Disrupted epithelial permeability as a predictor of severe COVID-19 development.

BACKGROUND: An impaired epithelial barrier integrity in the gastrointestinal tract is important to the pathogenesis of many inflammatory diseases. Accordingly, we assessed the potential of biomarkers of epithelial barrier dysfunction as predictive of severe COVID-19. METHODS: Levels of bacterial DNA and zonulin family peptides (ZFP) as markers of bacterial translocation and intestinal permeability and a total of 180 immune and inflammatory proteins were analyzed from the sera of 328 COVID-19 patients and 49 healthy controls. RESULTS: Significantly high levels of circulating bacterial DNA were detected in severe COVID-19 cases. In mild COVID-19 cases, serum bacterial DNA levels were significantly lower than in healthy controls suggesting epithelial barrier tightness as a predictor of a mild disease course. COVID-19 patients were characterized by significantly elevated levels of circulating ZFP. We identified 36 proteins as potential early biomarkers of COVID-19, and six of them (AREG, AXIN1, CLEC4C, CXCL10, CXCL11, and TRANCE) correlated strongly with bacterial translocation and can be used to predict and discriminate severe cases from healthy controls and mild cases (area under the curve (AUC): 1 and 0.88, respectively). Proteomic analysis of the serum of 21 patients with moderate disease at admission which progressed to severe disease revealed 10 proteins associated with disease progression and mortality (AUC: 0.88), including CLEC7A, EIF4EBP1, TRANCE, CXCL10, HGF, KRT19, LAMP3, CKAP4, CXADR, and ITGB6. CONCLUSION: Our results demonstrate that biomarkers of intact or defective epithelial barriers are associated with disease severity and can provide early information on the prediction at the time of hospital admission.

Investigation of IL-35 and IL-39, New Members of the IL-12 Family, in Different Clinical Presentations of Brucellosis.

Brucellosis is significantly influenced by the interactions between the causative Brucella bacteria and host immunity. Recently identified cytokines have been described for their immunomodulatory effects in numerous inflammatory, autoimmune and infectious diseases. Some of them are new members of cytokine superfamilies, including several members of the IL-12 superfamily (IL-35, IL-39). The major purpose of the present study was to investigate the role of these new immunomodulatory cytokines in Brucella infections. The levels of IL-35 and IL-39 in the serum of 40 acute and 40 chronic brucellosis patients and 40 healthy controls were measured by ELISA. The mRNA levels of IL-35 and IL-39 in PBMCs were detected by RT-qPCR. Both IL-35 and IL-39 serum concentrations were significantly higher in healthy control subjects than in brucellosis patients, and IL-35 and IL-39 serum levels of chronic brucellosis patients were higher than those of acute cases. It was also found that the expression of Ebi3/IL-12A (IL-35 genes) and Ebi3/IL-23A (IL-39 genes) was upregulated in chronic brucellosis patients compared to healthy controls. Moreover, the expression of the Ebi3/IL-12A and Ebi3/IL-23A genes was lower in patients with acute brucellosis than in patients with chronic brucellosis. Overall, this study showed that IL-35 and IL-39 are positively correlated in brucellosis and significantly decreased during the disease. Significantly lower levels of IL-35 and IL-39 in acute brucellosis than in chronic brucellosis and healthy controls suggest that these cytokines may play a key role in suppressing the immune response to brucellosis and its progression to chronicity.

IL-35 and IL-39, new members of the IL-12 cytokine family, are immunomodulatory cytokines characterized as anti-inflammatory and pro-inflammatory, respectively.In acute and chronic brucellosis, serum IL-35 and IL-39 are significantly decreased.In acute brucellosis, serum IL-35 are significantly lower than in chronic brucellosis, suggesting that this cytokine may play a role in chronification.A positive correlation was found between IL-35 and IL-39 in acute and chronic brucellosis, suggesting that the common protein subunit Ebi may be suppressed.According to the results of this study, IL-35 and IL-39 may play a role in the pathogenesis of brucellosis.

The Age-Dependent Role of Th22, Tc22, and Tc17 Cells in the Severity of Pneumonia in COVID-19 Immunopathogenesis.

