Corrosive poisoning mimicking cicatricial pemphigoid: Munchausen by proxy.

BACKGROUND: Munchausen by proxy (MBP) is a severe form of abuse in which a caregiver simulates or fabricates illness in another person, primarily the elderly and children, which can even result in death. CASE: We report two siblings who were victims of MBP, one of whom died. A very rare diagnosis, cicatricial pemphigoid was suspected in the 2-year-old girl who was first abused. She was hospitalized twice, for 3 and 4 months, respectively. Her second hospitalization ended with her death. MBP was diagnosed after the second sibling's admission with similar atypical signs and symptoms. It was realized that a household-cleaning product, sodium hydroxide, was administered repeatedly by oral route to the children by their own mother. CONCLUSIONS: Physicians must consider the diagnosis of MBP whenever they are confronted with unusual, persistent or recurrent signs and symptoms in a child.

Evaluation of the nasal provocation test for its necessity in the diagnosis of nasal allergy to house dust mite.

The aim of this study was to evaluate rhinomanometric responses to nasal allergen provocation in children with allergic rhinitis sensitized to house dust mite. We studied 51 children, aged 6-16 years (mean: 11.5 +/- 2.6 years), with clinical symptoms of perennial allergic rhinitis without asthma and 20 non-atopic healthy controls in the same age range (mean: 11.8 +/- 3.8 years). All of the patients had positive skin prick test (SPT) results and serum specific IgE above 0.70 kU/l to Dermatophagoides pteronyssinus (Dp). Nasal provocation testing (NPT) was performed with increasing concentrations of Dp extracts and the nasal response was evaluated by active anterior rhinomanometry. A 100% increase of resistance in one or both nasal cavities was considered positive. There was a statistically significant difference of baseline nasal resistance (total, right and left sides) between the control and the patient groups (p < 0.001). A positive response to house dust mite allergens was recorded in 47/51 (92.2%) patients by rhinomanometry. The NPT presented no significant correlation with age, weight, height, SPT diameter, serum total and specific IgE levels to Dp and baseline nasal airway resistance values. This study suggests that a nasal provocation test with allergen is unnecessary in children with positive skin prick test and serum IgE specific to house dust mite. The rhinomanometric response to the allergen provocation does not correlate with the diameter of the skin prick test and the level of serum specific IgE.

Rising trend of asthma prevalence among Turkish schoolchildren (ISAAC phases I and III).

BACKGROUND: Asthma is a common chronic illness in childhood. The aim of the study was to examine time trends in the prevalence of asthma using the ISAAC questionnaire in 6- to 12-year-old schoolchildren in Istanbul and factors affecting asthma prevalence. METHODS: Two cross-sectional surveys were performed, 9 years apart (1995 and 2004) using the ISAAC protocol. The survey conducted in 1995 was repeated in 2004 using the same questionnaire in the same age group, in the same schools in the same season. The 2500 questionnaires were distributed to the children to be completed by their parents at home. RESULTS: A total of 2387 children (response rate 95.5%) in the 2004 study and 2216 children (response rate 94.3%) in 1995 were included in the final analysis. The overall lifetime prevalence of wheeze increased from 15.1% to 25.3%; prevalence odds ratio (POR) = 1.91, 95% confidence interval (95% CI) = 1.64-2.21, and P < 0.001. The overall 12-month prevalence of wheeze increased from 8.2% to 11.3%; POR = 1.43, 95% CI = 1.18-1.75, and P < 0.001. The prevalence of asthma increased significantly from 9.8% to 17.8%; POR = 1.99, 95% CI = 1.67-2.36, and P < 0.001. In both 1995 and 2004, family history of asthma, eczema diagnosed by a physician, food allergy diagnosed by a physician, frequent otitis, frequent sinusitis were associated significantly with high risk for asthma. CONCLUSIONS: In the 9-year period from 1995 to 2004, the prevalence of asthma symptoms has increased in 6- to 12-year-old schoolchildren in Istanbul. Risk factors affecting asthma prevalence remained unchanged during the 9-year period.

Atopy patch testing in children with asthma and rhinitis symptoms allergic to house dust mite.

