Severe Disease Activity Based on the Paris Classification Is Associated with the Development of Extraintestinal Manifestations in Korean Children and Adolescents with Ulcerative Colitis

Background@#There are limited data regarding the extraintestinal manifestations (EIMs) associated with pediatric inflammatory bowel disease (IBD) in Korea. We aimed to investigate the clinical features and factors associated with the development of EIMs in Korean children and adolescents with IBD. @*Methods@#This multicenter, retrospective study was conducted from 2010 to 2017. Baseline clinicodemographic, laboratory findings, disease activity, disease phenotypes, and EIMs were investigated. @*Results@#A total of 172 patients were included. One-hundred thirty-seven (79.7%) had Crohn's disease (CD), and 35 (20.3%) had ulcerative colitis (UC). EIMs occurred in 42 patients (24.4%). EIMs developed in 34/137 diagnosed with CD (24.8%), and in 8/35 diagnosed with UC (22.9%), during a median follow-up duration of 3.2 (interquartile range, 1.9–5.4) years for CD and 3.0 (1.0–4.0) years for UC, respectively. Arthritis/arthralgia was most commonly observed (n = 15, 35.7%), followed by stomatitis/oral ulcer (n = 10, 23.8%), hepatitis (n = 5, 11.9%), nephritis (n = 4, 9.5%), pancreatitis (n = 2, 4.8%), erythema nodosum (n = 2, 4.8%), pyoderma gangrenosum (n = 1, 2.4%), primary sclerosing cholangitis (n = 1, 2.4%), uveitis (n = 1, 2.4%), and ankylosing spondylitis (n = 1, 2.4%). A significant difference in disease severity based on the Paris classification (P = 0.011) and ESR at diagnosis (P = 0.043) was observed between the EIM positive and negative group in patients with UC. According to logistic regression analyses, S1 disease severity based on the Paris classification was the only factor that was significantly associated with the development of EIMs (odds ratio, 16.57; 95% confidence interval, 2.18–287.39; P = 0.017). @*Conclusion@#Severe disease activity based on the Paris classification in pediatric patients with UC was significantly associated with EIM development. As disease severity in the Paris classification is a dynamic parameter, treatment should be focused on disease control to minimize the occurrence of EIMs in Korean children and adolescents with UC.

A Case of COVID-19 in a 45-Day-Old Infant with Persistent Fecal Virus Shedding for More Than 12 Weeks

In this report, we describe the case of a SARS-CoV-2 infection (COVID-19) in an infant with mild fever and diarrhea in the absence of respiratory distress. A 45-day-old male infant with COVID-19 was transferred to our pediatric department. He had mild fever and diarrhea at admission. Positive-to-negative nasal swab conversion occurred on the 21st day from the onset of symptoms. However, stool swab positivity persisted during the 6-week admission period and for 7 weeks during follow-up at an outpatient clinic after discharge. Negative conversion in a stool specimen occurred on the 142nd day from the onset of symptoms. This case highlights the potential of fecal virus shedding as an important feature of viral transmission in infants and young children.

Characteristics and Incidence Trends for Pediatric Inflammatory Bowel Disease in Daegu-Kyungpook Province in Korea: a Multi-Center Study

BACKGROUND: Inflammatory bowel disease (IBD) is a heterogeneous chronic disease of unknown etiology. Although it is an important disease that shows a rapid increase in pediatric population, there are no pediatric studies that represent a specific region in Korea. Therefore, we studied the epidemiological and phenotypic characteristics of pediatric IBD in Daegu-Kyungpook province, Korea. METHODS: We included 122 children with pediatric IBD initially diagnosed at one of four university hospitals in Daegu-Kyungpook province between July 2010 and June 2016. We investigated the incidence trends, and the clinical characteristics at diagnosis were compared by Paris classification. RESULTS: We included 122 children: 98 with Crohn's disease (CD) and 24 with ulcerative colitis (UC). The average age at diagnosis was 13.6 years for IBD. The incidence shows an increasing trend. CD showed a significant increase, whereas UC appears to be increasing slowly. In CD, there was a significant male predominance. For disease activity sites, the most common location was L3 (77.6%), indicating ileocolonic involvement as the major type. B1 (88.8%) was the most common disease behaviors type. Perianal disease was noted in 43 patients (43.9%) and weight loss in 60 (61.2%). In UC, E4 (58.4%) was the most common disease activity site, indicating pancolonic involvement as the major type. CONCLUSION: We found that the number of pediatric patients with IBD is increasing rapidly in Daegu-Kyungpook province in Korea. Our study also revealed that the characteristics of pediatric IBD in our province differ somewhat from those of pediatric IBD in Western countries.

