Assessment of 17 Pediatric Cases With Colchicine Poisoning in a 2-Year Period.

AIM: The aim of the study is to discuss clinical effects, treatments, and outcomes of pediatric colchicine poisoning. METHOD: This study was designed as an observational case series study. The medical records of children aged between 0 and 18 years, who were hospitalized for colchicine poisoning at the Department of Pediatric Intensive Care Unit, Cumhuriyet University Faculty of Medicine, between January 2010 and January 2012, were retrospectively evaluated. RESULTS: We presented 17 children with colchicine poisoning. The mean (SD, range) age of patients was 71.5 (69.19, 18-204) months. The period to apply to the hospital after taking the medications was 7.3 hours (7.97, 30 minutes-26 hours) on average. The use of colchicine was due to diagnosis of Familial Mediterranean fever (FMF) in the families of 8 patients, diagnosis of Behçet disease in 1 patient's father, diagnosis of Behçet disease in 1 patient herself, and diagnosis of FMF in 6 patients themselves. Thirteen patients had taken colchicine at the dose of less than 0.5 mg/kg known as subtoxic and 1 patient had taken colchicine at the dose of greater than 0.8 mg/kg, and doses taken by 3 patients were not known. Fourteen patients (82.4%) had involuntary drug intake. Fifty percent of them were symptomatic at the moment of application and all had gastrointestinal complaints. All patients were observed in intensive care unit upon first admission and received supportive care. One of patients showed total alopecia, one showed leucocytosis, and another one showed acute abdomen picture. None of the patients showed mortality. CONCLUSIONS: Mortality of colchicine toxicity is high and quick assessment is absolutely required. In regions where FMF is common and the use of colchicine is high, clinicians should pay attention to symptoms and findings related to colchicine intoxication and keep them in mind in differential diagnosis.

Elevated chemokine levels during adult but not pediatric Crimean-Congo hemorrhagic fever.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a tick-borne viral zoonosis. Clinical reports indicate the severity of CCHF is milder in children than adults. The chemokines are important chemo-attractant mediators of the host immune system. OBJECTIVES: The main aim of the study was to identify whether or not there were any differences in chemokine levels between the pediatric and adult patients and control groups, and whether there was any correlation with disease severity. STUDY DESIGN: The serum levels of select chemokines including chemokine (C-C) ligand 2 (CCL2), CCL3, CCL4, chemokine (C-X-C) ligand 8 (CXCL8), CXCL9, and granulocyte-colony stimulating factor (G-CSF) in 29 adult and 32 pediatric CCHF patients and in 35 healthy children and 40 healthy adult control groups were studied by flow cytometric bead immunoassay method. RESULTS: Great variability was detected in the serum levels of the chemokines for both the adult and pediatric patients and controls. With the exception of G-CSF, the median serum levels of CCL2, CCL3, CCL4, CXCL8, and CXCL9 were found to be significantly higher in the adult patients compared to adult controls (2364.7 vs. 761 pg/ml; 714.1 vs. 75.2 pg/ml; 88.6 vs. 25.5 pg/ml; 217.9 vs. 18.3 pg/ml; 875 vs. 352.2 pg/ml, respectively, p < 0.0001 for all comparisons). Among the chemokines the median CCL4 and G-CSF levels were significantly higher in the pediatric patients compared to pediatric controls (40.3 vs. 7.1 pg/ml, p < 0.0001; 0.1 vs. 0.1 pg/ml, p = 0.049, respectively). CONCLUSION: The results of this study showed prominent chemokine raising in adult CCHF patients compared to children CCHF patients.

Value of ABO blood group in predicting the severity of children with Crimean-Congo hemorrhagic fever.

