Successful treatment of hepatic and mesh Aspergillosis in a neonate with giant omphalocele.

Aspergillosis is a rare and life-threatening fungal infection in immunocompetent children, particularly in infants. We present a case of invasive Aspergillosis (IA) that developed hepatic and mesh infection due to Aspergillus flavus following the rupture of a giant omphalocele. A male baby was born at 37 weeks of gestation with a giant omphalocele. No other congenital abnormalities were found. In the pediatric surgery operation room, the amniotic membrane seemed to be ruptured in some parts, which had been repaired within a few hours of birth. No further intervention to reduce the volume of visceral organs could be performed due to the tiny abdominal cavity. Postoperatively piperacillin-tazobactam and fluconazole were empirically initiated. Abdominal defects had been covered with polypropylene polylactic acid synthetic Mesh on postnatal day 11 to protect the organs and prevent abdominal infections. Fungal hepatic lesions were observed during surgery, and black necrotic lesions were also observed on the mesh on day 12. On the 16th postnatal day, Aspergillus flavus grew in the wound, graft, hepatic biopsy cultures. Serum galactomannan (GM) assay test was positive (GM:2.9), and voriconazole was initiated. All necrotic lesions resolved with liposomal amphotericin B (L-AmB) and voriconazole treatment, and antifungal therapy was discontinued after 134 days. Eye examination for the retinopathy didn't show any abnormalities. The patient was discharged with full recovery on day 155. In conclusion, IA is a rare and life-threatening infection in the neonatal period. To the best of our knowledge, this is the first case of hepatic and mesh infection caused by Aspergillus flavus that was successfully treated with voriconazole and l-AmB.

Saccharomyces boulardii CNCM I-745 reduces the duration of diarrhoea, length of emergency care and hospital stay in children with acute diarrhoea.

Evidence from the literature has shown that Saccharomyces boulardii provides a clinically significant benefit in the treatment of acute infectious diarrhoea in children. In this multicentre, randomised, prospective, controlled, single blind clinical trial performed in children with acute watery diarrhoea, we aimed to evaluate the impact of S. boulardii CNCM I-745 in hospitalised children, in children requiring emergency care unit (ECU) stay and in outpatient settings. The primary endpoint was the duration of diarrhoea (in hours). Secondary outcome measures were duration of hospitalisation and diarrhoea at the 3(rd) day of intervention. In the whole study group (363 children), the duration of diarrhoea was approximately 24 h shorter in the S. boulardii group (75.4±33.1 vs 99.8±32.5 h, P<0.001). The effect of S. boulardii (diarrhoea-free children) was observed starting at 48 h. After 72 h, only 27.3% of the children receiving probiotic still had watery diarrhoea, in contrast to 48.5% in the control group (P<0.001). The duration of diarrhoea was significantly reduced in the probiotic group in hospital, ECU and outpatient settings (P<0.001, P<0.01 and P<0.001, respectively). The percentage of diarrhoea-free children was significantly larger after 48 and 72 h in all settings. The mean length of hospital stay was shorter with more than 36 h difference in the S. boulardii group (4.60±1.72 vs 6.12±1.71 days, P<0.001). The mean length of ECU stay was shorter with more than 19 h difference in the probiotic group (1.20±0.4 vs 2.0±0.3 days, P<0.001). No adverse effects related to the probiotic were noted. Because treatment can shorten the duration of diarrhoea and reduce the length of ECU and hospital stay, there is likely a social and economic benefit of S. boulardii CNCM I-745 in adjunction to oral rehydration solution in acute infectious gastroenteritis in children.

Two cases of Guillain-Barré syndrome during measles elimination campaign in Izmir.

The authors report two cases of Guillain-Barré Syndrome (GBS) occurred during a national measles vaccination campaign in Izmir, Turkey. Among more than 325,000 vaccine recipients, only 2 cases of GBS were observed within the 10-week risk period. These cases yielded an incidence of 0.615 per 100,000 vaccine doses. The authors think that association between measles vaccination and GBS is coincidental, rather than causal. However, an epidemiological evaluation in Turkey is needed to clearly show that there is no causal association between measles vaccination and GBS.

QT prolongation and minor head trauma: a report of two cases.

