Vol 45, No 1 (2017)

ARTICLES

The etiology of viral respiratory infections in infants with community-acquired pneumonia

Bogdanova A.V., Samodova O.V., Bugaeva O.S., Turabova A.L., Pyatlina T.V., Konyukhov A.Y., Volkova I.I., Danilogorskaya E.V.

Abstract

Background: Community-acquired pneumonia can be caused by both bacterial and viral pathogens. The differential diagnosis based only on clinical data is not always feasible. The use of C-reactive protein (CRP) and procalcitonin might give some additional information for treatment decision-making.

Aim: To evaluate the structure and rates of viral isolation in community-acquired pneumonia in hospitalized infants and changes in CRP and procalcitonin levels.

Materials and methods: Seventy five infants at the age of up to 11 months and 29 days, who were hospitalized with community-acquired pneumonia confirmed by chest X-ray from March 2015 till February 2016, were included into the study. CRP and procalcitonin levels were measured. Detection of viruses in nasopharyngeal swabs was performed by a  real-time polymerase chain reaction.

Results: Nucleic acids of respiratory viruses were isolated in 72% (54/75) of infants. The most common were respiratory syncytial virus (in 70.4%, 38/54) and human rhinovirus (in 16.6%, 9/54). Median of white blood cell count in pneumonia associated with respiratory viruses was 10.95 (9; 14.1)×109/L, CRP level, 1.95 (0.5; 7) mg/L, procalcitonin level, 0.087 (0.067; 0.17) ng/mL.

Conclusion: The study showed a high prevalence of respiratory viruses in community-acquired pneumonia in infants. There was no increase in CRP and procalcitonin levels in pneumonia associated with respiratory viruses.

Almanac of Clinical Medicine. 2017;45(1):2-7
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Mycoplasma pneumoniae, Chlamydophila pneumoniae, Pneumocystis jirovecii and herpes infection in children with recurrent respiratory diseases

Khadisova M.K., Feklisova L.V., Meskina E.R.

Abstract

Rationale: Acute respiratory disorders (ARD) have the highest proportion among infectious disease in children. Despite the fact that serological diagnostics of Mycoplasma pneumoniae, Chlamydophila pneumoniae, Pneumocystis jirovecii, herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus type 6 (HHV-6) has been available for many years, up to now some objective limitations exist that hinder reliable differentiation between the viral carriage, past or current infection. There are no widely accepted guidelines that would suggest unified strategies for diagnosis and what is of utmost importance, for therapeutic intervention on a  case-to-case basis. The rationale for this study was based on underestimation of the burden of these infections in children with prolonged periods of cough and recurrent ARDs, as well as the necessity to further develop diagnostic and management strategies.

Aim: To determine causative role of M. pneumoniae, P. jirovecii, C. pneumoniae, HSV-1, -2, EBV, CMV, HHV-6 in children with recurrent ARDs hospitalized to an in-patient unit.

Materials and methods: We examined 50 children with recurrent ARDs aged from 1 to 7 years who were hospitalized with an acute respiratory infection. Laboratory assessments included determination of the markers of infections caused by M. pneumoniae, P. jirovecii, C. pneumoniae, HSV- 1, -2, EBV, CMV, HHV-6 by means of polymerase chain reaction, immunoenzyme analysis, and indirect immunofluorescence reaction.

Results: Markers of mycoplasma, chlamydial, pneumocystic infection, as well as HSV-1, -2, EBV, CMV, HHV-6 were found in 84% (42 / 50) cases. Active infection (acute or active persistent) was found in 38% (19 / 50) patients. The most prevalent was pneumocystic infection diagnosed in 12 (24%) patients; one fifth of all patients had mycoplasma (in 10 (20%) of cases), whereas herpetic and chlamydial infections were less frequent (4 (8%) and 1 (2%) of cases, respectively). Twelve (24%) patients had a single infection, while the others had mixed infections.