Clinical Study of Prevalence of Antibiotic Resistance of Escherichia coli in Urinary Tract Infection in Children: A 9-year Retrospective, Single Center Experience

PURPOSE: The aim of this study was to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli in urinary tract infections (UTIs) in children. METHODS: We retrospectively reviewed the clinical records of 212 inpatients aged 18 years or younger with UTIs treated at the Pediatric Department of Dongguk University Gyeongju Hospital between January 2008 and December 2016. For comparison, patients were divided into three groups according to age as follows: group 1, ≤1 month; group 2, >1 month to ≤12 months; and group 3, ≥13 months. The antibiotic resistance rates from January 2008 to December 2012 (study period 1) and from January 2013 to December 2016 (study period 2) were analyzed statistically by group. RESULTS: As the patient age increased, the antibiotic resistance rate to ampicillin (P=0.013), levofloxacin (P=0.050), piperacillin/tazobactam (TZP) (P<0.001), and trimethoprim/sulfamethoxazole (P=0.002) increased. The frequency of extended spectrum beta-lactamase producing E. coli showed a significant difference from 5 cases (4.6%) in study period 1 and 16 cases (15.8%) in study period 2 (P=0.007). The antibiotic resistance rate of E. coli was compared between the two time periods and we found that the antibiotic resistance rate to cefotaxime was significantly increased from 5.4% to 16.8% (P=0.008) and that to TZP was significantly decreased from 40.5% to 7.9% (P<0.001). CONCLUSION: Over the past 9 years, the resistance rate to cefotaxime has increased but the resistance rate to TZP has decreased. Thus, it is important to continue to investigate the antibiotic resistance rates of bacteria in the community.

Clinical Study of Prevalence of Antibiotic Resistance of Escherichia coli in Urinary Tract Infection in Children: A 9-year Retrospective, Single Center Experience

PURPOSE: The aim of this study was to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli in urinary tract infections (UTIs) in children. METHODS: We retrospectively reviewed the clinical records of 212 inpatients aged 18 years or younger with UTIs treated at the Pediatric Department of Dongguk University Gyeongju Hospital between January 2008 and December 2016. For comparison, patients were divided into three groups according to age as follows: group 1, ≤1 month; group 2, >1 month to ≤12 months; and group 3, ≥13 months. The antibiotic resistance rates from January 2008 to December 2012 (study period 1) and from January 2013 to December 2016 (study period 2) were analyzed statistically by group. RESULTS: As the patient age increased, the antibiotic resistance rate to ampicillin (P=0.013), levofloxacin (P=0.050), piperacillin/tazobactam (TZP) (P<0.001), and trimethoprim/sulfamethoxazole (P=0.002) increased. The frequency of extended spectrum beta-lactamase producing E. coli showed a significant difference from 5 cases (4.6%) in study period 1 and 16 cases (15.8%) in study period 2 (P=0.007). The antibiotic resistance rate of E. coli was compared between the two time periods and we found that the antibiotic resistance rate to cefotaxime was significantly increased from 5.4% to 16.8% (P=0.008) and that to TZP was significantly decreased from 40.5% to 7.9% (P<0.001). CONCLUSION: Over the past 9 years, the resistance rate to cefotaxime has increased but the resistance rate to TZP has decreased. Thus, it is important to continue to investigate the antibiotic resistance rates of bacteria in the community.