QT prolongation is rarely seen after acute stress reactions such as burn injury and severe head trauma. Although pathophysiologic mechanism is not entirely clear, acute stress is thought to contribute to the inhomogeneity of ventricular repolarization and it is hypothesized that QTc dispersion increases with severity of acute stress conditions. In the present study, we report long QT syndrome in 2 patients with minor head trauma. Their QTc intervals, i.e. QT intervals corrected for heart rate by the standard Bazett formula, were found to be prolonged (545 and 450 ms, respectively) without creatine phosphokinase - MB elevation. These findings suggest that myocardial effects may occur as a result of probable catecholamine discharge, even if they are not at a level to affect creatine phosphokinase - MB values in minor head trauma. But these findings have not been supported by experimental data, for this reason we need a lot of study in order to confirm this hypothesis.

Effects of Saccharomyces boulardii in children with acute diarrhoea.

AIM: Certain probiotic agents, e.g. Lactobacillus GG, have shown efficacy in clinical trials for the treatment of acute childhood diarrhoea, but few studies have examined the effect of Saccharomyces boulardii. We evaluated the effect of S. boulardii in children with acute diarrhoea. METHODS: Two hundred children were randomized to receive S. boulardii in a granulated form in a daily dose of 250 mg (S. boulardii group) or placebo (placebo group) for 5 d. Clinical and demographic characteristics on admission were similar between the study groups. RESULTS: The medians of the average stool frequency after the second day of the treatment were significantly lower in the S. boulardii group than in the placebo group (p = 0.003). The duration of diarrhoea significantly reduced in the S. boulardii group compared with the placebo group (4.7 vs 5.5 d, p = 0.03). The effect of S. boulardii on watery diarrhoea became apparent after the second day of the treatment. The duration of hospital stay was shorter in the S. boulardii group than in the placebo group (2.9 vs 3.9 d, p < 0.001). Four children from the placebo group versus only one child from the S. boulardii group had persisting diarrhoea. CONCLUSION: The placebo-controlled study suggested that S. boulardii significantly reduced the duration of acute diarrhoea and the duration of hospital stay. S. boulardii seems to be a promising agent for the amelioration of the course of acute diarrhoea in children when used therapeutically.

Measles seroprevalence in Izmir with special emphasis on measles vaccination policy for Turkey.

BACKGROUND: Measles outbreaks seem to occur every 2- to 3-year intervals in Turkey. However, sero-epidemiological studies are limited. Knowing the prevalence of measles susceptibility as measured either by serologic markers of immunity or surveys of vaccination coverage is an important tool to assess the risk for measles outbreaks. METHODS: In order to determine the seroprevalence of measles antibodies among a 1 to 29-year-old population in Izmir (Turkey) and to develop the best vaccination policy for measles, a total of 600 people aged from 1 to 29 were selected for the study with cluster sampling. The information on sociodemographic characteristics, vaccination status and measles history was gathered for each participant. Measles-specific IgG antibodies were screened qualitatively by using microenzyme immune assay for 595 subjects. RESULTS: Of the 595 participants screened for the measles antibodies, 56 (9.4%) were seronegative. The proportion of the susceptible individuals in the age groups of 1-4, 5-9, 10-14, 15-19 and 20-29 was 20.0, 10.4, 6.0, 10.3 and 3.0%, respectively. The logistic regression analysis showed that none of the independent characteristics (sex, socioeconomic status, past measles history, vaccination status) with the exception of age group, was significantly associated with measles seronegativity. CONCLUSION: The optimal measles vaccination policy for Turkey may be to increase vaccination coverage above 90%, to conduct a catch-up campaign covering persons aged 1-19, regardless of previous vaccination status. Another factor to consider is to adopt a routine two-dose vaccination, giving the first dose at 12-15 months of age and the second dose at school entry.

Lupus anticoagulant and protein S deficiency in a child who developed disseminated intravascular coagulation in association with varicella.

Varicella is not always a benign disease it may cause serious complications. We report a two-year-old boy with disseminated intravascular coagulation in association with varicella. The patient had the lupus anticoagulant, the antiphospholipid antibody, acquired free protein S deficiency, and increased concentrations of the prothrombin F 1+2 fragment. Intravenous immunoglobulin was administered due to its potential antibody-blocking activity, and the patient responded well. We recommend that children with varicella and disseminated intravascular coagulation should be examined for the lupus anticoagulant, the free protein S antigen, the prothrombin fragment F 1+2 and the other coagulation parameters. Intravenous immunoglobulin administration could be useful in such conditions because of its antibody-blocking activity.

Low-dose intradermal administration of recombinant hepatitis B vaccine in children: 5-year follow-up study.