Conclusion: We were able to confirm the possibility of combined M. pneumonia / P. jirovecii infection (8%) in children with recurrent ARDs and history of longstanding cough; this is important for an assessment of efficacy of causative treatment. Measurement of serum titers of specific immunoglobulins M and G along with DNA/antigens of potential causative organisms can be sufficient to choose specific antibacterial treatment of obstructive bronchitis and pneumonia in children with the history of longstanding cough and recurrent bronchial obstruction.

Almanac of Clinical Medicine. 2017;45(1):8-13
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Efficacy analysis of tomosynthesis in the diagnosis of the femoral head osteochondropathy (Legg-Calvé-Perthes disease)

Vasil'ev A.Y., Karpov S.S.

Abstract

Background: Despite the fact that the prevalence of the femoral head osteochondropathy is 2.9% of all bone and muscle disorders and 25% of the disorders of the hip joint, this problem demands special attention, while late diagnosis could lead to disability of the patient.

Aim: To compare and clarify X-ray symptomatology of Legg-Calvé-Perthes disease found by standard digital radiography and by tomosynthesis.

Materials and methods: Eighty six patients aged from 5 to 12 years with the femoral head osteochondropathy were allocated into two groups: 43  patients from the group  1 were assessed by standard two-plane digital radiography (frontal and Lauenstein projections), whereas 43  patients from the group  2 were assessed by direct plane tomosynthesis only. The investigations were performed with the X-ray machine FDR AcSelerate  200 (Fujifilm, Japan) with the function of tomosynthesis. Radiographic symptoms of the disease were assessed in the subgroups that were identified depending on the disease stage: 24 patients had stage I, 20 – stage II, 20 – stage III, and 22 – stages IV and V.

Results: Standard radiography could not detect any bone abnormalities in any patient with stage I of Legg-Calvé-Perthes disease (n= 12, 100%); however, by means of tomosynthesis, all patients from this subgroup (n= 12, 100%) had minimally increased density on the affected side. In 9  (75%) patients, tomosynthesis showed cystiform remodeling of trabecular structure in subchondral parts of the femoral head of the affected hip, and in 2 (17%) patients, flattening of the inner epiphysis pole was visualized. At stage II of the disease standard radiography showed femoral head compression with widening of the joint space in 8 (80%) patients, absence of subchondral lucency in 6 (60%), and increased density of the femoral head in 4 (40%). In all these patients (n= 10, 100%) tomosynthesis showed signs of intra-articular effusion, in 6 (60%) cases there were areas of osteonecrosis, and in 8 (80%) cases, non-congruent edge of the femoral head and acetabulum. At stage III of the disease, all patients in whom standard radiography was performed (n= 10, 100%) had homogeneous blurring of the femoral head with loss of its bony structure, and with the femoral neck shortening in 6 (60%) of them. With the use of tomosynthesis, all these patients (n= 10, 100%) displayed synovial effusion, in 9  (90%) of cases, head fragmentation, and 7  (70%) patients had shortening and thickening of the femoral neck. Patients with stages IV and V had similar number of symptoms, excluding lateral subluxation of the femoral head (in  63.6% by standard radiography and in 81.8% by tomosynthesis). Accuracy, sensitivity and specificity of standard radiography were 73.3, 70.3, and 71.2%, whereas those of tomosynthesis 91.8, 92.4, and 93.1%.

Conclusion: Tomosynthesis is more accurate, sensitive, and specific and has better positive and negative prognostic values, compared to standard digital radiography. Tomosynthesis can be recommended as a method of choice for diagnosis of the femoral head osteochondropathy.

Almanac of Clinical Medicine. 2017;45(1):14-22
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Continuous glucose monitoring in children with glycogenosis

Strokova T.V., Prokhorova  I.V., Surkov  A.G., Bagaeva M.E., Pavlovskaya  E.V., Taran  N.N., Zubovich  A.I.

