Multisystemic Disease in a Child and Successful Recovery With Antiviral Treatment.

Cytomegalovirus (CMV), a member of the Herpesviridae family, typically causes asymptomatic infections or mild mononucleosis-like syndromes in immunocompetent individuals. However, severe manifestations are well-documented in immunocompromised populations. This case report presents a previously healthy seven-year-old girl with a rare and complex presentation of primary CMV infection leading to severe multiorgan involvement, hepatosplenomegaly, cholestasis, bicytopenia, and a prolonged disease course. The patient's condition prompted an exhaustive diagnostic investigation, ruling out other potential causes. The diagnosis was confirmed by positive CMV IgM and IgG antibodies and a significantly elevated CMV DNA viral load. Treatment with intravenous ganciclovir resulted in a remarkable recovery. The case underscores the importance of considering CMV as a potential etiology of hepatitis, even in immunocompetent children, and the challenges of diagnosing complicated CMV infections. While guidelines for treating CMV in immunocompetent individuals are lacking, this report suggests that antiviral therapy may be beneficial in severe cases. Further research is needed to establish clear treatment protocols for such instances. This report contributes to the limited body of literature on severe CMV-induced hepatitis in immunocompetent children, emphasizing the need for heightened clinical awareness and timely interventions to prevent progression to acute liver failure.

Impact of genetic and non-genetic factors on phenotypic diversity in NBAS-associated disease.

Biallelic pathogenic variants in neuroblastoma-amplified sequence (NBAS) cause a pleiotropic multisystem disorder. Three clinical subgroups have been defined correlating with the localisation of pathogenic variants in the NBAS gene: variants affecting the C-terminal region of NBAS result in SOPH syndrome (short stature, optic atrophy, Pelger-Huët anomaly), variants affecting the Sec 39 domain are associated with infantile liver failure syndrome type 2 (ILFS2) and variants affecting the ß-propeller domain give rise to a combined phenotype. However, there is still unexplained phenotypic diversity across the three subgroups, challenging the current concept of genotype-phenotype correlations in NBAS-associated disease. Therefore, besides examining the genetic influence, we aim to elucidate the potential impact of pre-symptomatic diagnosis, emergency management and other modifying variables on the clinical phenotype. We investigated genotype-phenotype correlations in individuals sharing the same genotypes (n = 30 individuals), and in those sharing the same missense variants with a loss-of-function variant in trans (n = 38 individuals). Effects of a pre-symptomatic diagnosis and emergency management on the severity of acute liver failure (ALF) episodes also were analysed, comparing liver function tests (ALAT, ASAT, INR) and mortality. A strong genotype-phenotype correlation was demonstrated in individuals sharing the same genotype; this was especially true for the ILFS2 subgroup. Genotype-phenotype correlation in patients sharing only one missense variant was still high, though at a lower level. Pre-symptomatic diagnosis in combination with an emergency management protocol leads to a trend of reduced severity of ALF. High genetic impact on clinical phenotype in NBAS-associated disease facilitates monitoring and management of affected patients sharing the same genotype. Pre-symptomatic diagnosis and an emergency management protocol do not prevent ALF but may reduce its clinical severity.

Kaposi sarcoma in three pediatric liver transplantation recipients.

BACKGROUND: Kaposi sarcoma (KS) is an endothelial cell tumor, rare in children. It is 200 times more frequent after solid organ transplantation than in the general population. METHODS: We report three cases of pediatric patients who developed KS after liver transplantation (LT). RESULTS: Case 1, a 4-year-old boy undergoing LT due to familial intrahepatic cholestasis. Five months after LT, he presented with fever, dyspnea, and cough with enlarged lymph nodes and splenomegaly, anemia, thrombocytopenia, elevated liver enzymes, and positive EBV viral load. Lymph node biopsy diagnosed KS with an elevated HHV8 viral load. Case 2, a 4-year-old boy who underwent LT due to secondary biliary cirrhosis resulting from extrahepatic biliary atresia. Two years later, graft dysfunction was noticed with positive EBV viral load, thrombocytopenia, massive cervical lymph node enlargement, and splenomegaly. Lymph node biopsy diagnosed KS, Castleman's disease, and plasmablastic lymphoma related to HHV8 infection. Case 3, a 15-month-old girl, who received two LT due to biliary cirrhosis. Six months later, she presented with diarrhea, abdominal distension, anemia, thrombocytopenia, enlarged lymph nodes, splenomegaly, and positive CMV viral load. Axillary lymph node biopsy diagnosed KS and HHV8 infection was confirmed. In all three cases, tacrolimus was discontinued and, after diagnosis, sirolimus was started. All recovered without relapse and have a good graft function. CONCLUSIONS: Kaposi sarcoma is a rare disease post-LT in children. Recognizing keywords and early diagnosis is crucial for timely treatment and survival.

