Growth failure as the first expression of malnutrition in children with human immunodeficiency virus infection.

BACKGROUND: To define the onset, pattern, and earliest manifestations of malnutrition related to HIV infection. METHODS: A retrospective cross-sectional analysis of changes in weight and growth in a group of 54 children with perinatally acquired HIV infection was conducted. Eight children had asymptomatic HIV infection, 26 had symptomatic infection, and 20 had symptomatic infection and were referred for nutritional support. RESULTS: We found an early decline in the rate of linear growth with a relative preservation of the weight-for-age. Weight-for-height measurements were preserved until there was advanced HIV-related disease. CONCLUSIONS: This pattern can result in a false impression of adequate nutrition and emphasizes the importance of longitudinal growth data of the child with HIV infection. Evidence of linear growth failure before clinical wasting is apparent is an absolute indication for aggressive nutritional support.

Osseous metaplasia in benign colorectal polyps.

We report two unique cases of metaplastic ossification occurring within a tubulovillous adenoma and a juvenile polyp. In both lesions, well-formed bony spicules were present that were adjacent to living epithelial cells. The metaplastic bone revealed vimentin positivity and cytokeratin negativity. The pathogenesis of osseous metaplasia in colorectal tumors remains unclear, but the process seems to have no clinical significance.

Chronic active hepatitis in a child with human immunodeficiency virus infection.

The pathologic changes in the liver of a child with human immunodeficiency virus infection are described. The liver biopsy specimens show chronic active hepatitis with bile duct damage. To our knowledge, the etiology and pathogenesis of chronic liver disease in children with acquired immunodeficiency syndrome is not known. In this child, chronic active hepatitis is probably related to hepatitis B.

Fatal massive hepatic necrosis: a probable hypersensitivity reaction to sulfasalazine.

Sulfasalazine (salicylazosulfapyridine) is a commonly prescribed oral medication for inflammatory bowel disease. We report a case of a 15-yr-old boy with ulcerative colitis who developed a generalized hypersensitivity reaction with a serum sickness-like syndrome and severe hepatotoxicity while taking sulfasalazine, perphenazine, and amitriptyline. The injury to the liver persisted for 5 months after withdrawal of the drugs, and the patient died of terminal hepatic failure with massive hepatic necrosis. Severe hepatic toxicity to sulfasalazine is uncommon, but it can be fatal.

Esophageal cryptosporidiosis in a child with acquired immune deficiency syndrome.

Oral Candida and Candida esophagitis are common findings in patients with the acquired immune deficiency syndrome. The intestinal protozoan, Cryptosporidium, is known to cause gastrointestinal symptoms in these patients. We report a 2-yr-old child with acquired immune deficiency syndrome, who had oral candidiasis, dysphagia, and vomiting. Upper gastrointestinal endoscopy and esophageal biopsy led to a diagnosis of esophageal cryptosporidiosis. We recommend upper gastrointestinal endoscopy as a diagnostic tool in selected patients with acquired immune deficiency syndrome. This is in contradistinction to a previous report that concludes that endoscopy is not necessary in this setting.

Failure to thrive associated with chronic ulcer disease in a 9-year-old boy.

Chronic peptic ulcer disease is not generally considered to cause failure to thrive. We are reporting a 9-year-old child who suffered from chronic recurrent abdominal pain and failure to thrive. Investigation revealed that the child also had bacterial overgrowth and evidence of malabsorption. These findings were considered to be due to chronic peptic ulcer disease which caused intermittent small bowel obstruction and gastric outlet obstruction. Successful treatment of the ulcer alone resulted in catch-up growth and an end to the chronic recurrent pain. Recurrent abdominal pain when associated with atypical features or failure to thrive should be adequately investigated. Although rare, chronic peptic ulcer disease with its sequelae should be considered in the differential diagnosis of failure to thrive.

Cyclosporine as an alternative to surgery in children with inflammatory bowel disease.