Abstract

Rationale: Glycogen storage diseases (GSD, glycogenosis) are a group of hereditary disorders of carbohydrate metabolism that is characterized by excess glycogen accumulation in various organs and tissues due to deficiency or absence of glycogen-splitting enzymes. GSD diagnostics requires an assessment of the patient's health status, severity and frequency of hypoglycemias, as well as the choice of a strategy for nutritional support to prevent hypoglycemia.

Aim: To assess efficacy of continuous glucose monitoring (CGM) as a  new method to diagnose hypoglycemia in children with hepatic types of GSD and the role of this assessment method in personalization of nutritional regimen in these disorders.

Materials and methods: The study included 51 child with confirmed diagnosis of GSD at the age of 6.9 ± 0.7  years, of them 36  boys and 15  girls. Thirty three percent of patients had GSD type I, 22% – type III, 45% – types VI and IX. All patients had their glycemic levels measured as glycemic profiles and oral glucose tolerance test (OGTT), as well as by means of real-time CGM. The results were analyzed both in the whole group of patients and in the groups with various GSD types.

Results: Measurement of glycemic profiles in children with GSD at daytime did not detect any significant abnormalities. During OGTT, more rapid decline of glucose levels was seen in younger kids and in patients with GSD type I; however, the differences were not statistically significant (11  patients (65%  of cases) had the lowest glucose levels at 180  minutes of the test: 3.1 ± 0.3 mmol/L, p > 0.05). Fasting hypoglycemia in the OGTT was found in 4  (24%) children with GSD type I  and in 3  (13%) children with GSD types VI and IX. Hypoglycemia at the end of the test was seen in 13 (76%) patients with GSD type I, in 3 (27%) with type III, and in 12 (55%) with types VI and IX. CGM showed hyperglycemia (10.2 ± 0.3 mmol/L) for 1 to 1.5 hours after a meal. Hypoglycemic episodes were registered at night time in 48 (94.1%) of children indicating the need for additional night feeding. Maximal total duration of low glucose levels was found in type  I  of the disease (10.2 ± 2.4  hours). Analysis of CGM results depending on GSD type showed that despite comparable glucose levels, more significant abnormalities are found in GSD type I (the proportion of hyperglycemic periods was 10.2 ± 2.3%, their duration 6.9 ± 1.8  hours; the proportion of hypoglycemic periods was 13.5 ± 2.6%, their duration 10.2 ± 2.4 hours, p < 0.05).

Conclusion: The results obtained indicate the necessity to use CGM in all GSD patients to diagnose and prevent hypoglycemia that would be the basis to elaborate individual nutritional recommendations.

Almanac of Clinical Medicine. 2017;45(1):23-32
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Effect of a synbiotic containing Lactobacillus rhamnosus GG and fructooligosaccharides on the dynamics of the level of fecal calprotectin in children of first year of life

Migacheva N.B., Pechkurov D.V., Kaganova T.I., Sushkova T.V.

Abstract

Rationale: As clinical efficacy of probiotics and prebiotics is determined by their joint effects both on the mechanism of immune tolerance, gut inflammation and intestinal wall permeability, one of the objective methods to assess efficacy of probiotic strain-containing agents could be based on measurement of fecal calprotectin levels.

Aim: To evaluate changes in fecal calprotectin as an efficacy parameter of treatment with the Lactobacillus rhamnosus GG  – fructooligosacсharide complex for prevention of atopic dermatitis in infants.

Materials and methods: Sixty healthy newborns from the risk group for allergic disorders were randomized (envelope randomization) into two groups: the infants from the control group (n = 31) were given widely used recommendations to prevent atopic dermatitis, whereas the infants from the study group (n = 29) were additionally administered a synbiotic containing Lactobacillus rhamnosus GG with fructooligosaccharides. The efficacy of the synbiotic therapy was assessed by measurement of fecal calprotectin levels at 3 and 6  months of the follow-up.