Long-term follow-up of hepatitis-associated aplastic anaemia.

Prognosis of hepatitis-associated aplastic anaemia (HAAA) was improved with haematopoietic stem cell transplantation (HSCT) and immunosuppression, but the long-term outcome remains undefined. Case 1: a girl aged 3 years with acute liver failure (ALF) submitted to orthotopic liver transplantation (OLT) subsequently developed aplastic anaemia and HSCT from a compatible sibling was performed. Post-HSCT, the patient developed post-transplant lymphoproliferative disorder and rituximab was administered with good response. Fifteen years later, both grafts show good outcome. Case 2: a girl aged 10 years submitted to OLT due to ALF, developed pancytopenia 2 months later. Due to the absence of a human leucocyte antigen compatible donor, she was treated with ciclosporin and antithymocyte globulin with very good long-term outcome. These clinical cases suggest that, for patients with HAAA that underwent OLT, aggressive therapy with HSCT or immunosuppression may provide a benign long-term outcome.

Mutations in the X-linked ATP6AP2 cause a glycosylation disorder with autophagic defects.

The biogenesis of the multi-subunit vacuolar-type H+-ATPase (V-ATPase) is initiated in the endoplasmic reticulum with the assembly of the proton pore V0, which is controlled by a group of assembly factors. Here, we identify two hemizygous missense mutations in the extracellular domain of the accessory V-ATPase subunit ATP6AP2 (also known as the [pro]renin receptor) responsible for a glycosylation disorder with liver disease, immunodeficiency, cutis laxa, and psychomotor impairment. We show that ATP6AP2 deficiency in the mouse liver caused hypoglycosylation of serum proteins and autophagy defects. The introduction of one of the missense mutations into Drosophila led to reduced survival and altered lipid metabolism. We further demonstrate that in the liver-like fat body, the autophagic dysregulation was associated with defects in lysosomal acidification and mammalian target of rapamycin (mTOR) signaling. Finally, both ATP6AP2 mutations impaired protein stability and the interaction with ATP6AP1, a member of the V0 assembly complex. Collectively, our data suggest that the missense mutations in ATP6AP2 lead to impaired V-ATPase assembly and subsequent defects in glycosylation and autophagy.

Congenital Shunts of the Portal Venous System: Case-series of Uncommon Shunts.

BACKGROUND AND AIMS: Congenital shunts of the portal venous system are rare entities that can present in children with clinical heterogeneity. To evaluate the clinical course of children with uncommon shunts presenting to our institution and examine the available literature on this topic. Medical records of children with rare forms of congenital shunts were retrospectively reviewed for demographics, symptoms, management, and outcome between 2003 and 2016. RESULTS: Three female patients with congenital shunts, including a congenital mesenterico-portal Rex shunt (n = 1) and congenital portosystemic shunts (CPSS) (n = 2), were referred for surgical evaluation between ages 4 and 9. Median follow-up was 8 years (range, 6-13 years). One asymptomatic patient did not require treatment and remained disease-free during long-term follow-up. The other 2 patients with CPSS and unusual symptoms, including liver focal nodular hyperplasia (FNH) in infancy (n = 1) and bleeding from esophageal varices (n = 1), showed subsequent progression to liver nodules that were managed by endovascular shunt occlusion. One patient showed symptom resolution and the other showed stable lesions at last follow-up. Literature yielded descriptions of two cases of congenital mesenterico-portal Rex shunt, one case of coincident CPSS and FNH in infancy, but zero reports of bleeding from esophageal varices. CONCLUSIONS: This case series examines each distinct patient's presentation, discusses the diagnosis, management and outcome and compares findings while discussing literature on this topic. A high index of suspicion and familiarity with unusual forms and treatment options is required to allow timely diagnosis and appropriate treatment.

Primary Budd-Chiari Syndrome in Children: King's College Hospital Experience.

Primary Budd-Chiari syndrome is a rare cause of liver disease in children in the western world. Here we present a retrospective review of children with Primary Budd-Chiari syndrome presenting from January 2001 to November 2015 to our hospital. Seven children were identified. Their presentation was mostly chronic. All had predisposing factors for thrombosis and were started on anticoagulation. Radiological interventions (2 transjugular intrahepatic portosystemic shunts and 1 hepatic vein stenting), liver transplant and mesocaval shunt were done in 3, 2, and 1 patients, respectively; 1 child underwent bone marrow transplantation following transjugular intrahepatic portosystemic shunts and 1 child was managed only medically. After liver transplantation, one child died 3 years later as a result of subarachnoid haemorrhage, whereas others remain well at a median follow-up of 6 years. Despite high morbidity, the disease can have a good long-term outcome with a multidisciplinary approach.