Coronavirus disease 2019 (COVID-19) has clinical manifestations ranging from mild symptoms to respiratory failure, septic shock, and multi-organ failure. Lymphocytes are divided into different subtypes based on their cytokine production pattern. In this study, we investigated the role of cytokine expressions of CD4+ T (T helper [Th]1, Th2, Th17, Th22) and CD8+ T cell subtypes (T cytotoxic [Tc]1, Tc2, Tc17, Tc22) in the pathogenesis of COVID-19. Peripheral blood mononuclear cells (PBMCs) were extracted with Ficoll by density gradient centrifugation from blood samples of 180 COVID-19 patients (children and adults) and 30 healthy controls. PBMCs were stimulated with PMA and Ionomycin and treated with Brefeldin A in the fourth hour, and a 10-colored monoclonal antibody panel was evaluated at the end of the sixth hour using flow cytometry. According to our findings, the numbers of Th22 (CD3+, CD4+, and interleukin [IL]-22+) and Tc22 (CD3+, CD8+, IL-22+) cells increased in adult patients regardless of the level of pneumonia (mild, severe, or symptom-free) as compared with healthy controls (p < 0.05). In addition, the number of Tc17 (CD3+, CD8+, and IL-17A+) cells increased in low pneumonia and severe pneumonia groups compared with the healthy controls (p < 0.05). Both IL-22 and IL-17A production decreased during a follow-up within 6 weeks of discharge. Our findings suggest that the increase in only IL-22 expressed Tc22 cells in the 0-12 age group with a general symptom-free course and higher levels of Th22 and Tc22 in uncomplicated adult cases may indicate the protective effect of IL-22. On the contrary, the association between the severity of pneumonia and the elevation of Tc17 cells in adults may reveal the damaging effect of IL-22 when it is co-expressed with IL-17.

Assessment of CD39 expression in regulatory T-cell subsets by disease severity in adult and juvenile COVID-19 cases.

COVID-19 is a disease characterized by acute respiratory failure and is a major health problem worldwide. Here, we aimed to investigate the role of CD39 expression in Treg cell subsets in COVID-19 immunopathogenesis and its relationship to disease severity. One hundred and ninety COVID-19 patients (juveniles, adults) and 43 volunteers as healthy controls were enrolled in our study. Flow cytometric analysis was performed using a 10-color monoclonal antibody panel from peripheral blood samples. In adult patients, CD39+ Tregs increased with disease severity. In contrast, CD39+ Tregs were decreased in juvenile patients in an age-dependent manner. Overall, our study reveals an interesting profile of CD39-expressing Tregs in adult and juvenile cases of COVID-19. Our results provide a better understanding of the possible role of Tregs in the mechanism of immune response in COVID-19 cases.

A rare pediatric case of neurobrucellosis with bilateral optic neuritis.

BACKGROUND: The estimated incidence of central nervous system involvement in brucellosis ranges between 0 and 17.8%. Optic neuritis is infrequently seen in the clinical presentation of neurobrucellosis. Only six cases of neurobrucellosis manifesting with optic neuritis have been previously reported in the literature during childhood. Moreover, four of these were isolated optic neuritis. CASE: An 11-year-old boy presented with the complaint of bilateral visual loss which was more prominent in the left eye than the right. He was diagnosed with brucellosis two months prior. His fundus examination revealed mild papilledema of the right eye and remarkable papilledema of the left eye. Brucella agglutination titer of serum was 1/640. Cerebrospinal fluid (CSF) cultures were negative, but polymerase chain reaction (PCR) examination in CSF was positive for Brucella melitensis. Antibiotic and pulse methylprednisolone treatments were administered. The visual acuity returned incompletely within the 12-month follow-up period. CONCLUSION: Isolated optic neuritis is a rare manifestation of neurobrucellosis in children.

Roles of novel IL-1 family (IL-36, IL-37, and IL-38) members in chronic brucellosis.

