A Case of Epiploic Appendagitis with Acute Gastroenteritis / 대한소아소화기영양학회지

Epiploic appendagitis is an inflammation of the epiploic appendage in which the small sacs projecting from the serosal layer of the colon are positioned longitudinally from the caecum to the rectosigmoid area. Epiploic appendagitis is rare and self-limiting; however, it can cause sudden abdominal pain in children. Epiploic appendagitis does not typically accompany other gastrointestinal diseases. Here, we report on a healthy eight-year-old girl who presented with abdominal pain, fever, vomiting, and diarrhea. Based on these symptoms, she was diagnosed with acute gastroenteritis, but epiploic appendagitis in the ascending colon was revealed in contrast computed tomography (CT). The patient was treated successfully with conservative management. CT is beneficial in diagnosis and further assessment of epiploic appendagitis. Pediatricians need to be aware of this self-limiting disease and consider it as a possible alternate diagnosis in cases of acute abdominal pain.

Factors Related to Decreased Bone Mineral Density in Childhood Cancer Survivors

The risk of osteoporosis or osteopenia is known to increase after childhood cancer treatment. The purpose of this study was to evaluate patterns of bone mineral density (BMD) and to identify factors related to the decreased BMD in childhood cancer survivors. We studied 78 patients (34 boys, 44 girls) treated for childhood cancer. Twenty (25.7%) patients had lumbar BMD (LBMD) standard deviation score (SDS) lower than -2. Nineteen (24.4%) patients had femur neck BMD (FNBMD) SDS lower than -2. The patients treated with hematopoietic stem cell transplantation had lower LBMD SDS (-1.17 +/- 1.39 vs -0.43 +/- 1.33, P = 0.025). The risk of having LBMD SDS < -2 was higher in the patients treated with glucocorticoid (GC) for graft-versus-host disease (GVHD) (36.6% vs 13.5%; odds ratio [OR], 3.7; P = 0.020). In multivariate logistic regression analysis, longer duration of GC treatment for GVHD (OR, 1.12; 95% confidence interval [CI], 1.05-1.20) and lower body mass index (BMI) SDS (OR, 0.59; 95% CI, 0.36-0.95) were associated with decreased LBMD SDS. These findings suggest that prolonged GC use and reduction in BMI are risk factors for decreased BMD in childhood cancer survivors. Anticipatory follow-up and appropriate treatment are necessary, especially for the patients with risk factors.

A Case of Type 2 Diabetes Mellitus in Adolescent Presenting with Bell's Palsy

Bell's palsy is manifested by unilateral facial paralysis, but its cause is not clearly elucidated yet. Though the relationship between Bell's palsy and diabetes mellitus (DM) has been well established in adults, the relationship is not obvious in children and adolescents. Here, we report a case of adolescent Bell's palsy accompanied by DM. In this case, steroids were used for the treatment of Bell's palsy, and the blood glucose level in the patients was well controlled by metformin alone without additional use of insulin. We suggest that the presence of diabetes should be determined by blood test in the childhood and adolescent patients with facial paralysis, especially who are obese. As the use of steroids, however, is associated with the elevated blood glucose levels, it should be used with caution.

Factors Affecting Growth Velocity during Gonadotropin-Releasing Hormone Agonist Treatment in Girls with Idiopathic Central Precocious Puberty

PURPOSE: In some girls with central precocious puberty (CPP), growth velocity (GV) decreases below the age-appropriate normal range during gonadotropin-releasing hormone agonist (GnRHa) treatment. The purpose of this study was to investigate clinical and laboratory factors related to changes in GV during GnRHa treatment in girls with CPP. METHODS: We analyzed clinical and laboratory data of 49 girls (aged 7.8+/-0.5 years) with idiopathic CPP who were treated with GnRHa. GV, height standard deviation score (SDS), hormonal parameters, pubertal stage, chronological age and bone age (BA) were evaluated. RESULTS: GV during the first year of GnRHa treatment was 5.9+/-1.0 cm/yr and decreased significantly to 5.4+/-1.1 cm/yr during the second year of treatment (P = 0.005). GV during the third year (5.0+/-1.0 cm/yr) was not different from GV during the second year. During the second year of treatment, 8.2% and 36.7% of the girls had a GV or = 11 yr) at 1 year (55.6% vs. 19.4%; odds ratio [OR], 5.2; P = 0.022). In multivariate logistic regression analysis, more advanced BA at 1 year (OR, 6.1; 95% confidence interval [CI], 1.57-23.87) and lower height SDS for BA at 1 year (OR, 0.24; 95% CI, 0.06-0.94) were associated with relatively decreased GV (< 5 cm/yr) during the second year of GnRHa treatment. CONCLUSION: GV during and after the second year of GnRHa treatment in girls with idiopathic CPP remains within the normal prepubertal range, and relatively low GV during GnRHa treatment is associated with more advanced BA and lower height SDS for BA.