PURPOSE: The aim of this study was to assess the role of ABO blood groups in predicting disease severity and bleeding potential in children with Crimean-Congo hemorrhagic fever (CCHF). METHODS: One hundred fifty-one hospitalized patients with CCHF were enrolled in this retrospective study. The patients were divided according to O- and non-O- (A, B and AB) blood groups (n=91 and n=60, respectively). They were also classified into two groups (severe and non-severe) based on disease severity (n=29 and n=122, respectively). Demographic characteristics, clinical findings, and hematologic and biochemical parameters of all patients were recorded on admission and discharge. RESULTS: Although, in all cases, compared to the non-O blood group, the ratio of the blood group O was considerably higher (60% vs. 40%) and similarly so in severe cases (58.6% vs. 41.4%), this difference was not statistically significant (p>0.05). The aPTT at discharge and fever duration of the O-blood group were significantly higher than those of the non-O-blood group (p=0.042, p=0.034, respectively). The factor VIII level of the O-blood group was significantly lower than that of the non-O-blood group (p=0.040). Although the ratios of bleeding and severity were higher in the O-blood group compared to the other group, statistical significance was not reached (p>0.05). CONCLUSIONS: Consideration of the ABO blood group is important during diagnostic follow-up to assess the severity of CCHF. In clinical practice, pediatric CCHF patients with the O blood group need to be followed closely for tendency to bleed.

Plasma oxidative stress and total thiol levels in Crimean-Congo hemorrhagic fever.

In this study, we investigated the pro- and antioxidant status of patients with a pathogenesis of Crimean-Congo hemorrhagic fever (CCHF) in terms of their role in its pathogenesis. During the study period, 34 children and 41 adults were diagnosed with CCHF. The control group consisted of healthy age- and gender-matched children and adults. Serum levels of the total antioxidant capacity (TAC), total oxidant status (TOS), oxidative stress index (OSI), and plasma total thiol (TTL) were evaluated and compared between groups. The difference in mean TAC values between CCHF patients and healthy controls was not statistically significant (P > 0.05). Mean TOS, OSI, and TTL values were significantly lower in CCHF patients than in healthy controls (P < 0.001). Comparisons between the 2 groups revealed that mean TOS and OSI values were significantly lower in adults with CCHF than in their healthy counterparts (P < 0.001). Similarly, mean TTL levels were lower in both children and adults with CCHF when compared separately with healthy controls (P < 0.05). There was no significant difference in the mean serum TTL levels between children and adults with CCHF (P > 0.05). Our results suggest that TTL may play a more important role in CCHF pathogenesis than the other parameters investigated. The mean TOS and OSI values were higher in the control group than in CCHF patients.

Effect of antiepilepsy drug therapy on ventricular function in children with epilepsy: a tissue Doppler imaging study.

Impaired cardiac myocardial function may contribute to the risk for sudden unexpected death of a patient with epilepsy. This study aimed to investigate the effect of antiepilepsy drugs (AEDs) on cardiac function in pediatric epileptic patients using standard and tissue Doppler imaging (TDI) echocardiography. This hospital-based, prospective cross-sectional study investigated 52 epileptic children (mean age 9.3 ± 3.1 years) treated with AEDs (duration 2.4-10.0 years) and 36 healthy children (mean age 9.5 ± 4.0 years). In the epilepsy group, standard echocardiography showed increased left ventricular (LV) end-diastolic and end-systolic diameters, an increased LV mass index, and preserved ejection fraction. The patients also exhibited increased mitral peak A-wave velocity and mitral E-wave deceleration time as well as a decreased mitral E/A ratio. The E/Em ratio was significantly higher in the epilepsy group (5.6 ± 1.2) than in the control group (5.2 ± 1.1) (p = 0.016). In the epilepsy group, TDI showed an increased isovolumetric relaxation time and myocardial performance index (MPI). It also exhibited decreased early diastolic velocity (Em) and a decreased mitral annular displacement index in these patients. There were positive correlations between the LV lateral wall MPI (r = 0.231), septal MPI (r = 0.223), and LV mass index (p < 0.05) but no correlation with the duration of AED treatment. The authors detected subclinical ventricular dysfunction associated with AEDs at a preclinical stage. They suggest that TDI can be useful for determining the short- and long-term cardiac effects of AEDs.

Resting heart rate in children with Crimean-Congo hemorrhagic fever: a tool to identify patients at risk?

