Clostridium difficile infection in pediatric patients (Review).

Clostridium difficile (C. difficile) infection (CDI) is the most common cause of healthcare-associated diarrhea and among adults, the worldwide incidence rate of the infection is increasing. There is a small amount of data in the literature for pediatric patients, but most indicate an increasing trend. C. difficile is a constituent of the normal microbiota; however, under specific conditions that cause a disruption of the normal bacterial flora, colonization of C. difficile and the released toxins that cause inflammation and mucosal damage occurs. Risk factors for CDI at any age include hospitalization, exposure to antibiotics, administration of proton pump inhibitors, invasive mechanical ventilation, immunosuppression and presence of associated comorbidities. Clinical manifestations range from asymptomatic colonization to fulminant disease characterized by toxic megacolon, intestinal perforation and, rarely, death. The aim of the present review was to outline the features of CDI in pediatric patients.

Treatment approaches in autoimmune pancreatitis (Review).

Autoimmune pancreatitis (AIP) is a rare disease. There are two distinct types of AIP: AIP type 1 (AIP-1), a pancreatic manifestation of a multi-organ disease linked to immunoglobulin (Ig)G4, and AIP type 2 (AIP-2), a pancreas-specific disease unrelated to IgG4. The usual course of treatment for AIP is oral corticosteroid medication. Rituximab has also been recommended for recurrent AIP-1 in order to initiate remission and provide ongoing treatment. Immunomodulators such as azathioprine are used to keep certain patients in remission. Evaluation also takes into account a number of pharmacological alternatives, including biologic drugs like anti-tumor necrosis factor therapy, a safe and efficient second-line treatment for AIP-2 relapse or steroid dependence. Corticosteroids and immunosuppressants, which are poorly tolerated due to considerable side effects, are being replaced by other biologic drugs, which may offer a beneficial therapeutic alternative.

Non-alcoholic fatty liver disease and hematologic manifestations (Review).

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease, and it is associated with numerous extra-hepatic manifestations or additional co-occurring diseases. The aim of the present review was the identification and management of the hematologic manifestations of NAFLD. One of the triggers is considered to be iron abnormalities. Increased ferritin levels, hepatic iron deposits and iron overload are associated with NAFLD. The iron overload degree and severity are associated with the level of liver fibrosis and with the risk for hepatocellular carcinoma. Excess iron deposits refers to the dysmetabolic iron overload syndrome (DIOS) and it is characterized by steatosis associated with moderate tissue iron deposition and increased levels of serum ferritin, while the serum transferrin saturation was normal. Further prospective studies are necessary to determine whether NAFLD has an independent risk for hematologic symptoms, besides the known risk factors. Future studies are also needed in order to assess the increasing impact of NAFLD on the micro- and macro-vascular complications of this systemic disease.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (Review).

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are clinically characterized by the sudden onset of obsessive-compulsive manifestations, motor and verbal tics, as well as other behavioral symptoms in a group of children with B-hemolytic streptococcal infection. PANDAS are considered autoimmune diseases because the streptococcal infection and response can be demonstrated. The most frequent physiopathological mechanism is molecular mimicry: A foreign antigen shares sequence or structural similarities with self-antigens. A thorough review of the literature was carried out using the PubMed database and SCOPUS, searching for immunological, clinical and microbiological aspects, as well as the treatment of the PANDAS syndrome. The diagnosis is clinical and it requires a careful medical history and a thorough physical examination, while the treatment is complex. Untreated or unrecognized manifestations of PANDAS can increase the risk of obsessive-compulsive manifestations and tics during adulthood. Taking this into consideration, further studies are required to establish the best method of therapy.

Non-Steroidal Anti-Inflammatory Drug Etoricoxib Facilitates the Application of Individualized Exercise Programs in Patients with Ankylosing Spondylitis.

