Urticarial eruption in COVID-19-positive children: A report of two cases

Recent literature has reported a variety of dermatological manifestations in children and adults associated with COVID-19. Herein, we report urticarial eruptions in two COVID-19-positive children. In the first case, urticaria with angioedema preceded a febrile episode and only partially responded to conventional doses of antihistamines. In the second case, urticaria followed the appearance of fever and upper respiratory symptoms. Both cases recovered completely within two weeks of diagnosis. These cases demonstrate that urticaria and angioedema, precedent or following a febrile illness, with or without respiratory symptoms, may be a presenting symptom of COVID-19 infection in children. A high index of suspicion in such cases helps the early administration of treatment and isolation of the patients to limit the spread of the virus.

O-BN07 Transesophageal Endoscopic Resection of Mediastinal Cysts

Background Primary mediastinal cysts are infrequent lesions derived from a variety of mediastinal organs or structures. Complete surgical resection is the treatment of choice even in asymptomatic patients to prevent severe adverse events (AEs) and establish the diagnosis. Transesophageal endoscopic resection of benign mediastinal tumors has been proven feasible. The aim of this study is to evaluate the feasibility, safety and efficacy of transesophageal endoscopic surgery for mediastinal cysts. Methods From January 2016 to May 2021, patients with mediastinal cysts who underwent transesophageal endoscopic resection were retrospectively included. Clinicopathological characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed. Results A total of 10 patients with mediastinal cysts were included in this study. The mean cyst size was 3.3±1.3 cm. Histopathology revealed 3 bronchogenic cysts (30.0%), 4 esophageal duplication cysts (40.0%), 2 gastroenteric cysts (20.0%), and 1 lymphatic cyst (10.0%). All procedures were performed uneventfully. En bloc resection was achieved in 6 patients (60.0%). Aggressive resection was avoided to prevent damage to the surrounding vital organs. Mean procedure time was 63.4±36.5 min. No major pneumothorax, bleeding, mucosal injury or fistula occurred. One patient had a transient febrile episode (>38.5 °C). Mean postoperative hospital stay was 2.7±0.9 days. No residual or recurrent lesions were observed in any patient during a mean follow-up period of 29.8±19.5 months. Conclusions Transesophageal endoscopic surgery appears to be a feasible, safe, effective and much less invasive approach for mediastinal cyst resection. Larger prospective studies are required to fully assess the efficacy and safety of this novel technique.

P084 Recurrent fever in children: why not a mevalonate kinase deficiency?

Background Mevalonate kinase deficiency (MKD) is a rare autosomal recessive auto inflammatory disease. The clinical spectrum of this disease is a continuum ranging from the moderate form of Hyper-IgD syndrome (HIDS) to lethal forms of mevalonic aciduria (MA). An autoinflammatory disease should be considered in children with recurrent fever of unexplained origin. Case report M, 28 months old boy from a non-consanguineous marriage of Algerian parents, presented since the age of two months’ episodes of unexplained fever resistant to antibiotics and requiring several hospitalizations. Family history found that the mother and a maternal uncle experienced an unexplained recurrent fever. Personal history found episodes of fever lasting in average 6 days, with no obvious cause and recurring every 15–20 days; associated with bilateral cervical adenopathy, mouth ulcers, arthralgia, abdominal pain with vomiting and diarrhea. Clinical examination confirmed the fever with temperature of 38.7°, Chills and irritability, Multiple cervical adenopathy oral aphthae, tongue of geographical aspect, cervical pain and large joint arthralgia, tender abdomen with no organomegaly. Biologic workups found major inflammatory syndrome with hyper leucocytosis at 14X103/mm3 predominantly polynuclear, high CRP level, high ESR at 110 mm. Blood cultures and viral serologies were negative. Immunoelectrophoresis found elevated IgA, IgG and IgM with a normal IgD level. Chest X-ray and abdominal ultrasound were normal. The diagnosis of MKD in its moderate form was supported by elevated urinary mevalonic acid excretion to 5.1 mmol/mol during the febrile episode and subsequently confirmed by a 2nd contributory urine assay during another febrile episode. Conclusion MKD is a rare disease. The clinical spectrum of this condition is variable and could benefit of an effective treatment. Our patient developed a moderate form with a better long-term prognosis.