The secretion of interleukin (IL)-1 family cytokines is one of the most potent and earliest pro-inflammatory responses triggered by brucellosis. However, the roles of the most recently discovered IL-1 family members, IL-36, IL-37, and IL-38, in the transition into the chronic form of brucellos is remain largely unknown. Therefore, in this study, the roles of IL-36, IL-37, and IL-38 in brucella infections and their effects on the transition from the acute to chronic form of the disease were investigated. Using peripheral blood samples from 40 patients with acute brucellosis, 40 patients with chronic brucellosis, and 40 healthy control subjects, we analysed the serum concentrations of secreted IL-36, IL-37, and IL-38 using ELISA. The findings were confirmed by using RT-qPCR to analyse the mRNA levels of the genes encoding IL-36, IL-37, and IL-38 in peripheral blood mononuclear cells (PBMCs) from 10 randomly selected patients from each of the three groups. Our results showed that serum IL-37 (p < 0.001) and IL-38 (p < 0.001) concentrations were lower in patients with brucellosis than in the healthy controls. In addition, serum IL-37 and IL-38 concentrations were higher in the chronic patient group than in the acute patient group. The mRNA expression levels of IL-37 and IL1F10, genes that encode IL-38, did not affect serum cytokine secretion levels. This result suggests that the high secretion levels of IL-37 and IL-38 may be related to the progression into the chronic form of brucellosis. Our findings will aid in clarifying the mechanism of the transition of brucellosis from the acute to the chronic form of the disease.

Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study.

PURPOSE: Ventriculoperitoneal shunt (VPS) is the most common treatment modality for hydrocephalus. However, VPS infection is a common and serious complication with high rates of mortality and morbidity. The objective of this study was to investigate causative agents and the management of VPS infections and to identify risk factors for re-infection in children. MATERIALS AND METHODS: Retrospective, multicentre study on patients with VPS infection at paediatric and neurosurgery departments in four tertiary medical centres in Turkey between January 2011 and September 2014. RESULTS: A total of 290 patients with VPS infections were identified during the study period. The aetiology of hydrocephalus was congenital malformations in 190 patients (65.5%). The most common symptom of shunt infection was fever in 108 (37.2%) cases. At least one pathogen was identified in 148 VPS infections (51%). The most commonly isolated pathogen was coagulase-negative staphylococci, which grew in 63 cases (42.5%), followed by Pseudomonas aeruginosa in 22 cases (14.9%), Klebsiella pneumoniae in 15 cases (10.1%), and Staphylococcus aureus in 15 cases (10.1). The median duration of VPS infection was 2 months (range, 15 days to 60 months) after insertion of the shunt, with half (49.8%) occurring during the first month. VPS infection was treated by antibiotics and shunt removal in 211 cases (76.4%) and antibiotics alone without shunt removal in 65 patients (23.5%). Among the risk factors, CSF protein level greater than 100 mg/dL prior to VPS insertion was associated with a potential risk of re-infection (OR, 1.65; p =.01). CONCLUSION: High protein levels (>100 mg/dL) before the re-insertion of a VPS may be a risk factor for VPS re-infection.

Evaluation of Gelatin Tannate Against Symptoms of Acute Diarrhea in Pediatric Patients.

BACKGROUND Acute diarrhea is the second most common cause of morbidity and mortality worldwide, especially in children aged ≤3 years. Some drugs (e.g., the mucoprotector gelatin tannate) plus a reduced osmolality oral rehydration solution (ORS) may effectively reduce symptom duration and severity. The current trial was therefore designed to assess the efficacy and safety of gelatin tannate in pediatric patients with acute diarrhea. MATERIAL AND METHODS This was a randomized, controlled, double-blind, parallel-group, single-center study comparing gelatin tannate plus ORS (103 patients) with ORS plus placebo (100 patients) in children aged 3 months to 12 years with infectious or noninfectious acute diarrhea. Details about stool consistency and total time to resolution of diarrhea comprised the primary study endpoints. Secondary study endpoints included symptoms of diarrhea at 12, 24, 36, 48, and 72 hours after the first dose of study medication. RESULTS From 12 hours onwards, the incidence of watery stools was significantly lower in the gelatin tannate group than in the ORS group (at 12 hours: 59.2% vs. 77.0%; p=0.01). The same was true for stool frequency (at 12 hours: mean 2 vs. 3 stool productions in the previous 12 hours; p<0.01). At all timepoints during the study, the proportion of patients with Stool Decrease Index improvement was significantly greater (p<0.01) in the gelatin tannate group than in the placebo group (at 12 hours: 66.6% vs. 33.3%; p<0.01). CONCLUSIONS Gelatin tannate plus ORS is an effective and safe option for the treatment of acute diarrhea in children. Significant symptom relief is evident 12 hours after starting treatment.

