Urinary thrombin as a marker of local disseminated intravascular coagulation in patients with chronic kidney disease

The aim of this research was to study the diagnostic markers of nonovert local disseminated intravascular coagulation (DIC) syndrome in the urine of patients with chronic kidney disease (CKD). We conducted a prospective study involving 140 patients with CKD, of these patients, 100 patients (71.4%; 95% CI 53.4-76.7) had glomerulonephritis (GN) and 40 patients (28.6%; 95% CI 21.3-36.8) had diabetic nephropathy (DN). We diagnosed overt DIC syndrome on the International Society of Thrombosis and Haemostasis (ISTH) scale (>5 points) in 18.6 % of patients. We determined the level of thrombin in the urine of patients who had <5 points on ISTH scale for the diagnosis of local nonovert DIC syndrome in the kidneys. In the urine of healthy individuals, the level of thrombin did not exceed 1 ng/ml, so we found no thrombinuria at a thrombin level <1 ng/ml. In 56.1% of patients, we found urinary thrombin levels >1 ng/ml. The average level of thrombin in the urine of these patients was 6.5 (4.8; 10.6) ng/ml. In our opinion, the presence of thrombinuria indicates the intensity of monocytic-macrophage inflammation in the glomeruli and may be a criterion for nonovert, local DIC syndrome in the kidneys. The association of overt DIC syndrome with decreased blood albumin, reduced glomerular filtration rate (GFR), increased daily protein excretion (DPE) indicates its occurrence in severe underlying disease, in the presence of nephrotic syndrome and in the severe stages of CKD. Early diagnosis of nonovert local DIC syndrome would be more useful, since the process is still reversible and controlled, and timely use of antiplatelet and anticoagulant therapy would affect the course and the progression of CKD.

Causes of poor eye contact in infants: a population-based study

Background Establishing eye contact between infants and parents is important for early parent-child bonding and lack of eye contact may be a sign of severe underlying disease. The aim of the study was to evaluate the causes of poor or lacking eye contact in infants. Methods Cross-sectional study reviewing all referrals of infants ≤1 year of age from January 1rst, 2016 to December 31rst, 2018. Medical information was retrieved from patient files covering pregnancy, birth, diagnostic work-up and ocular parameters such as refraction, visual acuity and structural findings. Results We identified 99 infants with poor or lacking eye contact. The relative frequency of causes was neurologic disease 36.4% (36/99), delayed visual maturation 24.2% (24/99), ocular disease 21.2% (21/99) and idiopathic infantile nystagmus 4.0% (4/99). Fourteen infants had a visual function within age-related norms at first examination despite poor eye contact at the time of referral. Of the infants with available data, 18/27 (33.3%) with neurologic cause, 15/23 (65.2%) with delayed visual maturation and 9/21 (42.9%) with ocular cause had visual acuity within the age-related norm at latest follow-up (0-41 months). In 23 infants, a genetic cause was found. Conclusion Poor eye contact in infants may be a sign of severe underlying disease, such as neurological or ocular disease. Close collaboration between pediatric ophthalmologists and neuro-pediatricians are warranted in the management of these infants.

Death of a 3 Month-Old Infected Infant with Dilated Cardiomyopathy after COVID-19 Infection: A Case Report

Background: Several numbers of studies have reported that coronavirus disease-2019 (COVID-19) in infants and children have shown milder symptoms and a better prognosis than in adult patients. However, there is no sufficient evidence on the effect of cardiovascular involvement in COVID-19 in the infant. Case Report: Here, we report an infant infected with COVID-19 with the manifestations of dilated myocarditis. The patient was referred to Pediatric Emergency with lethargy and tachypnea. On physical examination, she had holosystolic murmur with grade 3/6. The laboratory examinations showed anemia as well as increased alkaline phosphatase (ALP) levels. Due to respiratory distress, she was intubated and put under mechanical ventilation. The diagnosis of COVID-19 infection was confirmed by real-time polymerase chain reaction (RT-PCR) using a pharyngeal specimen. Finally, dilated cardiomyopathy (DCM) was diagnosed and one day after hospitalization the infant was died due to complications of DCM. Conclusion: It seems that in the infant with severe underlying disease, even a mild COVID-19 infection, may be lethal. Focal viral myocarditis is a very rare condition described by localized disturbance of the myocardium occurring in ventricular dysfunction with significant morbidity and mortality. Thus, due to the possibility of cardiac injury in infected neonates with COVID-19 disease and the manifestation of myocarditis, effective measurement is recommended.