Five children with ulcerative colitis for whom surgery was recommended were treated with cyclosporine. The five had received corticosteroids for 1-24 months. The group included two patients with acute-onset ulcerative colitis and three with acute exacerbations of intractable corticosteroid-dependent chronic ulcerative colitis. The average age at initiation of cyclosporine therapy was 13.8 years (range, 11.5-16); all five patients were boys. Cyclosporine was initiated in the hospital by continuous i.v. infusion. Trough levels of 400-600 ng/dl (measured by radioimmunoassay) were achieved, at which point oral cyclosporine was given and oral dosage was adjusted to similar levels. Significant hypertension requiring medical attention was seen in one patient. Of the two recently diagnosed acute cases, one failed to respond and required subtotal colectomy after 2 weeks of treatment, and the other, despite an initial response, had a subtotal colectomy 10 months later. Of the three corticosteroid-dependent children, none was able to be weaned from corticosteroids and all underwent subtotal colectomy. Our experience emphasizes that the appropriate role of cyclosporine as therapy for children with ulcerative colitis is yet to be determined. Cyclosporine was not effective as an alternative to surgery in our patients.

Identical twins concordant for Crohn's disease.

Identical twin adolescent girls developed Crohn's disease within 15 months of each other. Clinical symptoms, growth retardation, barium studies, disease course, and pathologic findings at the time of resection were remarkably similar. Seventeen pairs of twins concordant for Crohn's disease have now been reported, but only four discordant pairs. Such observations lend support to a considerable genetic influence on the development and course of Crohn's disease.

Helicobacter pylori and gastric lymphonodular hyperplasia in children.

The association of gastric lymphonodular hyperplasia and Helicobacter pylori infection has been reported only in children. Lymphonodular hyperplasia of the stomach is a well known radiographic and endoscopic entity. Over the past three decades, it has been associated with many conditions, ranging from a normal variant to a premalignant lesion. We have recently encountered five children with gastric lymphonodular hyperplasia, all of whom had H. pylori infection of the antrum. The literature regarding this association is reviewed, and a possible explanation for this age-dependent expression of H. pylori infection is offered.

Recurrence of autoimmune hepatitis in children after liver transplantation.

BACKGROUND: Liver transplantation is recognized as the appropriate treatment for end-stage liver disease due to chronic active autoimmune hepatitis. While it was initially thought that the disease did not recur after transplant, it is now generally accepted that adult patients may develop recurrent disease, with studies reporting a recurrence rate of < or = 25%. We have noted a higher incidence of recurrent autoimmune hepatitis in our pediatric patients undergoing liver transplant, with a high incidence of associated morbidity. METHODS: We reviewed the records of six children followed up for autoimmune hepatitis who underwent orthotopic liver transplant for complications of end-stage liver disease. RESULTS: Of the six, five developed recurrent autoimmune hepatitis at a mean time of 11.4 months after transplant. The disease was aggressive, leading to cirrhosis and retransplant in three patients, within 1 year of recurrence. A second recurrence of disease occurred in all three retransplanted patients. One patient has received a third liver transplant, one has died, and one patient is asymptomatic on medical therapy. Autoimmune hepatitis recurred in all four patients receiving tacrolimus. CONCLUSION: We conclude that liver transplant for autoimmune hepatitis is likely to be palliative for most pediatric patients. Potent immunosuppressives such as tacrolimus do not protect against the development of recurrent autoimmune hepatitis.

Double-blind, placebo-controlled trial of famotidine in children with abdominal pain and dyspepsia: global and quantitative assessment.