OBJECTIVE: We aimed to assess the association between resting heart rate (RHR) and severe infection in children with Crimean-Congo hemorrhagic fever (CCHF). METHODS: In all, 121 patients under 18 years of age with a laboratory-confirmed diagnosis of CCHF were enrolled in the study. Patients were classified into two groups based on disease severity (severe group and nonsevere group). RHR was measured by electrocardiography (ECG) on admission. Maximum P-wave duration (Pmax), P-wave dispersion (Pd), QRS duration, corrected QT interval, and QT dispersion were also measured. RESULTS: Mean age was 11.4±3.9 years and 84 patients were male. Twenty-six patients were classified as severe. Patients in this group had a higher RHR (103.6±10.4 vs. 80.5±8.1, p=0.001) than those with nonsevere disease. There was no difference in Pmax, Pd, QRS duration, QTcmax, or QTc dispersion. The optimal cutoff value of RHR to predict disease severity was>96 beats per minute (bpm), with 70.6% sensitivity and 50.1% specificity. Bleeding, thrombocytopenia (≤80×10(9)/L), elevated aspartate transaminase (AST) (>208 IU/L), elevated alanine transaminase (ALT) (>87 IU/L), elevated lactate dehydrogenase (LDH) (>566 IU/L), long activated partial thromboplastin time (aPTT) (>42 s), and increased hospitalization days were more frequent in patients with RHR >96 bpm. Multivariate logistic regression analysis revealed low platelet count (<80×10(9)/L), long aPTT (>42 s), high LDH (>566 IU/L), and elevated RHR (>96 bpm) as independent risk factors for severe disease. CONCLUSIONS: We conclude that elevated RHR was significantly associated with severe disease in children with CCHF, thus offering the potential to identify patients with increased risk.

Can the mild clinical course of crimean-congo hemorrhagic fever in children be explained by cytokine responses?

Cytokines are possibly one of the factors responsible for death due to Crimean-Congo hemorrhagic fever (CCHF). This study aimed to determine the differences between the cytokine levels in children and adult patients with CCHF; the influence of cytokines; and the severity of the course of the disease, which seems to be milder in children. Thirty-four children and 36 adult patients diagnosed with CCHF between 2010 and 2011 were included in this study. Diagnosis was performed by serology or by the polymerase chain reaction for CCHF virus. Levels of IFN-γ, TNF-α, IL-1ß, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12 p70, IL-13, IL-17A, and IL-22 were measured in all serum samples. Although the disease had a fatal course in three adult patients, there were no deaths in children. Statistically significant differences were not observed between the cytokine concentrations in the adults and children. No differences were detected between the serum cytokine levels in the children with moderate and those with a severe clinical course of the disease. In the adult patients with fatal outcome, significantly higher serum levels of IL-2, IL-5, IL-9, IL-12 p70, and IL-13 were detected as compared to the cytokine levels in patients who survived the infection. No differences were detected between the serum levels of IFN-γ, IL-1ß, IL-17A, IL-22, IL-10, IL-6, IL-4, and TNF-α in the patients who died and those who survived. Thus, the milder clinical course in children with CCHF cannot be explained by the cytokine network alone. The incomplete maturation of the immune system and timing and scale of immune responses could change the outcome dramatically.

Tularemia in children: evaluation of clinical, laboratory and therapeutic features of 27 tularemia cases.

Tularemia is a zoonotic disease caused by Francisella tularensis. We aimed to explicate the clinical and laboratory findings of 27 consecutive tularemia patients who were included into the study. The average duration between onset of symptoms and diagnosis was 19.1 +/- 7.3 days. Sore throat (100%), fever (93%) and myalgia (100%) were the most frequently observed symptoms, while lymphadenopathy (100%), pharyngeal hyperemia (85%), tonsillitis (74%), and rash (7%) were the most frequently observed physical findings. Treatment failed in 6 patients: 1/13 streptomycin- (changed to doxycycline + streptomycin), 1/7 ciprofloxacin- (changed to streptomycin), and 4/7 gentamicin- (changed to streptomycin) receiving patients who had longer duration to treatment (26.5 +/- 2.9 days) than the 21 successfully treated cases (17.0 +/- 6.8 days). Tularemia should to be taken into account in the differential diagnosis in cases having tonsillopharyngitis and cervical lymphadenopathy without response to beta lactam/macrolide-group antibiotics in rural areas. We believe that streptomycin should be the first-line antibiotic in the treatment of pediatric tularemia cases, but it should be supported by comprehensive studies with larger patient series.