Several studies have documented the efficacy of low-dose intradermal administration of hepatitis B vaccine. However, little is known about the duration of protection provided by low-dose intradermal administration of hepatitis B vaccine. This study reports results from a 5-year follow up period of 200 healthy children (100 infants and 100 preschool children) immunized intradermally with 2 microg doses of recombinant hepatitis B vaccine (GenHevac B) at months 0,1, and 6. In the 8th week after the third vaccine dose, 97% of the children developed anti-HBs antibodies higher than or equal to 10 mlU ml(-1), and the antiHBs geometric mean titre (GMT) was 676 mlU ml(-1). In month 18 and year 5, the anti-HBs GMT decreased to approximately one-third (220 mlU ml(-1)) and one-tenth (68 mlU ml(-1)) of the initial levels, respectively. However, 87% of the children had protective levels of anti-HBs (> or =10 mlU ml(-1)) after 5 years. Among 156 children followed for 5 years, none became positive for anti-HBc and/or HbsAg. Seven children who were seronegative after 5 years developed anti-HBs antibodies higher than 1000 mlU ml(-1) after an additional 10 microg intramuscular hepatitis B vaccine. Persistent immunologic memory over periods of 5 years or more is evident, the anamnestic antibody response to a booster dose of vaccine, even in these children who have lost antibody. We conclude that intradermal administration of 2 microg recombinant hepatitis B vaccine provides long-term protection against hepatitis B virus in infants and preschool children.

Lupus anticoagulant and protein S deficiency in otherwise healthy children with acute varicella infection.

UNLABELLED: Acquired protein S deficiency and lupus anticoagulant have been described in children with varicella who had purpura fulminans, disseminated intravascular coagulation or thrombosis. The aim of this study was to investigate the natural anticoagulants, hypercoagulability markers, other parameters of coagulation and fibrinolytic systems, and the presence of the lupus anticoagulant in otherwise healthy children with acute varicella infection. Blood samples were obtained from 17 children with varicella without thrombosis during acute varicella infection and 1 mo after onset. Coagulation tests included determinations of the prothrombin time, the activated partial thromboplastin time, the thrombin time, the thrombin antithrombin complex, the prothrombin fragment F 1 + 2, the tissue plasminogen activator, the plasminogen activator inhibitor-1, protein C activity and free protein S antigen. Antiphospholipid antibodies were determined in enzyme-linked immunosorbent assays. The mean free protein S concentration in the acute phase (0.63 +/- 0.16 U/ml) was significantly lower than that of the concentration determined 1 mo later (0.82 +/- 0.17 U/ml). The children with acquired free protein S deficiency also had a lupus anticoagulant. Elevated concentrations of the prothrombin fragment F 1 + 2, the thrombin antithrombin complex, D-Dimer, tissue plasminogen activator and plasminogen activator inhibitor-1 were detected in most of the children. CONCLUSION: There is a significantly increased prevalence of lupus anticoagulant, a significantly reduced plasma concentration of free protein S and elevations in coagulation and fibrinolytic parameters in otherwise healthy children with acute varicella infection.

Influence of feeding regimens on non-invasive inferior vena cava and hepatic vein velocity measurements in infants.

UNLABELLED: The aim of this study was to investigate the effects of feeding type and osmotic load on intravascular volume status. Ninety term, healthy infants 2 mo of age were included in the study. The breastfed and formula-fed groups each consisted of 45 infants. Echocardiographic examination was performed before and after feeding. The collapse index of the inferior vena cava (IVCIC) and right atrial pressure (RAP) were calculated. No statistically significant differences were found between before- and after-feeding values of IVCIC, RAP and hepatic vein velocities in breastfed infants. In the formula-fed group, after-feeding values of IVCIC were significantly lower and RAP, hepatic vein systolic and diastolic velocities were significantly higher compared to the before-feeding values. Most of the mothers (78%) were unsuccessful at preparing the formula at appropriate concentrations. No statistically significant differences were found between the before-and after-feeding values of IVCIC, RAP and hepatic vein velocities in infants being fed appropriately prepared formula. The after-feeding values of hepatic vein velocities were higher than those of before-feeding values; after-feeding values of IVCIC were lower than before-feeding values in infants being fed highly concentrated formula. CONCLUSION: The values of inferior vena cava indices and hepatic vein velocities were not effected by feeding in infants receiving appropriately concentrated formula, like those of infants receiving breast milk. However, feeding with highly concentrated formula may cause intravascular volume expansion.

A case of primary chylous ascites resolved within 4 months by exclusive breast-feeding.