Use of Colistin in a Neonatal Intensive Care Unit: A Cohort Study of 65 Patients.

BACKGROUND The emergence of infections related to multidrug-resistant Gram-negative bacilli (MDR-GNB) reintroduced the use of colistin, an antibiotic that was previously abandoned due to adverse effects. However, because of its limited use in neonatal intensive care units, there is very little data about the effectiveness and safety of colistin in children and newborns. In this study, which will be the largest case study in the literature, we aimed to evaluate the effectiveness and safety of colistin in full-term and preterm newborns. MATERIAL AND METHODS The study included patients admitted into 2 level 3 neonatal intensive care units between January 2013 and June 2015. The medical records of patients diagnosed with sepsis, meningitis, pneumonia, and urinary tract infection based on the diagnostic culture results and treated with colistin were analyzed retrospectively. The patients whose infections were not verified were excluded from the study. RESULTS The study included 65 patients (18 term, 47 preterm). The most frequently isolated pathogens were Klebsiella pneumoniae and Acinetobacter baumannii followed by Pseudomonas aeruginosa and Enterobacter cloacae. Mean colistin treatment time was 15±3.5 days. All patients treated with colistin were being treated with at least 1 other antibiotic. While a complete clinical response was achieved in 51 (72.3%) patients, 14 (21.5%) patients died during treatment. Four (7.7%) patients died during as a result of another infection. Three patients developed renal toxicity, another 3 patients had seizures, and apnea was observed in 3 patients. CONCLUSIONS Colistin was found to be effective and safe for treatment of MDR-GNB infections in preterms and infants with very low birth weight. Given the severity of the infection, the adverse effects of colistin were at acceptable levels.

Intravenous Colistin Use for Multidrug-Resistant Gram-Negative Infections in Pediatric Patients.

BACKGROUND: The emergence of infections due to multidrug-resistant Gram-negative bacilli (MDR-GNB) has led to the resurrection of colistin use. The data on colistin use and drug-related adverse effects in children are scarce. AIMS: In this study, we aimed to evaluate the clinical efficacy and safety of colistin use in critically ill pediatric patients. STUDY DESIGN: This study has a retrospective study design. METHODS: Sixty-one critically ill children were identified through the department's patient files archive during the period from January 2011 to November 2014. RESULTS: Twenty-nine females and thirty-two males with a mean±standard deviation (SD) age of 61±9 months (range 0-216, median 12 months) received IV colistin due to MDR-GNB infections. Bacteremia (n=23, 37.7%) was the leading diagnosis, followed by pneumonia (n=19, 31%), clinical sepsis (n=7, 11.4%), wound infection (n=6, 9.8%), urinary tract infection (n=5, 8.1%) and meningitis (n=1, 1.6%). All of the isolates were resistant to carbapenems; however, all were susceptible to colistin. The isolated microorganisms in decreasing order of frequency were: Acinetobacter baumanni (n=27, 44.2%), Pseudomonas aeruginosa (n=17, 27.8%), Klebsiella pneumoniae (n=6, 9.8%), K. pneumoniae and Stenotrophomonas maltophilia (n=1, 1.6%), K. pneumoniae and A. baumanni (n=1, 1.6%), K. oxytoca (n=1, 1.6%) and Enterobacter cloacae (n=1, 1.6%). In seven patients, no microorganisms were detected; however, five of these patients were colonized by carbapenem-resistant K. pneumoniae. The mean duration of colistin therapy was 12 days (range 3-45). Colistin was administered concomitantly with one of the following antibiotics: carbapenem (n=50, %82), ampicillin-sulbactam (n=5, 8%), quinolones (n=5, 8%), rifampicin (n=1, 1.6%). Carbapenem was the most frequently used antibiotic. Nephrotoxicity was observed in only 1 patient, and we did not observe neurotoxicity in this study. All the patients received intravenous colistin (colisthimethate) at a dosage of 5 mg/kg daily by dividing it in three equal doses. Seven (11.4%) patients died during the study period. CONCLUSION: Colistin appears to be a safe and efficacious drug for treating MDR-GNB infections in children.