To determine the benefit of using an H2-receptor antagonist in children with abdominal pain and dyspepsia, 25 such children were enrolled in a double-blind, placebo-controlled trial of famotidine. Global and quantitative pain assessments were done before and after each treatment period. The quantitative assessment was calculated based on the abdominal pain score that was the sum of three components. Based on the global evaluation, there was a clear benefit of famotidine over placebo (68% vs 12%). Using the quantitative assessment, however, the mean improvement of the score using famotidine versus placebo was not statistically significant (3.37+/-3.53 vs 1.66+/-2.7). There was a significant improvement in this score during the first treatment period regardless of medication used (period effect: P = 0.05). A subset of patients with peptic symptoms demonstrated a significant drug effect that outweighed the period effect (drug effect: P = 0.01; period effect: P = 0.02). We conclude that famotidine subjectively improves the symptoms of children with recurrent abdominal pain but not objectively using the derived score. However, famotidine is significantly more effective than placebo among children with peptic symptoms. The use of this simple scoring scale may facilitate selecting those children who will benefit from H2-receptor antagonist therapy.

Sonographic evaluation of portal hypertension in children.

Portal hypertension, an expected consequence of cirrhosis, often has an insidious course in children. A noninvasive technique using abdominal sonography has been previously employed by several investigators as a means of diagnosing this condition. Their technique involves sonographically measuring the diameter of the lesser omentum, which increases as a result of engorged collaterals. In this communication, the method is successfully employed in two children, an infant in whom cirrhosis developed who eventually died from acquired immunodeficiency syndrome, and one whose portal hypertension was relieved after orthotopic liver transplantation. Although successful in these two instances, the theoretical basis on which this technique is based is critically evaluated. Anatomical relationships are reviewed that would caution sonographers who attempt to duplicate these studies. Modifications of the technique that will minimize potential false positive results are also discussed.

Atypical presentation of childhood acquired immune deficiency syndrome mimicking Crohn's disease: nutritional considerations and management.

A child with acquired immune deficiency syndrome became severely malnourished presumably as a result of multiple gastrointestinal infections, with numerous organisms including campylobacter, giardia, and cryptosporidium. These opportunistic infections preceded laboratory evidence of immune deficiency. Despite severe diarrhea and marked weight loss, there was no laboratory evidence of significant malabsorption. By using nasogastric feedings, we were successful in promoting a 60% weight gain, and a rise in serum albumin from 1.2 to 4.3 g/dl. While eventual outcome was not altered, this particular patient's clinical course was improved. We suggest that malnutrition should not be accepted as inevitable and that malabsorption should not be assumed in similar acquired immune deficiency syndrome patients. Appropriate studies for malabsorption should be done, and high caloric enteral feedings should be used whenever feasible.

Orthotopic liver transplantation for urea cycle enzyme deficiency.

Hyperammonemia, abnormalities in plasma amino acids and abnormalities of standard liver functions were corrected by orthotopic liver transplantation in a 14-day-old boy with carbamyl phosphate synthetase-I deficiency and in a 35-yr-old man with argininosuccinic acid synthetase deficiency. The first patient had high plasma glutamine levels and no measurable citrulline, whereas citrulline values were markedly increased in Patient 2. Enzyme analysis of the original livers showed undetectable activity of carbamyl phosphate synthetase-I in Patient 1 and argininosuccinic acid synthetase in Patient 2. Both patients were comatose before surgery. Intellectual recovery of patient 1 has been slightly retarded because of a brain abscess caused by Aspergillus infection after surgery. Both patients are well at 34 and 40 mo, respectively, after surgery. Our experience has shown that orthotopic liver transplantation corrects the life-threatening metabolic abnormalities caused by deficiencies in the urea cycle enzymes carbamyl phosphate synthetase-I and argininosuccinic acid synthetase. Seven other patients--six with ornithine transcarbamylase deficiency and another with carbamyl phosphate synthetase-I deficiency--are known to have been treated elsewhere with liver transplantation 1 1/2 yr or longer ago. Four of these seven recipients also are well, with follow-ups of 1 1/2 to 5 yr. Thus liver transplantation corrects the metabolic abnormalities of three of the six urea cycle enzyme deficiencies, and presumably would correct all.