Chylous ascites is a rare disease in infancy. A two-month-old male infant was admitted to the Department of Pediatrics with chylous ascites. No cause was found throughout the investigation period. The baby recovered spontaneously through breast-feeding without any specific treatment and chylous ascites disappeared at the age of six months.

Adequate immune response to tetanus toxoid and failure of vitamin A and E supplementation to enhance antibody response in healthy children.

The effects of vitamin A and vitamin E supplementation on the IgG response to tetanus toxoid after primary immunization were evaluated in a prospective, randomized controlled clinical trial involving 89 healthy infants with normal serum vitamin A and E levels at 2 months of age. Before the first dose of DPT vaccine, the infants were randomly enrolled into four different study groups [Group I (n=24): 30,000 IU vitamin A for 3 days just after each three doses of primary vaccination, Group II (n=21): 150 mg oral vitamin E for only 1 day after the injections for primary immunization, Group III (n=21): vitamins A and E together in the same order, Group IV (n=23) no vitamin after DPT vaccines]. Serum tetanus antitoxin (IgG) titres were measured three times; initially at 2 months of age before the first dose of DPT, secondly at 5 months of age 1 month after primary immunization and thirdly at 16-18 months of age before the booster dose of DPT. Before the first dose of the DPT vaccine, 1 month after the third DPT injection and at 16-18 months before the booster dose of DPT, there was no significant difference in serum tetanus antitoxin levels between these four groups. A significant increase was observed in all the groups when serum tetanus antitoxin levels before (2 months) and after (5 months) primary immunization were compared. In addition, serum antibody levels against tetanus significantly decreased in the four groups before booster vaccination. Before the beginning of primary immunization, 15 infants (16.8%) had serum tetanus antitoxins (IgG) below protective level. After three doses of DPT, all the infants had protective antitoxin levels. At 16-18 months of age before booster dose, four infants (10%) also had serum tetanus antitoxins (IgG) below the protective level. No side-effects were observed except bulging fontanelle in two infants in Group I.

Should hemophiliac patients be circumcised?

Social and cultural integration of hemophilic boys into society is one of the most important cornerstones of modern hemophilia therapy. Circumcision, a traditional procedure, is an important ritual for Muslims and Jews and an important social problem for the hemophiliac patient and his family. The aim of this study was to evaluate the psychosocial dimension of circumcision and the opinions of parents and children. A total of 105 hemophiliac patients and parents were interviewed and surveyed. Of these, 94% of the parents of uncircumcised patients wanted circumcision for their children. Most parents saw circumcision as a mandatory procedure. Hemophilic boys (60%) and their parents (82%) have an inferiority complex because the boys are unable to be circumcised. Bleeding risk is the primary reason of anxiety (70%). The parents of all the circumcised patients were happy after circumcision. In conclusion, circumcision is an important social problem of hemophilic patients that needs to be solved.

Vitamin A deficiency in healthy children aged 6-59 months in Izmir Province of Turkey.

Vitamin A deficiency even at subclinical levels is associated with increased childhood mortality. There have been few studies related to vitamin A status of children in Turkey. The aim of this study was to assess vitamin A status of children aged 6-59 months in Izmir, Turkey, and to evaluate the relationship of these levels with nutritional status. One hundred and sixty children were selected for the study using the cluster sampling method. Serum retinol levels were measured by high-performance liquid chromatography (HPLC) and ranged from 9.8 to 59.2 micrograms/dL (mean 29.3 +/- 9.5 micrograms/dL). Levels were below the lower limit of the normal range in 15.6% of the children. Deficient and marginal serum retinol among stunted children were observed in 16% and 42% respectively. There was a statistically significant relationship between low serum retinol and stunting (P < 0.05). Although xerophthalmia and other clinical signs of vitamin A deficiency are rarely seen, subclinical vitamin A deficiency is a public health problem in Izmir, Turkey.

Immunity to diphtheria in Izmir, Turkey.

In order to assess immunity to diphtheria in Izmir, Turkey, a total of 743 persons 1-70 years of age were selected with cluster sampling. The information on socio-demographic characteristics, vaccination status and diphtheria history was gathered for each participant. Diphtheria antitoxin levels were measured qualitatively by using micro-enzyme immune assay. Of studied population, 79.1% had fully protective antitoxin levels (> or = 0.1 IU/ml). Diphtheria protection rates showed a gradual age-related decrease, reaching minimum in the 30-44 age group, in which 40.2% of these subjects had antibody titre below the full protective level. The diphtheria antitoxin geometric mean titer was highest in the 5-9 year age group (1.05 IU/ml). Then, geometric mean titer decreased with increasing age, and reached the minimum level in the 30-44 age group (0.19 IU/ml). These results suggest that in Izmir, Turkey, full serological protection against diphtheria is only detectable in 60% of the adult population. The enhancement of diphtheria immunity by booster vaccinations in adolescents and adults should be considered in Turkey.