RSV Outbreak at a Single Postpartum Care Center in Gyeongsangbukdo / 대한주산의학회잡지

PURPOSE: We performed an analysis of the RSV outbreak in a postpartum center in Gyeongsangbukdo to provide preliminary data for health and hygiene management of postpartum care centers. METHODS: All of 22 newborns who were transferred to our hospital from a postpartum care center from December 2014 to January 2015 showed positive for RSV by viral culture and enrolled in the study group. To identify early symptoms in RSV infected newborn in the nursery 31 infants (1 month to 24 month of age) who were hospitalized in our hospital due to RSV infection during the same period were selected as control group and clinical symptoms were compared with the study group. A retrospective study was also performed on the newborns who were cared and not transferred to our hospital in the postpartum care center, as well as the facilities offered by the center. RESULTS: All of 22 neonatal patients who were transferred to our hospital had early symptoms of rhinorrhea and cough compared to control group. Rhinorrhea appeared 4.2±2.0 days before the admission, and cough occurred 1.0±1.1 days after rhinorrhea. The level of infection control specified by the law for general facilities relating to postpartum care centers was applied to the postpartum center, RSV infection was not controlled. Strict hand washing, individual equipment such as stethoscopes and exclusion of visitors with respiratory symptoms were done and infected neonates were segregated in separate air circulation system and cared by nurse-infant ratios from 1:1 to 1:2 depending on the needs of the individual neonates. Additional transmission was not observed after transfer to our hospital CONCLUSION: Neonates with cough and rhinorrhea were initial symptom for RSV infection in the postpartum center and should be evaluated for RSV infection during high risk season. Current guideline or support for infection control in postpartum center should be reevaluated for RSV infection control.

RSV Outbreak at a Single Postpartum Care Center in Gyeongsangbukdo / 대한주산의학회잡지

PURPOSE: We performed an analysis of the RSV outbreak in a postpartum center in Gyeongsangbukdo to provide preliminary data for health and hygiene management of postpartum care centers. METHODS: All of 22 newborns who were transferred to our hospital from a postpartum care center from December 2014 to January 2015 showed positive for RSV by viral culture and enrolled in the study group. To identify early symptoms in RSV infected newborn in the nursery 31 infants (1 month to 24 month of age) who were hospitalized in our hospital due to RSV infection during the same period were selected as control group and clinical symptoms were compared with the study group. A retrospective study was also performed on the newborns who were cared and not transferred to our hospital in the postpartum care center, as well as the facilities offered by the center. RESULTS: All of 22 neonatal patients who were transferred to our hospital had early symptoms of rhinorrhea and cough compared to control group. Rhinorrhea appeared 4.2±2.0 days before the admission, and cough occurred 1.0±1.1 days after rhinorrhea. The level of infection control specified by the law for general facilities relating to postpartum care centers was applied to the postpartum center, RSV infection was not controlled. Strict hand washing, individual equipment such as stethoscopes and exclusion of visitors with respiratory symptoms were done and infected neonates were segregated in separate air circulation system and cared by nurse-infant ratios from 1:1 to 1:2 depending on the needs of the individual neonates. Additional transmission was not observed after transfer to our hospital CONCLUSION: Neonates with cough and rhinorrhea were initial symptom for RSV infection in the postpartum center and should be evaluated for RSV infection during high risk season. Current guideline or support for infection control in postpartum center should be reevaluated for RSV infection control.

Changing Prevalence of Helicobacter pylori Infections in Korean Children with Recurrent Abdominal Pain / 대한소아소화기영양학회지

PURPOSE: The aim of this study is to investigate the changing prevalence rate of Helicobacter pylori infection in children, of different age groups, with recurrent abdominal pain over a 10-year period. METHODS: Children with recurrent abdominal pain who visited the pediatric outpatient clinic at university hospital were screened for H. pylori. Children were divided into 3 age categories of 4-5, 6-11, and 12-16 years. To study the changes in the annual prevalence rates of H. pylori infection, the study period was divided into 3 time periods: 2004-2007, 2008-2010, and 2011-2014. Urea breath test was performed for all children aged 4-16 years, with a cut-off value of 4.0per thousand for children aged > or =6 years and 7per thousand for children aged or =12 years of age (p=0.018). CONCLUSION: The prevalence of H. pylori infection in Korean children with recurrent abdominal pain was 7.4%, showing no significant decrease in the last 11 years; however, the prevalence rate in children or =12 years old.