Results: The first measurement of fecal calprotectin levels at 3 months showed its significant increase in all infants (mean 276.9 ± 128.8  mcg/G), compared to the normal range (below 50  mcg/G). The second measurement at 6  months demonstrated a  decrease in fecal calprotectin in infants from both groups (mean 75.8 ± 55.3 mcg/G). However, mean levels of fecal calprotectin in the infants from the study group who had been administered the synbiotic, was significantly lower than that in the control group (48.6 ± 38.5 and 99.7 ± 57.4  mcg/G, respectively; р < 0.05).

Conclusion: The observed changes in fecal calprotectin levels support the positive role of synbiotics and lyophilized complex of Lactobacillus rhamnosus GG with fructooligosaccharides in the growth of gut microbiota in infants and in the reduction of inflammation, all of this being an important prerequisite for development of the oral tolerance mechanisms.

Almanac of Clinical Medicine. 2017;45(1):33-39
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REVIEW

Вocavirus infection in children with acute gastroenteritis

Krasnova E.I., Tyumentsev A.I., Tikunova N.V., Khokhlova N.I., Provorova V.V.

Abstract

The review presents the data on the most important causative factors of acute gastroenteritis in children and on relatively new pathogens, such as bocavirus (HBoV), considering modern potential for verification of viral disorders. Human HBoV, belonging to Parvoviridae family, has been isolated from nasopharyngeal discharge in children with acute respiratory viral infection in 2005. Later on it was registered as a respiratory pathogen. Despite symptoms of an acute respiratory disease, HBoVinfected patients frequently present with acute gastroenteritis. In various regions of the world, fecal HBoV DNA has been found in children with acute intestinal infection by means of the polymerase chain reaction and subsequent sequencing. Molecular genetic studies showed the presence of 4 genetically different viral types. HBoV genotype 1 is more frequently found in nasopharyngeal smears from children with acute respiratory viral infection, whereas HBoV genotypes 2, 3, and 4 are isolated from feces in those with acute gastroenteritis. If HBoV is an intestinal pathogen, remain an unresolved issue. There is a  high rate of HBoV co-infection (up to 60% and more) with other intestinal viruses in children with acute gastroenteritis. High fecal DNA titers found in the studies in children with acute gastroenteritis have shown that HBoV is not only present in the bowel, but also is replicating there. The importance of studies on characteristics of molecular evolution of bocavirus is undoubted, while there are gaps in knowledge on its life cycle, mechanisms of genome replication; there is neither cultivation technique for this virus, nor animal models for disorders it may cause. The assay for anti-HBoV detection in human serum has been studied only in acute respiratory disease; high rates of HBoV seropositive patients and high antibody titers have been found in children correlating with a high viral load. It could be relevant to study prevalence and genetic variance of HВoV associated with acute gastroenteritis in various territories of the Russian Federation, because the international database GenBank does not have any genomic sequences of bocavirus isolated found in Russia. Investigation of molecular epidemiological and clinical characteristics of bocaviral infection in children with acute intestinal infection seems promising.
Almanac of Clinical Medicine. 2017;45(1):40-47
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Functional dyspepsia in adolescents: particulars of its etiology, premorbid background, and a comprehensive treatment approach

Pechkurov D.V., Romanova A.A.

Abstract

The adolescence is characterized by high rates of gastroenterological morbidity due to physiological characteristics of the body and social and psychological status of the teenager. Dyspepsia takes the leading position in the structure of functional pathology. Studies have shown the role of family, unhealthy habits and addictions in the development of this disorder. One should also bear in mind that the adolescence is characterized by an increase in organic pathology. There is a  close association of the functional dyspepsia and the premorbid background, such as autonomous dysfunction and vertebral abnormalities. The use of cholinolytics, prokinetics, opioid receptor antagonists, antacids and anti-secretory agents seems rational for treatment of dyspepsia. If the above mentioned groups of agents lack efficacy, the second line therapy is proposed, which includes tricyclic antidepressants.
Almanac of Clinical Medicine. 2017;45(1):48-55
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CLINICAL CASES

Proteus syndrome in a child aged 14 years and 11 months

Elizarova T.V., Zryachkin N.I., Khmilevskaya S.A., Zaytseva G.V., Kuznetsova M.A., Avdonchenkova N.S.