The impact of a pneumococcal conjugate vaccination program on the nasopharyngeal carriage, serotype distribution and antimicrobial resistance of Streptococcus pneumoniae among healthy children in Turkey.

BACKGROUND: The 7-valent conjugate pneumococcal vaccine (PCV7) was introduced by the Turkey National Immunization Program in 2008 and replaced by the PCV13 in 2011. We assessed the impact of PCV vaccination on the nasopharyngeal (NP) carriage, serotype distribution and antimicrobial resistance of Streptococcus pneumoniae (SP) among healthy Turkish children. METHODS: A prospective surveillance study was performed between September 2011 and September 2013 in Istanbul, Turkey. NP swabs, demographic data, and vaccination statuses were obtained from 2165 healthy children aged 0-18years. Pneumococcal carriage was defined by a positive culture; serotyping was performed via multiplex conventional PCR, and the antibiotic susceptibilities of the isolates were determined based on the minimum inhibitory concentration (MIC) values of the Clinical Laboratory Standards Institute (CLSI). RESULTS: The prevalence of pneumococcal carriage was 6.4%. The carriage rates were 8%, 7%, and 5% in the following age groups: 0-24months, 25-60months, and >60months, respectively. The carriage rate was significantly higher in the 0-24month age group than in the >60months age group (p=0.03). Sixty percent of the children were not vaccinated with any PCV; 4%, 2%, and 4% received at least 1, 2 or 3 doses and 30% children received the full schedule (4 doses) of either PCV7 or PCV13. Among the isolated S. pneumoniae strains, 45% were of the non-vaccine type (NVT) and 55% were of the vaccine type (VT). The children who received at least a single PCV dose had significantly lower odds of colonization via VT serotypes than the non-vaccinated children [odds ratio: 0.61 (95% confidence interval=0.41-0.91), p=0.01]. The percentages of the serotypes covered by PCV7 and PCV13 were 51% and 56%, respectively. The most frequently isolated serotypes were 6A/B/C (n=22, 16.5%), 19F (n=18, 13.5%), 23F (n=15, 11.2%), serotype 9V/A (n=10, 7.5%), 12F (n=5, 4.5%), 15A/F (n=7, 4.5%) and 22 A/F (n=6, 4.5%). Using the meningitis criteria and the MIC, 62% of the isolates were resistant to penicillin and 13% were non-sensitive to ceftriaxone. Erythromycin and clindamycin resistance were 43% and 31%, respectively. CONCLUSION: We shown that following nation-wide PCV vaccination, S. pneumoniae NP carriage was decreased.

The effect of magnesium sulfate on uncontrollable contractions in a tetanus case.

Tetanus is a rare disease caused by the exotoxins of Clostridium tetani. Higher mortality rates have been reported among the elderly and in the newborn. In this report of a tetanus case, the treatment and prognosis of contractions resistant to diazepam, midazolam, and atracurium infusion has been evaluated.

TAR syndrome and esophagial atresia: a concomitant or variant condition?

Thrombocytopenia with absent radii (TAR) is rare cause of neonatal thrombocytopenia. TAR syndrome and esophageal atresia with tracheoesophageal fistula has been reported in only two cases in literature. Our case was the first in literature with unilateral TAR syndrome and bilateral absence of thumbs accompanying EA.

Necrotizing fasciitis caused by Staphylococcus epidermidis in a neonate with extremely low birthweight.

Necrotizing fasciitis (NF) is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. The initial skin presentation ranges from minimal rash to cellulites. The lesions subsequently spread rapidly. Even with appropriate medical and surgical therapy, the mortality rate in NF is more than 50%. In cases of neonates, mortality rate is higher than that ratio. High index of suspicion, prompt aggressive surgery, appropriate antibiotics and supportive care are the mainstays of management in the newborn infant with NF. Herein, we report a case of invasive and mortal NF caused by Staphylococcus epidermidis in an infant with extremely low birthweight.