Factors Affecting Growth Velocity during Gonadotropin-Releasing Hormone Agonist Treatment in Girls with Idiopathic Central Precocious Puberty

PURPOSE: In some girls with central precocious puberty (CPP), growth velocity (GV) decreases below the age-appropriate normal range during gonadotropin-releasing hormone agonist (GnRHa) treatment. The purpose of this study was to investigate clinical and laboratory factors related to changes in GV during GnRHa treatment in girls with CPP. METHODS: We analyzed clinical and laboratory data of 49 girls (aged 7.8+/-0.5 years) with idiopathic CPP who were treated with GnRHa. GV, height standard deviation score (SDS), hormonal parameters, pubertal stage, chronological age and bone age (BA) were evaluated. RESULTS: GV during the first year of GnRHa treatment was 5.9+/-1.0 cm/yr and decreased significantly to 5.4+/-1.1 cm/yr during the second year of treatment (P = 0.005). GV during the third year (5.0+/-1.0 cm/yr) was not different from GV during the second year. During the second year of treatment, 8.2% and 36.7% of the girls had a GV or = 11 yr) at 1 year (55.6% vs. 19.4%; odds ratio [OR], 5.2; P = 0.022). In multivariate logistic regression analysis, more advanced BA at 1 year (OR, 6.1; 95% confidence interval [CI], 1.57-23.87) and lower height SDS for BA at 1 year (OR, 0.24; 95% CI, 0.06-0.94) were associated with relatively decreased GV (< 5 cm/yr) during the second year of GnRHa treatment. CONCLUSION: GV during and after the second year of GnRHa treatment in girls with idiopathic CPP remains within the normal prepubertal range, and relatively low GV during GnRHa treatment is associated with more advanced BA and lower height SDS for BA.

The Auxological and Hormonal Differences in Girls with Atypical Thelarche and Central Precocious Puberty / 대한소아내분비학회지

PURPOSE:We compared anthropomorphic measures and hormone levels in girls with atypical thelarche (AT) and central precocious puberty (CPP) and tried to find out factors discriminating AT from CPP. METHODS:We analyzed clinical and laboratory data of 62 girls with precocious breast development from May 2004 to May 2008 at Kangnam St. Marys Hospital. Immunoradiometeric assay (IRMA) was used to estimate gonadotropins and growth related hormones. CPP was diagnosed if peak luteinizing hormone (LH) level was >6.9 IU/L after gonadotropin hormone releasing hormone (GnRH) stimulation test. A multiple logistic regression analysis and the area under the receiver operating characteristics curve (AUC) were used to analyse the prediction capacity of variable factors to diagnose CPP. RESULT:The basal LH levels (P=0.001), IGF-I levels (P=0.049) and the peak LH levels (P<0.001) in GnRH-stimulation test in girls with CPP were higher than those with AT. Girls with AT had a lower degree of breast maturation than girls with CPP (P=0.001). A multivariate logistic regression model including the basal LH levels and IGF-I levels revealed a strong relation of the basal LH levels to CPP [OR:2.7, 95% confidence interval (CI): 1.1-6.7, P=0.035]. The AUC for basal LH levels showed prediction capacity of basal LH levels to diagnose CPP [AUC: 0.70, 95% CI: 0.57-0.81, P=0.009]. The statistically ideal cut-off value of basal LH levels to discriminate CPP from AT was 2.66 IU/L (sensitivity 40%, specificity 98%) and the clinically meaningful cut-off value was 1.86 IU/L (sensitivity 70%, specificity 62%). CONCLUSION:These results suggest that the basal LH level using IRMA could be a useful parameter discriminating AT from CPP. Further study with larger number of subjects will be needed.

A Case of 8 Year-old Boy with Testicular Microlithiasis Showing Bilateral Testicular Enlargement / 대한소아내분비학회지

Testicular microlithiasis is a rare cause of testicular enlargement. An 8.5-year-old boy presented with bilateral testicular enlargement accompanied by no other pubertal signs. His bone age was 8.5 years and serum levels of luteinizing hormone and follicle-stimulating hormone after gonadotropin-releasing hormone stimulation were within prepubertal limits. Scrotal ultrasonography showed multiple echogenic microcalcifications that are indicative of microlithiasis in both testes. During 2-year follow-up, he developed clinical manifestations of early puberty between 9.5 and 10.5 years of age. Testicular microlithiasis should be considered when boys show bilateral testicular enlargement without other findings of puberty.

Clinical Follow-Up of Children and Adolescents with Hashimoto Thyroiditis / 대한소아내분비학회지

