Recognition of asthmatic symptoms in the pediatric age group.

Asthma produces substantial morbidity in childhood. Under-diagnosis may lead to inappropriate treatment and prolonged periods of illness and absence from school. The results of a recent International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire study in Malta showed a higher prevalence of wheezy symptoms in the Central North Region. The present study was carried out to test the null hypothesis that there is no correlation between potential exposure to pediatricians (measured as pediatric private clinics/1000 childhood population/week) and percentage of children aged 13-15 years of age responding positively in the questionnaire to having had wheezy symptoms. A significant, positive correlation was found between potential exposure to pediatricians and percentage of children aged 13-15 years responding positively to having had wheeze in the previous year (p=0.009). A negative correlation was also found for severity of asthma (>12 attacks in the previous 12 months) and potential exposure to pediatricians (p=0.01). This is the first report of potential exposure to pediatricians influencing the regional incidence of asthma on a national basis. This skew may be caused by the greater exposure of pediatricians to patients with severe forms of asthma in a hospital setting, and hence a higher index of suspicion for the milder forms of the disease. Asthma may be less severe in regions where there are a greater number of pediatricians because of recognition of the condition with appropriate treatment and/or prophylaxis.

Absence of bone marrow amastigotes in a child with kala-azar and acute lymphoblastic leukaemia.

Visceral leishmaniasis is suspected on the basis of clinical findings and a pancytopenic blood picture and is usually confirmed by the detection of amastigotes (Leishman-Donovan bodies) in a bone marrow aspirate. We describe a child on maintenance treatment for acute lymphoblastic leukaemia who developed visceral leishmaniasis and in whom amastigotes could not be detected in repeated bone marrow aspirates. Immunofluorescence antibody testing was positive. Immunocompromised patients in endemic areas who develop features of visceral leishmaniasis should have serological tests performed in addition to bone marrow aspiration in order to maximize the chances of making a diagnosis.

Pigeon breeder's lung in childhood: varied clinical picture at presentation.

Extrinsic allergic alveolitis occurs rarely in childhood. We present 5 cases and briefly review the literature regarding this condition in the pediatric population. This report includes all cases (n = 5) of extrinsic allergic alveolitis known to have occurred in childhood on Malta. All cases were males, and were initially misdiagnosed as having other respiratory illnesses or mental disturbances. The diagnosis was based on a history of exposure to birds, clinical findings, positive avian precipitins, a restrictive defect on pulmonary function tests, and a suggestive chest X-ray appearance. All were treated with high-dose oral steroids for 3-4 weeks, with excellent response. Although these patients appear to have suffered no long-term sequelae, delayed diagnosis can lead to irreversible pulmonary fibrosis. The diagnosis of extrinsic allergic alveolitis should be entertained early in the differential diagnosis of children presenting with unusual respiratory symptoms and signs.

Asthma, rhinitis and eczema in Maltese 13-15 year-old schoolchildren -- prevalence, severity and associated factors [ISAAC]. International Study of Asthma and Allergies in Childhood.

BACKGROUND: Allergic conditions, especially asthma, seem to be increasingly common the world over. The International Study of Asthma and Allergies in Childhood [ISAAC] was the first worldwide study carried out with standardized questionnaires in order to create a reliable global map of childhood allergy. OBJECTIVES: The Maltese Islands were one of the centres participating in this study and in this paper the data obtained from 4184 13-15 year olds from 22 state and three private schools [88.7% response rate], and also data obtained from some added 'local' questions addressed to the same children, are included. in order to evaluate the problem of allergic conditions in Maltese schoolchildren. RESULTS: 27.9% of the participants were wheezers 'ever' while 16% were current wheezers. Of the latter children 15.1% were experiencing nocturnal wheezing at least once a week and 22% had a wheezing episode severe enough to limit speech. Nasal problems were present in 52.7% of these teenagers and 47.4% of all respondents persisted with these symptoms up to the year of answering the questionnaire. Hayfever had been diagnosed in 32.3% of all the children. 12.8% of respondents had a recurring itchy rash suggestive of eczema for at least 6 months of their lives and 10% had it currently. This was slightly lower than the global mean, unlike the case of wheezing, which in Malta was more common than the world average, and rhinitis, for which we had the second highest cumulative prevalence rate in the world. Multiple variables such as gender, smoking, family history of atopy, pets, soft furnishings and living in busy roads affected the prevalence and severity of the allergic conditions studied. CONCLUSIONS: Allergic conditions are very common in Maltese schoolchildren and are causing a lot of hardship to these same youngsters. The results of this study should serve as a stimulus to try and decrease this suffering through better management of these conditions, measures to control possible detrimental factors and further research on asthma, allergic rhinitis and eczema.

Familial disseminated atypical mycobacterial infection in childhood: a human mycobacterial susceptibility gene?

Inherited defects in specific components of the immune system have provided many clues to the immunological mechanisms underlying resistance to microbial infection. We report a familial immune defect predisposing to disseminated atypical mycobacterial infection in childhood. 6 children with disseminated atypical mycobacterial infection and no recognised form of immunodeficency were identified. Four, including two brothers, come from a village in Malta, and two are brothers of Greek Cypriot origin. They presented with fever, weight loss, lymphadenopathy, and hepatosplenomegaly. They had anaemia and an acute phase response. A range of different mycobacteria (Mycobacterium fortuitum, M chelonei, and four strains of M avium intracellulare complex) were isolated. Treatment with multiple antibiotics failed to eradicate the infection, although treatment with gamma interferon was associated with improvement. Three have died and the surviving children have chronic infection. Tumour necrosis factor-alpha production in response to endotoxin and gamma-interferon was found to be defective in affected patients and their parents. T-cell proliferative responses to mycobacterial and recall antigens were reduced in parents of affected children and gamma-interferon production was diminished in the affected patients and their parents. Clinical and immunological features suggest that these patients are phenotypically similar to Lsh/Ity/Bcg susceptible mice. Understanding of this defect may provide insights into the mechanisms responsible for susceptibility to mycobacteria.

Central hypoventilation in a seven year old child following pertussis treated with negative pressure ventilation.

We report the case of a 7 year old girl who developed central hypoventilation following pertussis and who was treated by negative pressure ventilation using a new portable tank respirator. We believe this is the first reported case of central hypoventilation following pertussis successfully treated by intermittent negative pressure ventilation.

Mechanism of anaemia in resistant visceral leishmaniasis.

We have studied the mechanism of a transfusion-dependent anaemia found in a two-year-old Maltese girl with visceral leishmaniasis that was resistant to multiple courses of antimonial therapy. Major factors contributing to the anaemia were haemolysis occurring in both the massively enlarged spleen and liver and haemodilution resulting from expansion of the plasma volume. There was no evidence of significant ineffective erythropoiesis, but a reduced plasma iron in the presence of greatly increased iron stores suggested that reticuloendothelial hyperplasia was accompanied by abnormal iron retention by macrophages typical of the 'anaemia of chronic disorders'. This may limit the erythropoietic response to anaemia in chronic visceral leishmaniasis.