Abstract

Proteus syndrome is an extremely rare genetic disorder with problematic genetic identification. It has been hypothesized that it is related to a lethal dominant somatic mutation occurring at a post-zygotic stage of embryonic development. Clinical presentation of the disease has much in common with a  number of hereditary disorders and is frequently associated with malignancies. We present a clinical case of Proteus syndrome in a child aged 14 years and 11 months, in whom late diagnosis and late administration of specific treatment resulted in disease progression with the development of the end stage chronic renal disease. Only correct and early diagnosis allows for timely referral of a  patient to a specialized hospital for adequate care.
Almanac of Clinical Medicine. 2017;45(1):56-61
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Ichthyosis hystrix disease or verrucous epidermal nevus (a retrospective analysis of 20-year observation)

El'kin V.D., Sedova T.G., Plotnikova E.V., Kuznetsov I.D., Novoselova M.Y.

Abstract

We present a  clinical case of ichthyosis hystrix, a rare genetic ichthyosiform dermatosis. Specifics of the disease are related to the complexity of differential diagnosis and verification of the diagnosis, because clinical manifestation of ichthyosis hystrix is similar with that of verrucous epidermal nevus. Clinical particulars of both nosologies are characterized by bizarre and widespread skin lesions of spicular hyperkeratotic growth, located along Blaschko lines. The exclusive feature of the clinical case described is a  long-term (20 years) clinical and laboratory monitoring of the patient. The literature review provides brief information on etiology, pathogenesis, clinical features, differential diagnosis, and pathomorphology of ichthyosis hystrix and verrucous epidermal nevus.
Almanac of Clinical Medicine. 2017;45(1):62-67
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Cavernous hemangioma of the bladder in a child of 6 years and 11 months

Zryachkin N.I., Chebotareva G.I., Khmilevskaya S.A., Buchkova T.N., Bezverkhova M.A.

Abstract

We analyze a clinical case of the patient at the age of 6 years and 11 months with a cavernous hemangioma of the bladder. The disease manifested with isolated macrohaematuria. During the diagnostic assessment by 3D-ultrasound examination of the urinary tract with tight bladder filling, a mass with tuberous shape and echonegative areas inside was visualized on the left bladder wall close to its anterior surface, while external bladder contours were unchanged. Color Doppler mapping showed some vessels in the projection of the mass sprouting from the muscular layer of the bladder. The neoplasm was confirmed by abdominopelvic magnetic resonance imaging (with and without contrast enhancement) and by cystoscopy. Taking into account familial cancer history of the patient (oncological disorders in the maternal and paternal lines) and high degree of vascularization of the mass, a malignancy (rhabdomyosarcoma) was deemed highly probable. At 2 months after the disease manifestation, transurethral endoscopic surgery was performed with coagulation and a resection of an exophytic mass of 1 cm in diameter, with a wide base, irregular tuberous shape, brown colored, with a cystic component. The mucous layer on the lateral bladder wall was abnormal with some hemorrhages. Histological examination of the tissue sample showed a  cavernous hemangioma, that was the final diagnosis in this patient. During subsequent 2-year follow up, there was no recurrence of the disease. The described case is of clinical interest because bladder hemangiomas are rare in children; therefore, this disease should be on the list for differential diagnosis in children with macrohaematuria.
Almanac of Clinical Medicine. 2017;45(1):68-72
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ANNIVERSARY

Yuriy L. Shevchenko, Member of the Russian Academy of Sciences (on the 70th anniversary)

Editorial A.

Abstract

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Almanac of Clinical Medicine. 2017;45(1):74-75
pages 74-75 views

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