Significance of bowel wall abnormalities at ultrasound in Henoch-Schönlein purpura.

OBJECTIVES: To describe the polymorphism of intestinal ultrasound findings in children with gastrointestinal symptoms of Henoch Schönlein purpura (HSP) and to investigate the clinical relevance of these findings in terms of symptoms and length of hospitalization. PATIENTS AND METHODS: Clinical and ultrasound data from 43 consecutive children with HSP (36 with and 7 without abdominal symptoms) were reviewed. Patients with abdominal symptoms of HSP were divided into 4 groups (0-III) representing at ultrasound normal appearance and differentiated, pseudodifferentiated, and dedifferentiated bowel wall thickening, respectively. The diagnostic value of ultrasound in diagnosing gastrointestinal involvement of HSP (grades I-III) was calculated using as the standard of reference the absence or presence of clinical symptoms. Average duration of symptoms and hospitalization in the 4 groups was compared. RESULTS: The respective sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for the diagnosis of gastrointestinal involvement of HSP was 83.3%, 100%, 100%, and 53.8%. Groups 0 to III contained, respectively, 5/36 (13.9%), 6/36 (16.7%), 22/36 (61.1%), and 3/36 (8.3%) patients. The groups' average duration of symptoms, respectively, was 2.20 +/- 2.06, 5.67 +/- 1.88, 6.29 +/- .94, and 17.67 +/- 2.66 days, whereas the length of hospitalization, respectively, was 4.80 +/- 2.96, 9.17 +/- 2.70, 11.46 +/- 1.35, and 24.67 +/- 3.82 days. The duration of both symptoms and hospitalization was significantly higher in group III than in the other groups (P < 0.05). CONCLUSIONS: In children with gastrointestinal involvement of HSP, dedifferentiated wall thickening as shown by ultrasound is associated with a poor clinical prognosis.

Efficacy and tolerance of infliximab in children and adolescents with Crohn's disease.

Infliximab, a monoclonal antibody against tumor necrosis factor-alpha, has been shown to be effective for the treatment of refractory Crohn's disease in adult patients, but experience in pediatrics is limited. This retrospective study included 88 children and adolescents, 39 girls and 49 boys, with a median age of 14 years (range 3.3-17.9). Infliximab was indicated for active disease (66%) and/or fistulas (42%) that were refractory to corticosteroids (70%), and/or other immunosuppressive (82%) agents, and/or parenteral nutrition (20%). Patients received 1 to 17 infusions (median 4) of 5 mg/kg (range 3.8-7.3) of infliximab during a median time period of 4 months (1-17 months). Infusion reaction was noted in 13 patients (15%), with a total of 16 reactions in 450 infusions (4%). At Day 90 after the first infusion of infliximab, symptoms improved in 49% of patients, whereas 29% of patients were in remission and 13% of patients relapsed. From Day 0 to Day 90, Harvey-Bradshaw score decreased from 7.5 to 2.8 (P < 0.001), C-reactive protein from 36 to 16 mg/L (P < 0.01), and 1-hour erythrocyte sedimentation rate from 35 to 17 mm (P < 0.01). Dosage of corticosteroids decreased from to 0.59 to 0.17 mg/kg/d (P < 0.001); 53% of patients could be weaned of corticosteroids and 92% of parenteral nutrition. Treatment with infliximab is well tolerated and effective in most children and adolescents with Crohn's disease that is refractory to conventional immunosuppressive therapy. Nevertheless, long-term efficacy remains to be shown, and further studies are urgently needed to precisely determine the best modality of continuing treatment.