Rubella seroprevalence in an unvaccinated population in Izmir: recommendations for rubella vaccination in Turkey.

BACKGROUND: The European Advisory Group on the Expanded Program on Immunization of WHO has recommended that by 2010 or earlier congenital rubella should be well-controlled or eliminated in all countries in Europe. Debate on the introduction of rubella vaccine into national immunization schedules continues to occur, and data on rubella and congenital rubella syndrome in Turkey are insufficient. OBJECTIVE: To determine age-specific rubella seroprevalence in the 1- to 29-year-old unvaccinated population in Izmir, Turkey. METHODS: A total of 600 unvaccinated persons 1 to 29 years old were selected for the study with cluster sampling in Izmir, Turkey. The information on sociodemographic characteristics and disease history was gathered for each participant, and in 580 of them rubella-specific IgG antibodies were assayed quantitatively by the micro-enzyme immunoassay. RESULTS: Of the 580 participants tested for rubella antibodies, 135 (23.3%) were seronegative. The proportions of susceptible individuals were 61.7, 29.5, 12.4, 10.3 and 8.4% in the age groups of 1 to 4, 5 to 9, 10 to 14, 15 to 19 and 20 to 29 years, respectively. Of the young women 15 to 19 years of age, 13.5% were susceptible to rubella infection. CONCLUSIONS: Because a substantial proportion of women in their childbearing years are susceptible to rubella, immunization efforts should be directed at infants or prepubertal children.

Low-dose intradermal versus intramuscular administration of recombinant hepatitis B vaccine: a comparison of immunogenicity in infants and preschool children.

Two hundred infants and two hundred preschool children were randomly assigned to receive either 10 micrograms of recombinant hepatitis B vaccine (GenHevac B) intramuscularly (i.m.) or 2 micrograms intradermally (ID) in the deltoid region at 0, 1 and 6 months. Antibody to hepatitis B surface antigen (anti-HBs) was tested eight weeks after the third vaccine dose. Standard dose i.m. and low-dose ID administration of recombinant hepatitis B vaccine produced comparable rates of anti-HBs equal to or higher than 10 mIU ml-1 in infants (98% and 94%, respectively) and preschool children (98% and 100%, respectively). Although i.m. vaccination produced higher anti-HBs concentrations than ID vaccination both in infants (geometric mean titre-GMT, 935 versus 621 mIU ml-1) and preschool children (GMT, 1393 versus 804 mIU ml-1), the differences were not statistically significant (p > 0.05). The preschool children tended to have higher anti-HBs concentrations than the infants. No clinically serious adverse effects were observed in both vaccine groups; however, induration and hyperpigmentation at the injection site were more often seen in the study population that was vaccinated intradermally. We conclude that intradermal administration of 2 micrograms recombinant hepatitis B vaccine is safe and effective in infants and preschool children, and may be an acceptable, less expensive alternative to full-dose i.m. vaccination for mass immunization, especially in developing countries.

Early determination of nutritional problems in pediatric cancer patients.

Mild and marginal malnutrition must be identified to prevent the development of severe protein-energy malnutrition in pediatric cancer patients. We aimed to evaluate nutritional status and determine daily energy, protein and micronutrient intake to identify mild or marginal malnutrition in pediatric cancer patients. Daily energy, protein and micronutrient intake, anthropometric measurements and biochemical indices were studied in 45 patients (25 in remission, 20 newly diagnosed or relapsed) who consumed energy, protein, vitamins and minerals below the recommended quantities. According to the weight-for-height index, 23 children (51.1%) were determined to be malnourished. Absolute and relative prealbumin values were 19.4 +/- 7.2 mg/dl and 74.3 +/- 29.1 mg/dl in the remission group, and 14.8 +/- 5.1 mg/dl and 58.1 +/- 23.3 in the active disease group, respectively (p < 0.05). Relative prealbumin values were found to be low in 63.6 percent of nonmalnourished children, and 80 percent of children with mild malnutrition. We conclude that malnutrition is common in pediatric cancer patients, and prealbumin is a reliable and sensitive indicator of mild and marginal malnutrition. Determining prealbumin values and assessing the deficiency of micro- and macronutrients before malnutrition is detected by anthropometric measures may provide a warming that nutritional problems may occur.