When Should Endoscopic Interventions Be Performed in Children with Severe Anemia?

OBJECTIVE: Anemia is a common problem in outpatient clinics, and endoscopic interventions are one of the initial steps to rule out the gastrointestinal causes. In this study, we aimed to analyze the diagnostic yield of endoscopic interventions in children with severe anemia. MATERIALS AND METHODS: The demographic features, laboratory findings, and endoscopic and histopathological findings of 65 children with severe anemia (hemoglobin <7 g/dL) (mean age of 12.1 ± 4.4 years, 73.8% female) who underwent endoscopic interventions were recorded from the files. Patients were divided into 2 groups according to the presence of positive endoscopic findings and/or histopathological examination. Factors that may predict the presence of positive endoscopic findings and/or histopathological examination were analyzed. RESULTS: After a colonoscopy and/or upper gastrointestinal endoscopy, the etiology of anemia was identified in 35 patients, and the major diagnosis of Helicobacter pylori gastritis in 16.9% and gastrointestinal ulcer in 10.8% of the patients was made. No gastrointestinal pathology was detected in 30 patients. The diagnostic yield of endoscopic examination in patients with severe anemia was 53.8% (95% CI: 63.3-67.7). Presence of hypoalbuminemia (P = .021), high erythrocyte sedimentation rate (P = .006), and high C-reactive protein (P = .03) was significantly associated with positive findings in endoscopic interventions. CONCLUSION: We recommend performing upper gastrointestinal endoscopy and/or colonoscopy in patients with severe anemia associated with gastrointestinal symptoms and using laboratory findings of hypoalbuminemia, high erythrocyte sedimentation rate, and C-reactive protein in order to rule out gastrointestinal pathologies.

Infantile tremor syndrome secondary to peroral vitamin B12 replacement therapy: a report of two cases with myoclonus.

BACKGROUND: Abnormal movements such as tremors and myoclonus may be observed during both treatment and deficiency of vitamin B12, particularly in infants. Infantile tremor syndrome (ITS) is defined by the tetrad of pallor, developmental delay/regression, skin pigmentation, and brown scanty scalp hair. CASE: In this report, two cases with ITS aged less than one year who had myoclonic movements during vitamin peroral B12 treatment are discussed based on hematologic, neurological, and magnetic resonance images (MRI) findings, one of whom developed a whole-body tremor and rhythmic myoclonic movements, titubation, and restlessness in the hands and feet as well as diffuse cerebral atrophy on brain MRI. CONCLUSION: The infants of mothers with nutritional vitamin B12 deficiency may develop sudden abnormal movements following peroral vitamin B12 therapy and that the differential diagnosis of these disorders is highly important for the prevention of long-term neurological sequela by treatment.

The first pediatric case of hemophagocytic lymphohistiocytosis secondary to Crimean-Congo haemorrhagic fever successfully treated with therapeutic plasma exchange accompanying ribavirin and intravenous immunoglobulin.

Although Crimean-Congo hemorrhagic fever (CCHF) is mild and self-limited in children, some patients may develop excessive bleeding, massive liver necrosis, and multiple organ failure associated with secondary hemophagocytic lymphohistiocytosis (HLH) induced by cytokine storm. Treatment of CCHF is mainly symptomatic and supportive. The efficacy of ribavirin, which is the only antiviral drug in the treatment of CCHF, remains controversial. Although therapeutic plasma exchange (TPE) has been shown to beneficial in small case series with primary and secondary HLH, there is no pediatric patient with HLH secondary to CCHF treated with TPE in the literature. In this report, we describe the first pediatric patient who was successfully recovered from HLH secondary to CCHF with ribavirin, intravenous immunoglobulin, and TPE.

Chemotherapy-related fever or infection fever?

BACKGROUND: The present study investigates the reason for the onset of fever after chemotherapy (CT) for cancer with the aim of reducing unnecessary medical care. METHODS: A total of 37 consecutive cycles of CT for cancer were analyzed retrospectively from the files of patients. Fever was defined as a temperature of ≥ 38 °C lasting for 1 h. RESULTS: The study sample included 23 males and 14 females (aged 8.43 ± 5.04 [min-max]). Fever was observed in all 37 cycles of chemotherapy agent (CA), which included cytarabine (ARA-C), dacarbazine, cyclophosphamide, irinotecan, adriamycin, etoposide, ifosfamide, cisplatin, and methotrexate. Fever was recorded within the first 12 h following treatment with ARA-C (45.9%), dacarbazine (16.2%), or cyclophosphamide (8.1%). A physical examination of the patients yielded normal results, C-reactive protein (CRP) and procalcitonin (PCT) values were within the normal range, the median absolute neutrophil count (ANC) was 3200/uL (0.00-16.340/uL), and a median sedimentation (ESR) level of 10 mm/h (2-59) was determined. All fevers were accepted as having resulted from CT based on the above criteria. Paracetamol and diphenhydramine were administered and the patients' treatments were continued. CONCLUSION: Febrile episodes occurring within the first 6 h following treatment were considered to constitute an adverse drug reaction after CT for the treatment of cancer. While ARA-C fever has been previously reported on in the literature, it should be kept in mind that CT fever can be seen with different CA. Physicians should be aware of this aspect of chemotherapy-associated fever and avoid unnecessary examinations and treatments, including antibiotics.

