 6.3% (n = 96) in the study population. A serogroup distribution of the 96 N. meningitidis strains isolated from the nasopharyngeal specimens revealed serogroup A in 5 specimens (5.2%), serogroup B in 9 specimens (9.4%), serogroup W in 64 specimens (66.6%), and serogroup Y in 4 specimens (4.2%); 14 were classified as non-grouped (14.4%). No serogroup C cases were detected. The nasopharyngeal meningococcal carriage rate was 5% in the 10-14 age group, 6.4% in the 15-17 age-group, and 4.7% in the 18-20 age group; the highest carriage rate was found in the 21-24 age group (9.1%), which was significantly higher than those of the other age groups (p < 0.05). The highest carriage rate was found in 17-year-old adolescents (11%). The carriage rate was higher among the participants who had had close contact with Hajj/Umrah pilgrims (p < 0.01) or a history of upper respiratory tract infections over the past 3 months (p < 0.05). The nasopharyngeal carriage rate was 6.3% among adolescents and young adults in Turkey and was similar to the recent rates observed in the same age groups in other countries. The most prevalent serogroup was W, and no serogroup C cases were found. In conclusion, the present study found that meningococcal carriage reaches its peak level by age 17, the highest carriage rate was found in 21 - to 24 - year-olds and the majority of the carriage cases were due to serogroup W. Adolescents and young adult carriers seem to be a potential reservoir for the disease, and further immunization strategies, including adolescent immunization, may play a role in the control of IMD.

Lactobacillus reuteri DSM 17938 shortens acute infectious diarrhea in a pediatric outpatient setting / O Lactobacillus reuteri DSM 17938 reduz a diarreia infecciosa aguda no cuidado pediátrico ambulatorial

OBJECTIVE: Two randomized controlled clinical trials have shown thatLactobacillus (L) reuteri DSM 17938 reduces the duration of diarrhea in children hospitalized due to acute infectious diarrhea. This was the first trial evaluating the efficacy of L. reuteri DSM 17938 in outpatient children with acute infectious diarrhea.METHODS: This was a multicenter, randomized, single-blinded, case control clinical trial in children with acute watery diarrhea. A total of 64 children who presented at outpatient clinics were enrolled. The probiotic group received 1 × 108 CFU L. reuteri DSM 17938 for five days in addition to oral rehydration solution (ORS) and the second group was treated with ORS only. The primary endpoint was the duration of diarrhea (in hours). The secondary endpoint was the number of children with diarrhea at each day of the five days of intervention. Adverse events were also recorded.RESULTS: The mean duration of diarrhea was significantly reduced in the L. reuteri group compared to the control group (approximately 15 h, 60.4 ± 24.5 h [95% CI: 51.0-69.7 h] vs. 74.3 ± 15.3 h [95% CI: 68.7-79.9 h], p < 0.05). The percentage of children with diarrhea was lower in the L. reuteri group (13/29; 44.8%) after 48 h than the control group (27/31; 87%; RR: 0.51; 95% CI: 0.34-0.79,p < 0.01). From the 72nd hour of intervention onwards, there was no difference between the two groups in the percentage of children with diarrhea. No adverse effects related to L. reuteri were noted.CONCLUSION:L. reuteri DSM 17938 is effective, safe, and well-tolerated in outpatient children with acute infectious diarrhea.

OBJETIVO: Dois ensaios clínicos randomizados controlados demonstraram que oLactobacillus (L) reuteri DSM 17938 reduz a duração de diarreia em crianças hospitalizadas devido a diarreia infecciosa aguda. Este é o primeiro ensaio que avalia a eficácia do L. reuteri DSM 17938 em crianças com diarreia infecciosa aguda no ambulatório.MÉTODOS: Ensaio clínico multicêntrico, randomizado, único cego, com grupos paralelos e controlado em crianças com diarreia aguda. Foram inscritas 64 crianças internadas na clínica ambulatorial. O grupo probiótico recebeu 1 × 108 CFU L. reuteri DSM 17938 por cinco dias, além de uma solução de reidratação oral (SRO), e o segundo grupo foi tratado apenas com SRO. O desfecho principal foi a duração da diarreia (em horas). O desfecho secundário foi o número de crianças com diarreia em cada um dos cinco dias da intervenção. Os eventos adversos também foram registrados.RESULTADOS: A duração média da diarreia foi significativamente reduzida no grupoL. reuteri em comparação com o grupo de controle (aproximadamente 15 horas; 60,4 ± 24,5 horas [51,0-69,7 horas, IC de 95%] em comparação com 74,3 ± 15,3 horas [68,7-79,9 horas, IC de 95%], p < 0,05). O percentual de crianças com diarreia foi menor no grupo L. reuteri (13/29; 44,8%) após 48 horas do que no grupo de controle (27/31; 87%) (RR: 0,51; 0,34-0,79; IC de 95%, < 0,01). A partir da 72a hora de intervenção, não havia diferença entre os dois grupos no percentual de crianças com diarreia. Nenhum efeito adverso com relação ao L. reuteri foi observado.CONCLUSÃO: O L. reuteri DSM 17938 é eficaz, seguro e bem tolerado por crianças com diarreia infecciosa aguda no ambulatório.