Stroke and dilated cardiomyopathy associated with celiac disease.

Celiac disease (CD) is manifested by a variety of clinical signs and symptoms that may begin either in childhood or adult life. Neurological symptoms without signs of malabsorption have been observed for a long time in CD. In this report, an 8-year-old girl with CD presented with rarely seen dilated cardiomyopathy and stroke. The girl was admitted with left side weakness. Her medical history indicated abdominal distention, chronic diarrhea, failure to thrive, and geophagia. On physical examination, short stature, pale skin and a grade 2 of 6 systolic murmur were detected. Muscle strength was 0/5 on the left side, and 5/5 on the right side. Coagulation examinations were normal. Tests for collagen tissue diseases were negative. Factor V Leiden and prothrombin GA20210 mutations were negative. Tandem mass spectrophotometry and blood carnitine profiles were normal. Brain magnetic resonance imaging and cerebral angiography showed an infarction area at the basal ganglia level. Examinations of serologic markers and intestinal biopsy revealed CD. We emphasize that in differential diagnosis of ischemic stroke, CD should be kept in mind.

Investigation of oxidant and antioxidant pathway changes in acute rheumatic fever.

AIM: The purpose of this study was to investigate the role of oxidant stress in the clinical process and pathogenesis of acute rheumatic fever (ARF). MATERIAL AND METHODS: The study included 33 children with ARF and 20 healthy control subjects. The diagnosis of ARF was established according to the Jones Criteria. Malondialdehyde (MDA), reduced glutathione (GSH), alpha-tocopherol, ascorbic acid, retinol and beta-carotene levels were measured as markers of oxidative stress together with some antioxidant markers. RESULTS: Our study includes 33 (19 male, 14 female) children with ARF and 20 (11 male, 9 female) healthy control subjects. The mean age ranged between 5-16 years and 5-15 years in the study and control groups, respectively. MDA was measured as 2.1 +/- 0.9 nmol/mL in the control group, 3.3 +/- 2.7 nmol/mL in the study group before treatment, and 2.1 +/- 1.2 nmol/mL after treatment. Blood GSH levels were 48.2 +/- 12.7 mg/dL in the control group, 24.7 +/- 16 mg/dL in the study group before treatment, and 40.6 +/- 21.3 mg/dL in the study group after treatment. MDA and GSH levels prior to the treatment were found to be significantly high and low as compared with the levels of the control group, respectively (P < 0.05, P < 0.001). After treatment, statistically important decrements and increments were determined in the levels of MDA (P < 0.05) and GSH (P < 0.01), respectively. Furthermore, alpha-tocopherol, retinol and beta-carotene levels prior to treatment in the study group, were significantly lower in comparison with control group levels (P = 0.05, P < 0.05, P < 0.01, respectively). CONCLUSION: We suggested that tissue damage in ARF may not only occur in the presence of increased oxidative stress, but also as a consequence of decreased antioxidant markers.

Periorbital cellulitis caused by Bacillus thuringiensis.

PURPOSE: Periorbital cellulitis is an inflammation of the lids and periorbital tissues without signs of true involvement such as proptosis or limitation of eye movement. METHODS: Bacillus thuringiensis is a Gram-positive, spore-forming soil bacterium with the ability to produce insecticidal crystal proteins. B thuringiensis is an extremely rare causative organism of orbital and periorbital infections. However, it was rarely seen isolated in pediatric cases with preseptal cellulites. Ocular infections of this bacteria quickly progress, within 12-48 hours from inoculation, leading to endophthalmitis or panophthalmitis and irreversible vision loss. RESULTS: Periorbital cellulitis should be recognized promptly and treated carefully. Hospitalization, prompt systemic antibiotic therapy, and careful monitoring for signs of sepsis and local invasion are critical. CONCLUSIONS: We report a rare presentation of periorbital cellulitis caused by B thuringiensis.