Acquired noncaustic esophageal strictures in children.

BACKGROUND: Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown. PURPOSE: We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists. METHODS: The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed. RESULTS: Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy. CONCLUSION: The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.

Therapeutic effect of N-acetylcysteine on chemotherapy-induced liver injury.

BACKGROUND: N-acetylcysteine (NAC) may be useful in the management of chemotherapy-induced liver injury. AIMS: The present study evaluates the possible therapeutic effects of NAC on chemotherapy-induced hepatotoxicity. METHODS: A total of 102 patients' files who were diagnosed with cancer between 2015 and 2019 were evaluated retrospectively. Two patient groups with and without NAC were selected. NAC was administered in a 3-µg/kg IV dose in a 24-h infusion to 70 patients when any alanine aminotransferase (ALT) or gamma-glutamyl transferase (GGT) values reached three times the normal levels. The other group consisted of 32 patients who were not treated with NAC. Alanine aminotransferase and GGT values were recorded at pretreatment, and on the 1st, 3rd, 5th, and 7th days in both the NAC and non-NAC groups from files. RESULTS: In the NAC group, ALT and GGT values on day 1, 3, 5, and 7 differed from each other, decreasing from day 1 to day 7. A statistically significant difference was noted between the values in the NAC group (p < 0.001). In the non-NAC group, the ALT values on day 7 were lower than the ALT values on day 1. A comparison of the ALT and GGT values in the NAC and non-NAC groups found that the values in the NAC group decreased earlier than in the non-NAC group. CONCLUSIONS: This study shows that NAC has a therapeutic effect on hepatotoxicity in children being treated with chemotherapeutic agents due to underlying malign diseases. The early reduction in the results of liver function tests is important for the continuation of chemotherapy.

Hepcidin levels in children with chronic liver disease.

BACKGROUND/AIM: We aimed to analyze serum hepcidin level in children with chronic liver disease (CLD) and its relationship with serum cytokines level, liver function tests, hepatic iron content, and liver fibrosis. PATIENTS AND METHODS: The study included 34 children with CLD, and 15 age- and gender-matched healthy children. Serum hepcidin, ferritin, iron level, interleukin-6 (IL-6), transforming growth factor-ß (TGF-ß ), total oxidant status (TOS), and antioxidant status (TAS) were studied in all patients and in the control group. Liver iron content (LIC) was measured from the liver biopsy specimen. RESULTS: Serum ferritin levels were higher in patients with CLD than control group (100.1 ± 98.2 ng/mL vs 50.5 ± 32.2 ng/mL, P = 0.016). No significant difference was found in hepcidin levels. Hepcidin levels in children with CLD was positively correlated with ferritin (r = 0.75, P = 0.001), pediatric end-stage liver disease (PELD) score (r = 0.56, P = 0.001), TAS (r = 0.42,P = 0.02), but negatively correlated with albumin level (r = -0.45,P = 0.008). Transferrin saturation and hepcidin:ferritin ratio were significantly low in patients with severe fibrosis compared with patients with mild/without fibrosis (15.5 ± 5.5 vs 34.3 ± 30.1, P = 0.017 and 1 ± 0.5 vs 1.9 ± 1.4,P = 0.04, respectively). CONCLUSION: Serum hepcidin levels in children with CLD reflect both liver functions and TAS, and severe fibrosis is associated with low hepcidin:ferritin ratio in children with CLD.

A Right Middle Cerebral Artery Infarct After Frontal Eosinophilic Granuloma Resection in an 8-Year-Old Boy with Factor V Leiden.

Stroke in children is relatively uncommon. We describe an 8-year-old boy diagnosed with primary eosinophilic granuloma (EG) of the frontal bone. After excision of the EG, the postoperative course was eventful. The patient had an acute right middle cerebral artery (MCA) infarct and had been comatose with a diminished Glasgow Coma Scale (GCS) score of 5. Urgent decompressive hemicraniectomy with duraplasty was performed. The postoperative course after the second operation was uneventful. Hematological tests revealed a diagnosis of factor V Leiden. The patient was discharged with left hemiparesis and GCS of 15. To the best of our knowledge, no such clinical picture of MCA infarction after EG excision has been described before. Neurosurgeons should be aware of inherited thrombophilias, such as factor V Leiden, if the postoperative clinical course worsens because of cerebral artery thrombosis. Also, decompressive hemicraniectomy could be life saving and should be performed urgently without any hesitation.

Bilateral paramedian thalamic syndrome after infection.

BACKGROUND: Although bilateral paramedian thalamic infarctions occur more frequently in adults than in children, they are rare entities at any age. The syndrome is thought to result from occlusion of the artery of Percheron, which arises as a common trunk from one of the posterior cerebral arteries to supply both paramedian thalamic regions. We describe two children with acute ischemic infarction involving both paramedian thalami developing after infection. PATIENTS: The first patient developed mutism with ataxia after chicken pox infection. The second child developed headache, somnolence, agitation, and speech dysfunction following an upper respiratory tract infection. Bilateral thalamic lesions were documented on magnetic resonance imaging of both children. CONCLUSION: Bilateral infarctions of the paramedian thalamus may result in severe illness and impairment. Common clinical manifestations include disorientation, confusion, hypersomnolence, deep coma and "coma vigil," or akinetic mutism (awake unresponsiveness), as well as severe memory impairment.