The atopy patch test (APT) is generally used to assess immunoglobulin E (IgE) mediated sensitization to allergens in patients with atopic dermatitis, but its diagnostic role in children with respiratory allergy is still controversial. The aim of the study was to evaluate APT with house dust mite (HDM) in children with asthma and rhinitis symptoms allergic to HDM and its relevance to skin prick test (SPT) diameters and specific IgE levels. The study population consisted of 33 children, aged 8-16 yr (median: 12 yr) with asthma and 30 children with allergic rhinitis in the same age range (median: 11 yr). All patients had positive SPT results and high serum specific IgE levels for Dermatophagoides pteronyssinus APT was performed on back skin of all patients with 200 index of reactivity (IR)/ml of D. pteronyssinus allergen extracts in petrolatum (Stallerpatch) and evaluated at 72 h. Of 63 patients, 16 (25%) showed a positive patch test result. APT with HDM showed 30% (10/33) positivity among the patients with asthma and 20% (6/30) positivity among the patients with allergic rhinitis. APT presented no significant correlation with age, SPT diameter, serum total and specific IgE levels for D. pteronyssinus, nasal provocation test or pulmonary function test results. Patch testing with HDM may partly identify mite sensitive children with respiratory allergy. Positive APT results may imply that delayed hypersensitivity reactions play a role in children with asthma and rhinitis allergic to HDM.

Indoor airborne fungal spores and home characteristics in asthmatic children from Edirne region of Turkey.

BACKGROUND: The contribution of indoor fungal exposure to childhood asthma is not completely clear. OBJECTIVE: To investigate airborne fungal flora within the homes of asthmatic and control children, and to assess the influence of housing characteristics regarding indoor fungi. METHODS: Forty-seven atopic asthmatic and 23 nonatopic control children were studied. Allergen sensitivity was determined by skin prick tests. A thorough assessment, using a questionnaire and inspection surveys, was carried out. Home visits were made between October 2000 and February 2001. Samples of airborne fungal spores were collected from four rooms by the "open Petri dish" method. Indoor temperature and humidity were measured. RESULTS: The total indoor fungal colony counts from the living rooms and bedrooms were significantly higher in the asthma group than in controls (p = .012 and p = .003, respectively). The most commonly isolated genus was Cladosporium. Twelve of the asthmatic patients (25.53 %) were found to be sensitive to fungal allergens. The factors found to be associated with indoor fungal growth in logistic regression were visible fungal patches in the bathrooms [(odds ratio (OR) = 5.75; 95 % CI 1.19 to 27.70)], and the age of the house [OR = 4.24; 95 % CI 1.34 to 13.45]. Total fungal colony numbers did not correlate with indoor temperature or humidity. CONCLUSION: Fungal colony numbers were higher in the homes of asthmatic children than in those of controls. Therefore, indoor fungal exposure may contribute to childhood asthma. Bathrooms were the main source of fungal propagules. Old houses were more prone to fungal growth.

Indoor airborne fungal spores and home characteristics in asthmatic children from Edirne region of Turkey

Background: The contribution of indoor fungal exposure to childhood asthma is not completely clear. Objective: To investigate airborne fungal flora within the homes of asthmatic and control children, and to assess the influence of housing characteristics regarding indoor fungi. Methods: Forty-seven atopic asthmatic and 23 nonatopic control children were studied. Allergen sensitivity was determined by skin prick tests. A thorough assessment, using a questionnaire and inspection surveys, was carried out. Home visits were made between October 2000 and February 2001. Samples of airborne fungal spores were collected from four rooms by the "open Petri dish" method. Indoor temperature and humidity were measured. Results: The total indoor fungal colony counts from the living rooms and bedrooms were significantly higher in the asthma group than in controls (p = .012 and p = .003, respectively). The most commonly isolated genus was Cladosporium. Twelve of the asthmatic patients (25.53 %) were found to be sensitive to fungal allergens. The factors found to be associated with indoor fungal growth in logistic regression were visible fungal patches in the bathrooms [(odds ratio (OR) = 5.75; 95 % CI 1.19 to 27.70)], and the age of the house [OR = 4.24; 95 % CI 1.34 to 13.45]. Total fungal colony numbers did not correlate with indoor temperature or humidity. Conclusion: Fungal colony numbers were higher in the homes of asthmatic children than in those of controls. Therefore, indoor fungal exposure may contribute to childhood asthma. Bathrooms were the main source of fungal propagules. Old houses were more prone to fungal growth (AU)