Comparison of acoustic radiation force impulse/serum noninvasive markers for fibrosis prediction in liver transplant.

OBJECTIVES: Fibrosis, related to several causes, can be diagnosed in children and adolescents' liver grafts that are >1 year old. At present, liver biopsy is the gold standard for assessing liver damage in the posttransplant setting. We aimed to evaluate the accuracy of noninvasive biomarkers of fibrosis, namely, acoustic radiation force impulse (ARFI), aspartate-to-platelet ratio index, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio index, either alone or in combination, for predicting fibrosis in pediatric patients submitted to liver transplantation. METHODS: We prospectively assessed liver fibrosis in 30 children/adolescents with liver transplant through biopsy (liver transplant follow-up during 12 months). ARFI with Virtual Touch Software (Acuson 2000) was performed, and blood samples were taken to determine liver function and platelet count. Two groups were analyzed according to the histopathologic stage of fibrosis, namely, none/mild (F0-F1) versus significant fibrosis (F2-4). RESULTS: The mean age of the 30 patients was 11 years (3-18 years), with a mean posttransplant period of assessment of 6.5 years. Twenty-four patients (80%) presented stage F0-F1 fibrosis and 6 patients (20%) presented stage F2-4. The area under the curve using receiver operating characteristic analysis for ARFI, aspartate-to-platelet ratio index, and AST/ALT ratio index for significant fibrosis was 0.76 (P = 0.052), 0.74 (P = 0.066), and 0.69 (P = 0.162), respectively. Through multivariate logistic regression analysis, the only independent predictor of significant fibrosis was ARFI (odds ratio 10.7, 95% confidence interval 1.2-95.7; P = 0.045). The combination of ARFI and AST/ALT ratio index presented a good diagnostic accuracy of fibrosis (area under the curve of 0.83; P = 0.013). CONCLUSIONS: ARFI may serve as a potential method for assessing significant fibrosis in pediatric patients with liver transplant, particularly in combination with AST/ALT ratio index.

Neonatal liver failure due to deoxyguanosine kinase deficiency.

Deoxyguanosine kinase (dGK) deficiency, a rare severe cause of mitochondrial DNA (mtDNA) depletion, has two forms of presentation: hepatocerebral syndrome and isolated hepatic disease. The authors report three cases with neonatal liver failure due to dGK deficiency. Consanguinity was present in all patients. One patient had a brother who died with a probable diagnosis of neonatal haemochromatosis. All patients had progressive cholestatic liver failure, hypoglycaemia, hyperlactacidaemia, elevated ferritin levels and nystagmus, since first day of life. Liver tissue study revealed: cholestasis, iron deposits, microvesicular steatosis and fibrosis/cirrhosis. Only one patient was submitted to liver transplantation. The other two died, at 2 and 5 months of age. mtDNA quantification and DGUOK gene study should be considered in infants/neonates with acute liver failure and systematically performed in patients with hepatocerebral presentation. Differential diagnosis with neonatal haemochromatosis is needed. Liver transplantation might be a therapeutic option. Early diagnosis is important for genetic counselling.

[Cytology role in healthy sexual life promotion of adolescent users of Centro de Atendimento a Jovens de Coimbra]. / As citologias na promoção da saúde sexual das adolescentes utentes do Centro de Atendimento a Jovens de Coimbra.

BACKGROUND: Adolescents usually have risky sexual behaviors which can result in an unwanted pregnancy and/or in transmission of sexually transmitted infections (STIs). Medical consultation can provide adequate and early sexual information. Medical surveillance and pelvic examination are essential for a healthy sexual life. Despite the availability of two vaccines against the major oncogenic types of human papilloma virus, the main agent of cervical cancer, performance of cytology is still needed. The purpose of this study was to characterize the group of adolescents/young adults who made their first cytology during 2005 and 2006 and determine the results of gynecological observation and first cytology. METHODS: This is a retrospective study of users of Centro de Atendimento a Jovens (CAJ) of Centro de Saúde de Celas de Coimbra, who made their first cytology in 2005 and 2006. Clinical data were analyzed to determine the following parameters: demographic data, habits, sexual parameters, gynecological observation, symptoms, first and subsequent cytology results and consultations dropout rate until January 2009. RESULTS: During these two years, 172 first cytologies were performed. At first consultation in CAJ, the average age was 19 years old (15-24). At first intercourse, which occurred on average at 17,5 years old (13-21), 75,6% of girls used condom, 4,6% only pill and 16,3% did not use any contraceptive method. The mean number of sexual partners at first consultation was 1,6. The majority needed to take emergency pill (43/54). Gynecological observation was abnormal in 50,6% of cases, but only 10% reported symptoms. First cytology was performed, on average, three years after first intercourse, and was normal in 149 cases, unsatisfactory for evaluation in one case and abnormal in 22 (eight bacterial vaginosis, six with signs of inflammation, six candidiasis and two low grade intraepithelial lesions). Fifty nine per cent of adolescents made, at least, once more cytology. Three more cases of low grade intraepithelial lesions were detected. Dropout rate of consultations was 17%. CONCLUSIONS: In adolescence, isolated pill use increases the risk of transmission of STIs. Not using any contraceptive method may be related to the increasing use of emergency contraceptive pills. Abnormal gynecological examination may be present in asymptomatic girls. Dysplastic lesions (which are increasing in adolescence) have the same course of adulthood, supporting the need for screening and continuity of follow-up in young people.