Use of Monoclonal Antibody to Treat COVID-19 in Children and Adolescents: Risk of Abuse of Prescription and Exacerbation of Health Inequalities

Monoclonal antibodies (mAbs) that neutralize SARS-CoV-2 in infected patients are a new class of antiviral agents approved as a type of passive immunotherapy. They should be administered to adults and children (≥12 years old, weighing ≥ 40 kg) with SARS-CoV-2 positivity, and who are suffering from a chronic underlying disease and are at risk of severe COVID-19 and/or hospitalization. The aim of this manuscript is to discuss the benefit-to-risk of mAb therapy to treat COVID-19 in pediatric age, according to current reports. A problem is that the authorization for mAbs use in children was given without studies previously evaluating the efficacy, safety and tolerability of mAbs in pediatric patients. Moreover, although the total number of children with chronic severe underlying disease is not marginal, the risk of severe COVID-19 in pediatric age is significantly reduced than in adults and the role of chronic underlying disease as a risk factor of severe COVID-19 development in pediatric patients is far from being precisely defined. In addition, criteria presently suggested for use of mAbs in children and adolescents are very broad and may cause individual clinicians or institutions to recommend these agents on a case-by-case basis, with an abuse in mAbs prescriptions and an exacerbation of health inequalities while resources are scarce. Several questions need to be addressed before their routine use in clinical practice, including what is their associated benefit-to-risk ratio in children and adolescents, who are the patients that could really have benefit from their use, and if there is any interference of mAb therapy on recommended vaccines. While we wait for answers to these questions from well-conducted research, an effective and safe COVID-19 vaccine for vulnerable pediatric patients remains the best strategy to prevent COVID-19 and represents the priority for public health policies.

MR Findings in the Bone Marrow of a Patient with Anorexia Nervosa

Gelatinous transformation of bone marrow (GTBM) is a hematological condition found to be associated with states of cachexia and malnourishment, which can be seen in patients with eating disorders, alcoholism, malignancy, and other systemic diseases (such as AIDS, tuberculosis, chronic kidney disease, and chronic heart failure). GTBM is not disease-specific but is a good marker of a severe underlying disease. Initially thought to be a rare finding, newer literature is now demonstrating more cases of GTBM over the past 2 decades, and the alleged rarity may have been attributed to the lack of clinical suspicion and awareness of this condition. We present a case of a young adult female, who has a background of anorexia nervosa and presented with a 4-month history of pain over her left shin. Magnetic resonance imaging (MRI) of the tibia demonstrated the gelatinous transformation of the bone marrow. In this case report, we aim to highlight the underlying pathogenesis of GTBM and its prevalence, its unique distribution within the marrow, its characteristic MRI findings, and how these findings may differ in comparison to normal reconversion marrow and neoplastic infiltration.

Cryptococcal empyema treated with tube thoracostomy and intrapleural fibrinolysis

A 55-year old woman with a history of relapsed T-cell ALL presented with right pleuritic chest pain and decreased breath sounds over the right hemithorax. Imaging of the chest showed loculated effusions. Tube thoracostomy was performed with intrapleural application of alteplase and dornase alpha over a 3-day period. Repeat imaging demonstrated a marked decrease in the volume of the effusion. In most prior published cases of pleural cryptococcosis, surgical drainage was required in addition to prolonged antifungal agents. More than 50% of patients with cryptococcal infection have severe underlying disease or immunodeficiency state making them high risk for surgery. This is the first case to our knowledge of cryptococcal empyema successfully treated with tube thoracostomy and intrapleural fibrinolysis.