Historial: La contribución al asma infantil a causa de la exposición a hongos de interior no está totalmente clara. Objetivo: Intentamos investigar la flora de hongos que se encuentra en el aire dentro de los hogares de los niños asmáticos y los niños controlados, así como determinar la influencia de las características de la casa respecto a los hongos de interior. Métodos: Cuarenta y siete niños asmáticos y veintitrés niños controlados no alérgicos. La reacción alérgica se determinó mediante pruebas de alergia. Se llevó a cabo una evaluación exhaustiva utilizando un cuestionario y encuestas de inspección. Las visitas domiciliarias fueron realizadas entre octubre de 2000 y febrero de 2001. Las muestras de las esporas de hongos aerotransportadas fueron recogidas en cuatro habitaciones por el método de la "placa de Petri abierta". Se midió la temperatura y la humedad interior. Resultados: El número total de hongos de interior en las salas de estar y en los dormitorios era notablemente más elevado en el grupo de asmáticos que en el otro grupo (p = ,012 y p = ,003, respectivamente). El género aislado más común fue el Cladosporium. Doce de los pacientes asmáticos (25,53 por ciento) resultaron ser sensibles a los hongos. La regresión logística puso en evidencia que las manchas de hongos visibles en los cuartos de baño [(cociente de las probabilidades (O) = 5,75; 95 por ciento del ci 1,19 a 27,70)], y la antigüedad de la casa [O = 4,24; 95 por ciento del ci 1,34 a 13,45], estaban correlacionados con el crecimiento de los hongos de interior. El número total de hongos de la colonia no está relacionado con la temperatura o la humedad interior. Conclusión: El número de hongos de la colonia era más elevado en los hogares de niños asmáticos que en los controlados. Por lo tanto, la exposición a hongos de interior puede contribuir al desarrollo del asma infantil. Los cuartos de baño eran la fuente principal de propagación de hongos. Las casas viejas eran más propensas al crecimientote los hongos (AU)

Childhood asthma perception in Turkey under real-life environment (CAPTURE) study.

Successful management of asthma requires good communication between patients and the healthcare team. The background and expectations of a patient inevitably influence the success of any partnership. A questionnaire-based survey was performed to obtain data on the perception of the impact of asthma in daily life among children (age-range 6-14 years) and adolescents (age-range 15-20 years). A total of 756 patients (384 children, 372 adolescents) were randomly selected from 11 Turkish cities and interviewed face-to-face. Of the total study population, 71.3% received regular follow-up and 75.9% currently took asthma medication. Almost 50% reported that asthma affected their lives significantly. Even though half of the patients had symptoms at least once a week, one-third were not receiving regular prophylactic treatment. Exercise produced asthma symptoms in 45.5% of children and 27.4% of adolescents. The finding that asthma continues to be a major health problem clearly indicates an urgent need for further management programs in Turkey.

Sonographic assessment of ceftriaxone-associated biliary pseudolithiasis in children.

PURPOSE: Ceftriaxone is a widely used third-generation cephalosporin. In this prospective study, we used sonography to investigate the incidence and outcome of biliary complications in children receiving ceftriaxone therapy. METHODS: Ceftriaxone was administered intravenously at a dosage of 100 mg/kg/day for 1-3 weeks to 118 children hospitalized for severe infection. Serial gallbladder sonograms were obtained on days 1, 5-7, and 10-14 of therapy and the day after therapy ended if it had lasted more than 2 weeks. When sonographic abnormalities were found, additional sonograms were obtained every 3 days until the abnormalities had completely resolved. RESULTS: Twenty patients (17%), all asymptomatic, demonstrated sonographic abnormalities: 8 had gallbladder sludge, defined as echogenic material without associated acoustic shadowing, and 12 had pseudolithiasis, defined as echogenic material with acoustic shadowing. These abnormalities spontaneously resolved within 2 weeks of stopping the ceftriaxone (mean time to disappearance, 8.2 +/- 3.4 days). No significant differences were found between patients with normal versus abnormal sonographic findings in sex, age, duration of treatment, or other risk factors for drug precipitation. CONCLUSIONS: Ceftriaxone-associated biliary pseudolithiasis is usually asymptomatic and was rapidly reversible after cessation of therapy in this group of Turkish children.

Egg and milk allergy in asthmatic children: assessment by immulite allergy food panel, skin prick tests and double-blind placebo-controlled food challenges.

There is a perception that asthmatic symptoms may be worsoned by ingestion of certain foods. This study aimed to investigate whether ingestion of cow's milk or egg might induce respiratory symptoms in asthmatic children. Fifty asthmatic children aged 1.5 to 6 years old, with positive Immulite Food Panel FP5 test results were included in the study. Fifty healthy children within the same age group were accepted as control group. Total serum IgE levels were measured and skin prick tests for food allergens including milk and egg were performed. All of the subjects underwent oral, double-blind, placebo-controlled challenge with fresh egg and cow's milk powder. Two medical histories were confirmed by double-blind, placebo-controlled challenge in 9 patients (22.2%). Skin prick tests were positive in 9 patients (18%) with milk and 18 patients (36%) with egg antigen. Two children experienced wheezing, one after ingesting milk and the other after egg challenge (4%). In the control group no positive reactions were seen with egg or milk challenges. Our findings confirm that food allergy can elicit asthma in children, but its incidence is low, even with major allergens such as egg and milk. History, specific IgE determinations and skin prick tests are not reliable in diagnosing food reactions. Since any diet can cause rapid deficiencies in infancy, diet restrictions must not be applied, without performing double-blind, placebo-controlled challenge.