Early Detection of Kawasaki Disease in Infants

BACKGROUND AND OBJECTIVES: This study aimed to investigate the clinical characteristics of infantile Kawasaki disease (KD), and to evaluate early diagnostic features of KD in febrile infants. SUBJECTS AND METHODS: We retrospectively reviewed the medical records of 64 KD patients from January 2010 to October 2014. There was an analysis of the clinical, laboratory data of the infants versus children groups. Furthermore, the clinical and laboratory data of infantile KD patients were compared with 16 infants who were admitted for other acute febrile diseases. RESULTS: A total of 64 patients with KD were identified; 20 (31.3%) were infants; 44 (68.8%) were >1 year old children. Incomplete KD was much more common in infants (n=13, 65.0%) than in children group (n=14, 31.8%) (p=0.013). The infants were characterized by significantly higher rates of inflammatory changes at the Bacille Calmett-Guerin (BCG) inoculation site (p<0.001), but lower rates of changes in the extremities (p=0.029) and cervical lymphadenopathy (p=0.006). The serum levels of platelet after 1 week (p=0.005), C-reactive protein (p=0.038), and N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.026) were all significantly higher in the infants group. Comparing the infants with KD versus the other acute febrile diseases, there were significantly higher serum levels of erythrocyte sedimentation rate (p=0.002), C-reactive protein (p=0.046) and NT-proBNP (p=0.001) for the infants with KD group. CONCLUSION: BCGitis and higher levels of NT-proBNP can be helpful for early diagnosis of the incomplete KD in infants, and may be a good predictor of KD in acute febrile infants, when combined with other acute phase reactants.

Feasibility of Foley Catheter Prior to Endoscopy for the Removal of Esophageal Coin in Children / 대한소아소화기영양학회지

PURPOSE: This study evaluated the efficiency and safety of the Foley catheter for esophageal removal of coins in children, compared to standard endoscopic extraction with respect to success rate, sedation, promptness and cost. METHODS: Twenty four children with coin lodgement in esophagus were managed with either a Foley catheter (n=14) or endoscopic extraction (n=10) from January 2007 through August 2010 at Kyungpook National University Hospital. A retrospective review of medical records and radiological findings was performed. RESULTS: Of the 14 patients who underwent Foley catheter extraction, successful and complication-free removal was achieved in 10 cases (71.4%). Of the 10 patients who underwent endoscopic extraction, all cases were successful (p=0.114). Sedation rate in the Foley catheter and endoscopic extraction group was 6/14 and 10/10 (p=0.006). The average wait time before the procedure and average hospital charge (US$) were 2.0+/-1.1 hours and 18.1+/-13.7 hours, and $113 and $428 for Foley catheter extraction and endoscopic extraction, respectively. CONCLUSION: Foley catheter extraction may be tried for the removal of esophageal coins in uncomplicated children. The technique is effective, safe, inexpensive and free of general anesthesia.

Experience with Entecavir Therapy for Lamivudine-Resistant Chronic Hepatitis B in Korean Children and Adolescents / 대한소아소화기영양학회지

PURPOSE: To estimate the viral suppressive effect of entecavir monotherapy in Korean children and adolescents with lamivudine-resistant chronic hepatitis B (CHB). METHODS: One milligram of entecavir was administered once daily to 6 patients (4 boys; mean age, 17.5 years; range, 15.10~24.6 years) with lamivudine-resistant CHB for a mean duration of therapy of 13.4 months (range, 1~21.1 months). The therapeutic results were compared with 11 patients who received adefovir (0.3 mg/kg/day [maximal dose 10 mg]) for at least 12 months (mean, 33.4 months; range, 12.4~58.3 months). The serum HBV DNA level and serologic markers were measured every 2 months. RESULTS: The interval to a HBV DNA titer decrement (>1 log(10)) was 1.2+/-0.2 and 4.4+/-5.2 months (p=0.185) for the entecavir and adefovir groups, respectively. The interval to a HBV DNA titer decrement (>2 log(10)) was 2.4+/-2.3 and 9.2+/-7.3 months (p=0.025), for the entecavir and adefovir groups, respectively. CONCLUSION: The therapeutic efficacy of entecavir was favorable in children and adolescents, especially in shortening the interval to a >2 log(10) decrement in the HBV DNA titer. Long-term follow up is needed to determine the therapeutic efficacy of entecavir for lamivudine-resistant CHB in children and adolescents.