Background and objectives: The main objective of this study is to highlight the efficiency of different therapeutic means in patients with ankylosing spondylitis, resulting in the improvement of their quality of life. Materials and Methods: We conducted a randomized, longitudinal, controlled trial on 92 patients with ankylosing spondylitis over a period of 6 years. Disease activity was assessed using the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) score. The assessment of functional disabilities was performed using BASFI (Bath Ankylosing Spondylitis Functional Index). We assessed the quality of life using the HAQ questionnaire (Health Assessment Questionnaire). Based on the HAQ, we calculated the minimum number of patients to be treated for 52 weeks to prevent a decrease in the quality of life for at least one of them (the number needed to treat (NNT)). Results: For the combination therapy group, the result we obtained was 2, lower than the other therapies compared (the medication group and the group with physical exercise). We point out a correlation between the improvement of the functional status (BASFI) and the increase of the quality of life (HAQ), estimated as moderately high (0.8). The superiority of the effects of the combined treatment, in which we combined a nonsteroidal anti-inflammatory drug (etoricoxib) to the exercise program, is reflected by the model of the significant improvements (p < 0.05) obtained for the functional status and quality of life scores (BASFI and HAQ). Conclusions: The nonsteroidal anti-inflammatory drugs, in our case, etoricoxib, facilitate the application of individualized exercise programs in patients with ankylosing spondylitis.

Aspiration pneumonia in an infant with neurological sequelae - case report.

Aspiration pneumonia is a frequent cause of morbidity and mortality in children with neurological deficits. We present the case of a 4-month-old infant from the Foster Care Center, with severe psychomotor retardation, blindness, and associated cardiac malformation, who was admitted to the Pediatrics Clinic of the Emergency County Hospital of Craiova, Romania, presenting aspiration pneumonia and moderate respiratory insufficiency. Under sustained, early instituted treatment, the evolution was towards death. The chest radiography and histopathological examination of the pulmonary tissue confirmed the diagnosis. The neurological impairment was not only a favoring factor for aspiration, through the deglutition disorders, but it was also an aggravating one, through the bacterial colonization of the lungs.

Brain abscess of unknown etiology in a 2-year-old child: a case report.

We present a case of brain abscess necroptically discovered in a 2-year-old child hospitalized in the Pediatrics Clinic of the "Filantropia" Municipal Hospital, Craiova, Romania. The family, with a poor financial situation, reports previous episodes that may be interpreted as comitial crises. Clinically speaking, he presents a height-weight hypertrophia, vitamin D loss rickets, and psychomotor retardation. At the objective examination, we found a weight of 10 500 g (!), second and third degree mesocardiac systolic beat and cardiomegaly in the thorax-cardiac-pulmonary X-ray examination. Despite the intensive treatment, death occurs few hours after hospitalization. During the autopsy, there is observed a partial dehiscence of the cranial arch sutures, with a 6/5 cm ovalary cavity in the parietal lobe, containing approximately 200 mL of yellow-green serous liquid, with uneven walls, but with no hemorrhagic or puss infiltrates. The heart is enlarged (in comparison to the general somatic development) of 9/7/4 cm, without any cardiac malformations. The microscopic examination showed degenerative neuronal and ischemic lesions on the left-brain hemisphere. Comparing to the data from specialty literature, we consider it as a yellow brain softening (according to Rokitansky's classification), most probably of an embolic cause.

Vertical transmission of HIV/TB in newborns: a case report.

We are presenting the case of a 19-day-old newborn with HIV-seropositive mother, under antiretroviral treatment since birth, who is admitted in the ICU (Intensive Care Unit) of the 1st Pediatric Clinic at the Emergency County University Hospital in Craiova, Romania, in critical general condition, with severe respiratory insufficiency. The examination of the tracheal and bronchial secretion revealed positive BK (bacillus of Koch). We considered it was an HIV/TB co-infection, the tuberculostatic treatment was instituted, but the evolution was towards exitus in the 11th day after admission.

Atypical debut manifestations in juvenile idiopathic arthritis.

Considering that destructive articular lesions may occur in the first stages of the illness, it is difficult but necessary to establish a diagnosis of Juvenile Idiopathic Arthritis (JIA) in due time. The authors present the case of a 9-year-old girl admitted to the Pediatrics Clinic of the "Filantropia" Municipal Hospital in Craiova, Romania, on November 26, 2002, for bilateral pain in the tarsometatarsal and carpometatarsal joints that had begun approximately four weeks before. After the clinical examination and paraclinical investigations, a diagnosis of unspecified arthritis is established and the adequate treatment is begun. Two months later, the patient returns to the clinic with bilateral knee pain and swelling. The results of laboratory tests indicate the persistence of anemia and of the inflammatory syndrome. The diagnosis of JIA is established. The evolution of the patient is unfavorable, both from a clinical point of view (a large number of articulations affected, a persistent rash, hepatomegaly) and a paraclinical one (increased acute phase reactants and radiological changes occurring two years after the onset of the illness).