The significance of sputum ECP levels in differential diagnosis of asthma in children.

Asthma and chronic bronchitis are diseases that may present similar symptoms. Because eosinophil granulocytes play an important role in the pathogenesis of asthma, the assessment of eosinophilic inflammation may be useful in making a differential diagnosis of these two diseases. This study investigated the serum and sputum eosinophil cationic protein (ECP) levels in children with asthma and chronic bronchitis and compared them with controls. Fifty asthmatic patients being treated for mild or moderately severe asthma at a university hospital were enrolled in the study. Fifteen children with symptoms of cough and sputum production lasting more than 3 months were studied in the chronic bronchitis group and 25 healthy children were included in the control group. Asthmatic patients were divided into subgroups according to the presence or absence of asthmatic exacerbations. Clinical evaluation and determination of ECP concentrations in serum and sputum were performed for each group. Increased activity of eosinophils was found in patients with asthma as assessed by high serum ECP (mean 21.44 +/- 20.33 microg/L) and sputum ECP (mean 129.65 +/- 125.01 microg/L) levels. In patients diagnosed with chronic bronchitis, serum ECP levels were similar to those of the control group (mean serum ECP 11.04 +/- 10.23 microg/L and 12.07 +/- 6.12 microg/L, respectively). More importantly, sputum ECP levels of the chronic bronchitis group were much lower (mean 53.36 +/- 55.43 microg/L) than those in patients with asthma (mean 129.65 +/- 125.01 microg/L). The serum and sputum ECP levels of the asthmatic patients who were evaluated during an acute exacerbation were also higher than those in the chronic bronchitis group. Sputum ECP levels may be helpful in the differential diagnosis of asthma and chronic bronchitis in children.

Calvarial tuberculosis.

We report a six-year-old boy who presented with swelling of the forehead, and had calvarial tuberculosis, a rare form of tuberculous osteitis.

The effect of prior BCG vaccination on the clinical and radiographic presentation of tuberculosis meningitis in children in Istanbul, Turkey.

SETTING: Department of Pediatrics, Istanbul University Faculty of Medicine, Istanbul, Turkey, between January 1984 and December 1996. OBJECTIVE: To explore whether neonatal BCG vaccination offers any protective effect on clinical and laboratory profiles of central nervous system (CNS) tuberculosis in children. DESIGN: A retrospective review of cases of CNS tuberculosis diagnosed and treated in one institution. RESULTS: Of the 145 patients identified with CNS tuberculosis, 9.6% were vaccinated during the neonatal period. The rate of close contact with contagious pulmonary tuberculosis in family, age distribution, clinical findings and laboratory investigations on admission were not significantly different in vaccinated and non-vaccinated children. Although mortality rate in the vaccinated patients (8.3%) was found to be nearly half of that in the non-vaccinated group (15.1%), severe sequelae were significantly more frequent (P < 0.02) among the vaccinated patients; CONCLUSION: This study shows that neonatal BCG vaccine has little effect on the clinical findings of subsequent CNS tuberculosis, and that these children have typical presentations of tuberculosis disease.

Community-acquired severe staphylococcal septicemia in children: the relationship with blunt trauma.

BACKGROUND: With the aim of establishing the role of blunt trauma, a trauma without any fracture or obvious wound, as a risk factor in children who were admitted for community-acquired severe staphylococcal septicemia with various organ involvement, 63 patients were investigated during a seven-year study period. All children were previously healthy. RESULTS: Blunt trauma was present in 12 (46%) of 26 septicemic patients in whom skeletal infections were diagnosed and the relative risk of trauma was high (odds ratio 15.0; confidence interval 2.9-75.8, P < 0.001) in these children. Patients with multiple organ involvement and with multifocal skeletal infections were more frequent among traumatized patients. Children with skeletal involvement were significantly older than others (P < 0.001). The period between the first symptom of infection and the diagnosis was shorter in traumatized children (P < 0.001). None of the children with staphylococcal pulmonary or soft tissue infection had any history of trauma. We conclude that blunt trauma is one of the important risk factors for skeletal involvement in staphylococcal septicemia. Its immunosuppressive nature, especially in local damage of the skin barrier, may be the cause of seeding and multifocal infection.

Low immunoglobulin G3 levels in wheezy children.