Behavioural and psychiatric disorders in paediatric Wilson's disease.

An 11-year-old boy was treated since 6-years-old with methylphenidate for combined attention deficit and hyperactivity disorder. At age nine his behaviour had worsened and he started to have phobias. One year later persistent hypertransaminasemia was found. Physical examination showed a dysdiadocokinesia. Laboratory investigation revealed a low caeruloplasmin and augmented basal urinary copper with a positive postpenicillamine test. Liver biopsy showed high liver copper (853 µg/g) and brain MRI was normal. D-penicillamine and zinc acetate were started without side effects. ATP7B gene mutation was confirmed after treatment initiation.

Foreign bodies in the airway: a quarter of a century's experience.

INTRODUCTION: Foreign body (FB) aspiration in children is a common and potentially dangerous situation that can be associated to significant morbidity. AIMS: To characterise the FB aspiration in children cases at the Hospital Pediátrico de Coimbra over a twenty five year period. STUDY DESIGN: This study was based on the retrospective analysis of all clinical files of children who were diagnosed with foreign body aspiration January 1982 to December 2006. RESULTS: Foreign body aspiration was confirmed in 316 children. The incidence was higher during the first twelve years of the study (64%). Around two thirds of the children were male (206) and the sample was aged 6 months to 12 years. Most children were younger than 3 years old (83%). In 88% of cases a choking episode was noticed while an early diagnosis (<24h) was obtained in only 39%. The most frequently described signs and symptoms were unilateral diminished breath sounds and cough. In 7% of cases no symptoms were described. The most frequently recorded radiology finding was focal hyperinflation (42%) and in 22% the chest x-ray was unremarkable. Treatment was exclusively by rigid bronchoscopy. Complications related to the bronchoscopy removal were described in 22 cases. Most aspirated FB were of vegetable origin (75%). The majority of FB was lodged in the right bronchial tree. Postremoval flexible bronchoscopy was performed in 116 cases. CONCLUSION: An unnoticed FB aspiration and absence of and/or non-specific initial symptoms may contribute to a late diagnosis. The significant reduction in the number of cases over the later years may be related to the implementation of preventive strategies.

Impact of imidapril on cardiac mitochondrial function in an ex-vivo animal model of global myocardial ischemia.

Imidapril is an angiotensin I converting enzyme inhibitor, a class of drugs with known cardioprotective activity. It is now known that this is due not only to their antihypertensive activity, but also to the fact that they decrease cellular and tissue levels of angiotensin II, a potent vasoconstrictor and inducer of myocardial fibrosis. These mechanisms may explain the good clinical results of this class of drugs in the treatment of coronary artery disease and heart failure, two diseases whose etiopathogenesis is closely related to the activation of the renin-angiotensin-aldosterone system. However, the impact of this class of drugs on cardiac mitochondrial function during acute myocardial ischemia is still largely unknown. With the aim of studying the effect of imidapril on cardiac mitochondrial function during acute ischemia, we used an ex-vivo animal model, perfused in a Langerdorff system and then subjected to ischemia in the presence or absence of imidapril. We evaluated mitochondrial membrane electrical potential, respiratory chain O2 consumption, and rate and amplitude of mitochondrial swelling. We conclude that imidapril did not significantly change oxygen consumption by cardiac mitochondria, as assessed by the rate of respiratory state 3 (the state that corresponds to the active phosphorylation phase). However, imidapril significantly increased transmembrane electrical potential and, in ischemic cardiac mitochondria, was able to prevent the calcium-induced increase in the rate and amplitude of mitochondrial swelling, thus enabling better preservation of mitochondrial membrane structure, with consequent improvement of electrical potential after the phosphorylation cycle. These findings enabled a better understanding of the mechanisms behind the cytoprotection provided by imidapril during ischemic cardiomyopathy, clearly highlighting, at a cellular biology level, the importance of pharmacological modulation of cardiac mitochondrial function during acute ischemia.