COVID-19 in a child with multiple comorbidities

A female child, 1 year-old and 2 months, diagnosed with multiple neurological conditions, including myelomeningocele and operated hydrocephalus, was diagnosed with SARS-CoV-2 in October 2020 and hospitalized in our clinic. At the time of the onset of the disease, the patient had a febrile episode, laboratory blood tests showed a slightly increased biological inflammatory syndrome, and mixed pneumonia was described radiologically. Thus, antibiotic treatment was initiated, with laboratory tests and control imaging within normal limits after several days of admission. Being an institutionalized child, according to the epidemiological recommendations of that time, she was hospitalized in our clinic during the 14 days of the illness. Thus, on the 15th day of the disease she was discharged, with negative SARS-CoV-2 control RT-PCR, with good general condition, afebrile over 10 days.

Glucocorticoid and Antibiotic Treatment-induced Recapitulated Hematological Remissions in Acute Myeloid Leukemia: Implications for Ligand-dependent Growth and Survival Advantage

Leukemia-transformed multipotential hematopoietic cells have acquired the increased self-renewal capacity and impaired myeloid differentiation to mature blood cells. The emergence of symptomatic leukemia also critically requires the acquisition of growth and survival advantage in leukemic cells. Untreated leukemia patients usually demonstrated a progressive process. However, spontaneous remission occasionally occurred in a very small number of leukemia patients, which frequently followed a febrile episode and antibiotic treatment and was generally attributed to the activation of anti-neoplastic activities. Here we report a 63-year-old Chinese man who presented with the main complaints of abdominal pain, febrile episode and urticaria-like skin lesions. He was diagnosed with acute myeloid leukemia (AML-M4) with t(8;21)(q22;q22)/RUNX1-RUNX1T1 on the basis of morphological, immunological, cytogenetic and molecular analysis. He also had a mutated FLT3-TKD gene. He was treated with antibiotics and glucocorticoid for the gastrointestinal infection and the urticaria-like skin lesions. The infection and skin lesions were quickly resolved. Unexpectedly, along with the relief of the febrile episode, abdominal symptoms and skin lesions, he achieved a hematological remission. After relapse, repeating this treatment resulted in the second hematological remission. These recapitulated treatment responses strongly suggested that inflammatory stresses arising from the gut inflammatory lesions, which could be largely mitigated by antibiotic and glucocorticoid treatment, sustained the growth and survival advantage of the leukemic cells.

Open-Label Phase II Prospective, Randomized, Controlled Study of Romyelocel-L Myeloid Progenitor Cells to Reduce Infection During Induction Chemotherapy for Acute Myeloid Leukemia