This study aimed to investigate the prevalence of IgG subclass deficiency in wheezy children aged <3 y. Serum levels of IgA, IgE and IgG subclasses were measured in 310 children with recurrent wheezing and in 100 healthy controls. IgG3 levels were below the normal lower limit in 123 (39.6%) patients. This finding may reflect delayed maturation of the immune system, predisposing young children <3 y of age to wheezing.

Home environment and asthma in school children from the Edirne region in Turkey.

Studies have shown that environmental factors contribute to the development of asthma. Hence, we investigated the relation between current asthma and indoor environmental factors such as exposure to pets, tobacco smoke, home dampness, number of people living in home, and stuffed toys in child's bedroom in a questionnaire based study in primary school children aged 6 to 12 years living in Edirne (Turkey). In a random sample of 4 primary schools, questionnaires were completed by parents of 1000 children. Following the evaluation of 682 of these, 85 were selected as cases of asthma of which 24 were diagnosed by a physician. When required certain laboratory tests were also performed in order to confirm the diagnosis. Logistic regression was used to investigate the associations between asthma and potential risk factors. In logistic regression analyses, the following factors were associated with asthma. Dampness in the house [(odd's ratio (O.R) = 2.61; 95% CI 1.13 to 6.81), stuffed toys in the child's bedroom (O.R = 2.18; 95% CI 1.27 to 3.74), and the crowding index (O.R = 2.73; 95% CI 1.08 to 6.82)]. In conclusion, it was found that presence of asthma was significantly associated with the presence of dampness in the house, and stuffed toys in the child's bedroom. Asthma can be prevented by improvement of the indoor environment. Therefore providing education to high-risk populations for avoidance of these risk factors is particularly important.

In vitro chromosomal radiosensitivity in common variable immune deficiency.

Common variable immune deficiency (CVID) is characterized by low immunoglobulin levels and recurrent infections in patients with a period of normal immune function several years after birth. It is associated with diarrhea, malabsorption, bronchiectasis, and lymphoreticular malignancies. Radiation-induced chromosome instability may contribute to the high degree of susceptibility to neoplasia. Peripheral blood lymphocyte cultures were obtained from six patients with CVID and the healthy control group matched by age and sex. The groups did not differ in the frequency of spontaneous chromosome aberrations. After exposure to X-ray radiation, mitotic indices were found to be significantly low and incidence of chromosomal alterations were high in the CVID group. We conclude that chromosomes of cells from patients with CVID are significantly more radiosensitive than those of controls. Thus these patients must be protected from unnecessary X-ray examinations and in case of radiosensitive tumour, the dose of irradiation should be carefully monitored.

Prevalence of childhood asthma in Istanbul, Turkey.

In order to determine the asthma prevalence in 6-12-year-old schoolchildren in Istanbul, we issued 2350 questionnaires, according to ISAAC criteria, in six randomly selected city primary schools to be completed at home by parents. A total of 2232 of the questionnaires were completed, an overall response rate of 94.9%, and 2216 questionnaires were taken into consideration. The prevalence of asthma was found to be 9.8% and wheezing 15.1%. To investigate the effect of socioeconomic status on the prevalence of asthma, we evaluated the heating system at home, the place of residence, the educational levels of the mother and father, the number of people living in the house, the sharing of bedrooms, and the annual family income. In conclusion, the prevalence of childhood asthma was not affected by any of these factors. Atopic family history, food allergy, eczema, and frequent otitis media and sinusitis attacks were evaluated and found to be significant in asthma prevalence.

Peripheral and nasal eosinophilia and serum total immunoglobulin E levels in children with ascariasis.

In order to evaluate peripheral and nasal eosinophilia and serum total IgE levels in ascariasis, 30 children between two and 12 years of age whose fecal samples were found to contain Ascaris lumbricoides, and 30 children between 1.5 and 12 years of age who did not have ascaris in their fecal samples, were enrolled in the study. Peripheral eosinophil counts and serum total IgE levels were significantly higher in the study group, but there was no significant difference between the nasal eosinophil counts of the two groups. Since total serum IgE levels differ according to age, the patients and the control groups were also evaluated within three age-groups. Peripheral eosinophil counts and serum total IgE levels of patients with ascariasis in all age ranges were significantly higher, but nasal eosinophil values did not differ significantly. These results show that in ascariasia the presence of peripheral eosinophilia and high total serum IgE levels are similar to those in atopic diseases, and some allergic symptoms such as nasal itching can be caused by parasites. However, nasal itching does not correlate with nasal eosinophilia in ascariasis. This is an important feature in the differential diagnosis.