Acute transverse myelitis complicating breakthrough varicella infection.

We report a 10-year-old girl who presented with acute transverse myelitis after breakthrough varicella infection. The diagnosis was based on the development of motor weakness, paraparesis and bladder dysfunction, spinal magnetic resonance imaging findings and detection of anti-varicella zoster virus IgG antibody in the cerebrospinal fluid. This case report highlights that breakthrough varicella can result in serious complications such as acute transverse myelitis.

Severe Hemolytic Anemia Associated with Mild Pneumonia Caused by Mycoplasma pneumonia.

We report a case of M. pneumoniae infection presenting with severe hemolytic anemia in a 4-year-old girl, with a ten-day history of paleness, weakness, and nonproductive cough. She was very pale and tachycardic. However, she was not tachypneic. Chest examination showed normal breath sounds. No rhoncus or whistling was heard. As the erythrocyte sedimentation rate was excessively elevated, the differential diagnosis primarily comprised hematological malignancies. Direct Coombs' test was positive. Diagnosis of M. pneumoniae infection was confirmed by elevated levels of M. pneumoniae IgG and IgM antibodies and a chest X-ray suggestive of atypical pneumonia. The patient was treated with clarithromycin and packed red cell transfusion and showed a favorable recovery within ten days after admission. In conclusion, this case demonstrates that severe hemolytic anemia caused by M. pneumoniae is not always associated with severe pulmonary involvement, even when the respiratory infection is very mild, M. pneumoniae may be the cause of severe anemia.

Human soluble tumor necrosis factor receptor I (sTNF-RI) and interleukin-I receptor antagonist (IL-I Ra) in different stages of acute rheumatic fever.

OBJECTIVE: Acute rheumatic fever (ARF) results from an autoimmune response to infection with group A streptococci. Serum concentrations of two anti-inflammatory cytokines, interleukin-I receptor antagonist (IL-IRa) and human soluble tumor necrosis factor receptor I (sTNF-RI) were determined in patients with ARF at the time of admission and 3 months after treatment in order to evaluate changes in cytokine concentrations occurring during different stages of the disease. METHODS: Serum concentrations of two anti-inflammatory cytokines, IL-I Ra and sTNF-RI , were investigated in children with ARF at the time of admission (n=21) and after 3 months following the cessation of treatment (n=15). The sTNF-RI and sIL-IRa were measured quantitatively in serum using enzyme-linked immunosorbent assay (ELISA). RESULTS: Levels of IL-1Ra and sTNF-RI were found to be significantly higher during acute phase and remission period of ARF when compared to age-matched healthy controls (p=0.001 and p=0.0001, respectively). CONCLUSION: Our study demonstrated that two anti-inflammatory cytokines, serum sTNFRI and IL-1Ra, are increased in acute and remission stages of ARF reflecting activation of the cellular immune response. We suggest this increase might probably be generated in an effort to counteract the already increased concentrations of proinflammatory cytokines.

Parainfluenza type 3 outbreaks in Izmir children, Turkey.

The present study was aimed to investigate characteristics of lower respiratory tract infections caused by parainfluenza type 3 viruses. Nasopharyngeal smears were taken from 178 patients with lower respiratory infections for the diagnosis of respiratory syncytial virus, adenovirus, influenza and parainfluenza viruses between December 2004 and April 2005. Parainfluenza type 3 was isolated from the viral specimens of 96 (53.9%) patients and it was noticeable that the parainfluenza type 3 outbreak occurs during winter. Obviously, improving the aetiological diagnosis of viral infections might avoid unnecessary therapy, antibiotics in particular, and would allow for preventive isolation of infected patients.