PURPOSE Standard cytotoxic induction chemotherapy for acute myeloid leukemia (AML) results in prolonged neutropenia and risk of infection. Romyelocel-L is a universal, allogeneic myeloid progenitor cell product being studied to reduce infection during induction chemotherapy. PATIENTS AND METHODS One hundred sixty-three patients with de novo AML (age ≥ 55 years) receiving induction chemotherapy were randomly assigned on day 0 (d0), of whom 120 were evaluable. Subjects received either romyelocel-L infusion on d9 with granulocyte colony-stimulating factor (G-CSF) starting daily d14 (treatment group) or G-CSF daily alone on d14 (control) until absolute neutrophil count recovery to 500/µL. End points included days in febrile episode, microbiologically defined infections, clinically diagnosed infection, and days in hospital. RESULTS Mean days in febrile episode was shorter in the treatment arm from d15 through d28 (2.36 v 3.90; P = .02). Similarly, a trend toward decreased microbiologically defined infections and clinically diagnosed infection in the treatment arm was observed from d9 to d28 (35.6% v 47.5%; P = .09), reaching a statistically significant difference from d15 to d28 (6.8% v 27.9%; P = .002). Because of this, antibacterial or antifungal use for treatment of an infection was significantly less in the treatment group (d9-d28: 44.1% v 63.9%; P = .01). Significantly fewer patients in the treatment arm received empiric antifungals from d9 tod28 (42.4% v 63.9%; P = .02) and d15-d28 (42.4% v 62.3%; P = .02). Patients in the treatment arm also had 3.2 fewer hospital days compared with control (25.5 v 28.7; P = .001). Remission rates and days to absolute neutrophil count recovery were similar in the two groups. No patients in the romyelocel-L plus G-CSF group died because of infection compared with two patients in the control arm. No graft-versus-host disease was observed. CONCLUSION Subjects receiving romyelocel-L showed a decreased incidence of infections, antimicrobial use, and hospitalization, suggesting that romyelocel-L may provide a new option to reduce infections in patients with AML undergoing induction therapy.

Iron Deficiency Association as A Possible Cause of First Febrile Seizure

Aim: A controlled clinical study was conducted to investigate the relationship between iron deficiency and first episode of febrile seizure in children 6-60 months of age. Place and Duration:In the Pediatric Medicine department of ShifaInternationalHospital Islamabadforsix months duration from 15thMay 2020 to 30thNovember 2020. Methods:Hematological parameters for iron levels, including HB, MCV, MCHC and plasma ferritin, were determined in 75 patients who experienced a first febrile episode. 75 children without febrile seizures were taken as controls and the same markers were compared in both groups. Results: The most important factors influencing the first attack of febrile seizure were HB, MCV, and serum ferritin levels. Conclusion: Iron deficiency is significantly associated with the occurrence of the first febrile episode in children. Key words:Iron deficiency anemia, Iron deficiency, Febrile convulsions, Febrile attacks.

Oculomotor synkinesis: an uncommon sequela of paediatric cavernous sinus thrombosis

We report an unusual case of acquired oculomotor synkinesis as a sequela of cavernous sinus thrombosis in a child. A 4-year-old male child presented to our emergency services with sudden onset periorbital swelling with complete ptosis of the left upper eyelid. This was preceded by a febrile episode and a furuncle at the tip of the nose. Computerised axial tomography of the orbit revealed orbital cellulitis in the left eye. The child was started on systemic antibiotics followed by a short course of systemic steroids. MRI of the brain with contrast revealed left cavernous sinus and superior ophthalmic vein thrombosis. Following administration of systemic anticoagulants and antibiotics, the ocular motility and ptosis improved remarkably. However, 6 months post-treatment, the child developed signs of aberrant regeneration of the third cranial nerve (oculomotor synkinesis).

Catheter-Related Sepsis by Candida pararugosa in an Adult Patient under Chemotherapy Regimen

Candida pararugosa is present in animals and humans in different organs and biological liquids, usually as a saprophyte. We report the case of a 61-year-old woman diagnosed with de novo stage IV metastatic lobular breast cancer, carrying a central venous catheter (port-a-cath) and bilateral stents for perirenal infiltration by malignancy. During chemotherapy regimen, a febrile episode occurred, along with a high level of serum glucan. The port-a-cath was removed after blood collection for culture, which gave isolation of Candida pararugosa strains. Given high glucan level and the patient’s frailty, empirical treatment with fluconazole was started with load-dose, 800 mg orally, at day 1 and, afterwards, with 400 mg daily for two weeks. The phenotype of susceptibility to antibiotics of the strain demonstrated lower minimal inhibitory concentration to fluconazole than that reported in the literature. The patient remained asymptomatic, and inflammation parameters showed normalization. Unfortunately, three weeks later, meningeal localization of cancer caused rapid deterioration and death.