Predictive factors for time to full enteral feeding after pyloromyotomy for infantile hypertrophic pyloric stenosis

BackgroundThe aim of the study was to evaluate how different parameters in the preoperative, perioperative, and postoperative period affect time to full enteral feeding (TFEF) in children undergoing pyloromyotomy.MethodsA retrospective study of all children operated for infantile hypertrophic pyloric stenosis between 2001 and 2017 was conducted. Parameters in demographics and in the preoperative and postoperative period were evaluated against TFEF (hours) using linear regression models.ResultsIn the whole cohort of 175 children, mean TFEF was 47 hours with Standard Deviation (SD) of ±35. In the multivariate model, TFEF decreased with age [beta (B): −0.62; 95% confidence interval (95% CI) −1.05 to −0.19; p=0.005) and increased with the presence of severe underlying disease (congenital heart defect or syndrome) (B: 26.5; 95% CI 3.3 to 49.7; p=0.026). Hence, for every day of age, the time to fully fed decreased by 0.6 hour, and the presence of an underlying disease increased the time to fully fed with over one day. TFEF did not seem to be affected by prematurity, weight loss, symptom duration, preoperative acid/base balance or electrolyte values, surgical method, or method of postoperative feeding.ConclusionsTFEF decreased with higher age and increased in children with a severe underlying disease. These results may be useful in providing adequate parental information regarding what affects TFEF and the length of hospital stay.

Chryseobacterium indologenesperitonitis in a peritoneal dialysis patient

Peritonitis remains an important complication of peritoneal dialysis. The Gram-negative bacillusChryseobacterium indologenescauses infection mostly in immunocompromised patients with severe underlying disease, mainly in Asia. Herein, we report the first case in Europe and the second case in an immunocompetent patient of peritoneal dialysis-associatedC. indologenesperitonitis. Our patient presented with abdominal pain and a cloudy effluent and was started on intraperitoneal antibiotics. The organism cultured from the peritoneal fluid was later identified asC. indologenesand antibiotic therapy was adjusted accordingly. Despite this, the peritonitis followed a relapsing course, requiring Tenckhoff catheter removal, temporary transfer to haemodialysis and intravenous antibiotics. Subsequently, a new Tenckhoff catheter was inserted and peritoneal dialysis was restarted. The patient remains peritonitis free after 18 months of follow-up. This case highlights the need to consider rare causes of peritonitis in peritoneal dialysis patients as well as the heterogeneous clinical course ofC. indologenesperitonitis.

Whole-Genome Sequence Analysis of Streptococcus pneumoniae Strains That Cause Hospital-Acquired Pneumonia Infections

ABSTRACT Streptococcus pneumoniae colonizes the nasopharyngeal mucus in healthy individuals and can cause otitis media, pneumonia, and invasive pneumococcal diseases. In this study, we analyzed S. pneumoniae strains that caused 19 pneumonia episodes in long-term inpatients with severe underlying disease in a hospital during a period of 14 months (from January 2014 to February 2015). Serotyping and whole-genome sequencing analyses revealed that 18 of the 19 pneumonia cases were caused by S. pneumoniae strains belonging to 3 genetically distinct groups: clonal complex 9999 (CC9999), sequence type 282 (ST282), and ST166. The CC9999 and ST282 strains appeared to have emerged separately by a capsule switch from the pandemic PMEN 1 strain (Spain 23F -ST81). After all the long-term inpatients were inoculated with the 23-valent pneumococcal polysaccharide vaccine, no other nosocomial pneumonia infections occurred until March 2016.

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Cough is a common problem in children. Acute cough lasts less than 3 weeks, subacute 3–8 weeks and chronic cough more than 8 weeks.Acute cough is usually caused by common viral upper respiratory tract infection. However, the child should be thoroughly evaluated to rule out a serious underlying condition or disease responsible for the cough.The commonest cause of subacute cough is a viral infection (postinfectious cough) and it usually resolves spontaneously. If the child is otherwise well and the cough is dry and there are no specific alerts for a serious disease and the cough is resolving, a period of observation is all that is recommended. If there are any specific pointers in history and examination identified for an inhaled foreign body, chronic lung disease, or in a case of progressive cough, immediate investigations are needed.Most chronic coughs in childhood are due to viral infections, but may signify a serious underlying disease too. Chronic cough is subdivided into specific cough (i.e., cough associated with other symptoms and signs suggestive of an associated or underlying problem) and nonspecific cough (i.e., dry cough in the absence of an identifiable respiratory disease of known etiology).To prevent unnecessary investigations and ineffective treatment, and at the same time not to overlook a severe underlying disease, cough guidelines have been designed which are based on evidencebased medicine.