Clinical Experience with Long-term Lamivudine Therapy toDetermine the Adequate Duration of Treatment in Childrenand Adolescents with HBeAg-Negative Chronic Hepatitis B / 대한소아소화기영양학회지

PURPOSE: To provide the primary data for reaching a consensus on the adequate duration of treatment of lamivudine in children with HBeAg negative chronic hepatitis B. METHODS: Seven of 83 children/adolescents with chronic hepatitis B were diagnosed with HBeAg-negative and HBV DNA-positive chronic hepatitis B and treated with lamivudine. Six children/adolescents were enrolled among 7 patients, who had been treated with lamivudine over 2 years. The primary goal of treatment was HBV DNA clearance and normalization of the serum ALT level; the final goal of treatment was the durability of the complete response after discontinuation of lamivudine. It was planned to continue lamivudine for more than two additional years after HBV DNA negativity and normalization of ALT. RESULTS: The mean duration of lamivudine treatment was 32.2 months (range, 26~40 months) and the mean duration of follow-up was 59.5 months (range, 26~110 months). HBV DNA levels became undetectable (<0.5 pg/mL) in 6 patients within 3 months of treatment. ALT levels were normalized in 3.5 months (range, 2~7 months) in all 6 patients. Biochemical breakthrough developed in 1 patient 18 months after the initiation of lamivudine treatment. No evidence of relapse could be found in 4 patients with a mean follow-up of 23.8 months (range, 4~75 months) after cessation of lamivudine treatment. CONCLUSION: Suppression of HBV replication and normalization of serum ALT levels were effectively achieved with long-term lamivudine treatment in children/adolescents with HBeAg-negative chronic hepatitis B. Two additional years of lamivudine may be needed after HBV DNA clearance and ALT normalization in HBeAg-negative chronic hepatitis B in order to decrease the relapse rate.

Comparison of lamivudine-induced HBsAg loss rate according to age in children with chronic hepatitis B / 대한간학회지

BACKGROUND/AIMS: The aim of this study was to establish the characteristics of children with hepatitis B e antigens (HBeAg) positive chronic hepatitis B who were cleared of hepatitis B surface antigens (HBsAg) as a result of lamivudine treatment. METHODS: Seventy-six children with chronic hepatitis B who were seropositive for HBeAg were treated with lamivudine for at least 6 months. HBeAg seroconversion occurred during treatment in 49 of these children, who were then followed up to assess their clearance of serum HBsAg. Various clinical variables were compared between those patients who were cleared of HBsAg and those who were not, including age, pretreatment serum levels of alanine aminotransferase (ALT) and hepatitis B virus (HBV) DNA, treatment duration, the time elapsed between initiation of treatment and ALT normalization, HBV DNA negativization, HBeAg seroconversion, and HBsAg clearance. RESULTS: HBsAg disappeared in 13 of the 49 (26.5%) patients who experienced lamivudine-induced HBeAg seroconversion; HBsAg did not reappear during follow-up period (1-86 months). The time that elapsed between initiation of lamivudine treatment and total HBsAg clearance was 25.9+/-27.1 months (mean+/-SD; range: 5-104 months). The age at which treatment was initiated was the only factor associated with HBsAg clearance. Children who were cleared of HBsAg were significantly younger than those who were not (5.1+/-4.3 years vs. 7.9+/-4.9 years, respectively; P=0.006). All 13 of these patients eventually produced antibodies to HBsAg. CONCLUSIONS: Younger children (age <7 years old) have a higher chance of HBsAg clearance than older children after the treatment of HBeAg-positive chronic hepatitis B with lamivudine.

A Case of Pneumoperitoneum After Mechanical Ventilation in A Child with Severe Bronchial Asthma / 소아알레르기및호흡기학회지

Massive pneumopritoneum developing immediately following initiation of artificial ventilation is an unusual sign of lung barotrauma and must be distinguished from pneumoperitoneum following rupture of a hollow abdominal viscus. Besides, pneumoperitoneum occurring in a mechanically ventilated asthmatic patient can present a diagnostic dilemma as the usual signs of an intestinal perforation may be masked by steroid therapy, sedation or paralysis, or combination of all three. We report a case of massive pneumoperitoneum after initiation of mechanical ventilation in a child with severe asthmatic attack.