Evidence of an association between mannose binding lectin codon 54 polymorphism and adenoidectomy and/or tonsillectomy in children.

Mannose binding lectin (MBL) is a calcium-dependent lectin that plays an important role innate immunity by activating the complement pathway. There have been a number of studies describing an association between the MBL genotype and disease susceptibility. MBL deficiency has been described as one of the factors leading to a number of infections in children with recurrent upper respiratory tractus infections (URTI). We hypothesized that MBL deficiency may be associated with recurrent URTI, which requires adenoidectomy and/or adenotonsillectomy. In this study to clarify this hypothesis we investigated whether there may be an association between two low producing MBL variants and adenoidectomy and/or tonsillectomy due to recurrent URTI in children. Blood samples were collected, adenoidectomy and/or tonsillectomy due to recurrent URTI and 50 controls (mean age 80.53 +/- 32.62 months). In all patients and controls codon 54 and codon 57 polymorphisms of the MBL gene were analyzed. None of the subjects from the patient group and control group carried codon 57 polymorphism of the MBL gene. The frequency of low-level MBL genotypes (AB and BB) for codon 54 polymorphism in the patient group was found to be significantly higher compared to the control subjects (55.7% versus 14%) (p<0.001). This study shows that the presence of low-level MBL alleles is associated with adenoidectomy and/or tonsillectomy caused by recurrent URTI in children.

Pyoderma gangrenosum in a six-month-old boy.

Pyoderma gangrenosum (PG) is an uncommon, chronic ulcerative condition of the skin that was first described in 1930. It can occur in any age group, but only 4% of the patients are infants or children. An underlying systemic disease is present in approximately 50% of the patients with PG. The most common associations include inflammatory bowel disease, arthritis, lymphoproliferative disorders and chronic recurrent multifocal osteomyelitis (CRMO). PG has been reported in association with CRMO in only a few children whose ages were between 18 months and 12 years. We report a six-month-old boy who was diagnosed as CRMO based on his clinical examination and histological findings. This is the youngest case reported in the literature (under 12 months of age) with PG associated with CRMO.

Evaluation of 80 children with prolonged fever.

BACKGROUND: Several studies have been published regarding the etiology and evaluation of a child with prolonged fever, however, the reasons for the prolonged fever have changed during the years. The present study aims to determine the causes of prolonged fever, to investigate the relationship of fever using some basic laboratory tests, and to establish guidelines for the approach in those children. METHODS: The charts of 80 out of 17490 hospitalized children who were seen between 1996 and 2001 with prolonged fever of longer than 2 weeks and unknown origin were reviewed in the university hospital of Izmir, Turkey. Their charts were evaluated in respect of age, sex, growth curves, educational level of their families, the duration and the magnitude of fever, causes of fever, and basic laboratory investigations such as white blood cell, blood smear, hemoglobin, erythrocyte sedimentation rate, and C-reactive protein. RESULTS: Forty-four (55.00%) were boys and 36 (45.00%) were girls. Forty-four children (55.00%) were aged between 1 month and 2 years, 21 (26.25%) were aged 3-6 years, seven (8.75%) were aged 7-10 years, and eight (10.00%) were older than 10 years. The mean age was 3.87 +/- 4.17 years (range 3 months-17 years). Forty-six children (57.50%) had a prolonged fever that had lasted from 15-30 days, 18 (22.50%) from 31-60 days, and 16 (20.00%) had fever lasting more than 60 days. Final diagnosis had been reached in 70 of the 80 children (87.50%). The most common causes were infection (47/80), followed by immune deficiency (6/80), collagen tissue disorder (5/80), neoplasia (2/80), and miscellaneous (10/80) such as central fever in three, diabetes insipidus in two, familial Mediterranean fever in two, Kawasaki disease, foreign body in the respiratory system, and Crohn disease in one patient each. Among the laboratory tests white blood cell count, hemoglobin level and blood smear distribution of infection group were statistically significant. CONCLUSIONS: The most common cause of fever of unknown origin remains infection. The proportion of collagen tissue disorders and neoplasia have been found to be decreased. Unusual reasons such as diabetes insipidus and foreign body in the respiratory system in the miscellaneous group have been detected. Age plays important role in the diagnosis of prolonged fever, while some basic laboratory tests might give clues in the evaluation and may suggest a diagnosis.