Cardiac findings in children with Crimean-Congo hemorrhagic fever.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) involves the multi-organ systems. The involvement of the heart in adult patients has been described previously. We investigated the electrocardiographic and echocardiographic findings of pediatric patients with CCHF. MATERIAL/METHODS: Patients younger than 16 years of age diagnosed with CCHF were enrolled in the study. The diagnosis of CCHF infection was based upon typical clinical and epidemiological findings and serological tests. All patients underwent a thorough cardiologic evaluation. A standard 12-lead electrocardiography and echocardiography were performed. RESULTS: Twenty-three consecutive patients who were hospitalized with diagnosis of CCHF were enrolled in the study (mean age: 12±2 years, 6 female). All electrocardiographic parameters were within normal ranges according to age. Seven patients (30%) had minimal (<1 cm) pericardial effusion. Fifteen (65%) patients had segmental wall motion abnormalities (hypokinesia). A second echocardiography revealed that all wall motion abnormalities had disappeared; the pericardial effusion persisted in only 2 of 7 patients (28%). CONCLUSIONS: Cardiac involvement appears to be more frequent in children with CCHF disease than in adults, but it is slighter and almost totally reversible; however, the course of the disease in children is milder than it is in adults.

Treatment failure of gentamicin in pediatric patients with oropharyngeal tularemia.

BACKGROUND: Tularemia is a zoonotic infection, and the causative agent is Francisella tularensis. A first-line therapy for treating tularemia is aminoglycosides (streptomycin or, more commonly, gentamicin), and treatment duration is typically 7 to 10 days, with longer courses for more severe cases. MATERIAL/METHODS: We evaluated 11 patients retrospectively. Failure of the therapy was defined by persistent or recurrent fever, increased size or appearance of new lymphadenopathies and persistence of the constitutional syndrome with elevation of the levels of the proteins associated with the acute phase of infection. RESULTS: We observed fluctuating size of lymph nodes of 4 patients who were on the 7th day of empirical therapy. The therapy was switched to streptomycin alone and continued for 14 days. The other 7 patients, who had no complications, were on cefazolin and gentamycin therapy until the serologic diagnosis. Then we evaluated them again and observed that none of their lymph nodes regressed. We also switched their therapy to 14 days of streptomycin. After the 14 days on streptomycin therapy, we observed all the lymph nodes had recovered or regressed. During a follow-up 3 weeks later, we observed that all their lymph nodes had regressed to the clinically non-significant dimensions (<1 cm). CONCLUSIONS: All patients were first treated with gentamicin, but were than given streptomycin after failure of gentamicin. This treatment was successful in all patients. The results of our study suggest that streptomycin is an effective choice of first-line treatment for pediatric oropharyngeal tularemia patients.

Crimean-Congo hemorrhagic fever disease due to tick bite with very long incubation periods.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral disease with a high mortality rate, and is one of the viral hemorrhagic fever syndromes. The average mortality rate of CCHF is 3-30%. Research indicates that the longest incubation period after a tick bite is 12 days in CCHF disease. However, in clinical practice, we encounter patients with CCHF as a result of tick bites with much longer incubation periods (max. 53 days) than those reported in the literature. We present herein CCHF cases presumably infected through tick bites and having incubation periods longer than the upper limit reported in the literature. METHODS: We analyzed the cases of the 825 CCHF patients admitted to our hospital from 2007 to 2010 and found that 312 of them had undoubtedly been bitten by a tick. We searched the patient records for information on the incubation period and found that 12 patients had experienced an incubation period of over 12 days, which is the longest incubation period stated in the literature for patients definitely bitten by a tick. RESULTS: A total of 12 patients (eight males and four females, with a mean age of 45 years) were recruited into this study. Five (41.7%) of the 12 patients had positive CCHF virus-specific IgM antibodies, three (25%) had a positive reverse transcription polymerase chain reaction test for CCHF virus, and four (33.3%) had positive results in both tests during the acute and/or convalescent phase of the disease. In these cases, the interval between tick bite and the onset of symptoms was a mean of 23.6 days (range 13-53 days). CONCLUSION: Physicians serving in endemic regions should be aware of these longer incubation periods after a tick bite. It is suggested that they perform more follow-ups on clinically and serologically highly suspected patients than they currently do.