PURPOSE: We aimed to study the clinical manifestations and clinical course of Hashimoto thyroiditis in children and adolescents. METHODS: We retrospectively analyzed the clinical manifestations and thyroid function in 59 children and adolescents with Hashimoto thyroiditis who were admitted at Kangnam St. Mary's Hospital between January 1999 and January 2009. RESULTS: We investigated thyroid function and clinical manifestations of thyroiditis in 50 female and 9 male patients. The mean age of the patients at the time of diagnosis was 10.6+/-2.7 years, and the mean duration of follow-up was 3.8+/-3.1 years. The most common complaints at the time of diagnosis were goiter (77.9%), fatigue (38.9%), weight gain, constipation, growth retardation, headache, nervousness, cold intolerance, and menstrual disturbances. Antithyroid peroxidase antibodies were detected in 52 patients (88.1%); antithyroglobulin antibodies, 45 patients (76.2%); and both antibodies, 42 patients (71.1%). The height, weight, and body mass index (BMI) standard deviation scores (SDS) of the patients at the time of diagnosis were not markedly different from the corresponding scores at the patients' last visit. At the time of the last follow-up, 19 patients were in remission and 40 were in non-remission state. At the first visit, there were no significant differences between the age, thyroid function test, positive rate of thyroid autoantibody, weight, and BMI SDS of patients in the remission group (RG) and non- remission group (N-RG). However, at the time of initial diagnosis, the height (Ht)-SDS of the patients in RG were greater than in N-RG (P=0.037). At the end of follow up, euthyroidism was achieved in 53 patients, 5 patients had compensated hypothyroidism, and 1 patient had overt hypothyroidism. CONCLUSION: The patients with thyroid dysfunction at diagnosis were 72.9% and 32.2% of patients were in remission. We could not find out significant predictive factor for remission at the time of diagnosis and further studies with a large number of subjects should be performed.

Analysis of gonadotropin-releasing hormone (GnRH) test results in girls with precocious puberty / 소아과

PURPOSE: The gonadotropin-releasing hormone (GnRH) test results of girls with precocious puberty were analyzed to determine whether this test can efficiently and clearly differentiate between central precocious puberty (CPP) and other disorders. METHODS: Clinical and laboratory data of 54 girls with precocious pubertal signs were reviewed. Intravenous GnRH test was performed with blood samples obtained at 0, 30, 60, and 90 minutes. A peak luteinizing hormone (LH) level of > or =5.0 IU/L was indicative of CPP. RESULTS: Of the 40 girls with CPP, 36 (90.0%), 3 (7.5%), and 1 (2.5%) showed peak LH levels at 30, 60, and 90 minutes, respectively. A percentage of girls whose peak LH > or =5.0 IU/L up to 30, 60, and 90 minutes was 92.5%, 100%, and 100%, respectively. The peak LH/follicle stimulating hormone (FSH) ratio of girls with CPP was 0.89+/-0.49 and was 1.0 showed higher chronological age (CA) (8.3+/-0.6 vs. 7.7+/-1.0 years, P=0.033), bone age (BA) (10.9+/-0.8 vs. 9.7+/-1.1 years, P=0.001), and BA-CA difference (2.6+/-0.7 vs. 2.0+/-0.7 years, P=0.009) than those of girls with peak LH/FSH ratio of 1.0 showed advanced breast development (> or =Tanner III) (93.7% vs. 41.7%, P=0.001). CONCLUSION: LH levels after 30 and 60 minutes of intravenous GnRH administration are the most useful for diagnosing CPP in girls.

Serum leptin, adiponectin and resistin levels in obese children and their correlations with insulin resistance / 소아과

PURPOSE: The objective of this study was to compare the levels of adipocytokines in obesity group with those in control group and examine their correlation with insulin resistance. METHODS: We enrolled 36 obese children (male:female [M:F]=17:19; age, 9.3+/-1.9 yrs) with > or =95th percentile body mass indexes (BMIs) (obesity group) and 35 healthy children (M:F=16:19; age, 9.1+/-2.1 yrs) with 25th-75th percentile BMIs (control group). We measured the serum leptin, adiponectin, and resistin levels and insulin resistance in both the groups. RESULTS: The weights, heights, BMIs, fasting sugar levels, insulin levels, and homeostasis model assessment for insulin resistance (HOMA-IR) values were higher in the obesity group than in the control group. As compared to the control group, the obesity group showed significantly higher leptin levels and lower adiponectin levels; no significant difference was observed in the resistin levels. The leptin/adiponectin (L/A) ratio was higher in the obesity group than in the control group. In the obesity group, HOMA-IR showed significant positive correlations with weight, height, BMI, and leptin level. However, it was not correlated with age and adiponectin and resistin levels. In the obesity group, leptin level showed significant positive correlations with age, weight, height, and BMI, while adiponectin and resistin levels showed no such correlations with the other variables CONCLUSION: We suggest that adiponectin plays an important protective role against weight gain in obese children. Further, L/A ratio can be used as a parameter for predicting the prognosis of obese children.

A rise and fall in AST and ALT level in nonspecific reactive hepatitis / 소아과

PURPOSE: The study was performed to assess the distribution of the diseases associated with nonspecific reactive hepatitis (NRH) for the past 10 years and to evaluate the change in the level of AST and ALT, and the difference by several variable factors. METHODS: From January 1997 to December 2006, 646 patients had elevated liver enzymes among 22,763 patients admitted to the Holy Family Hospital. We analyzed the difference in the age distribution, the period of elevated levels of AST and ALT, the resolution period, the peak value, the daily resolution value of AST and ALT, the sexual differences and the difference in several disease entities. One hundred and ninety-seven patients not confirmed as NRH or lost during follow-up were excluded. RESULTS: The prevalence rate of NRH was 2.84%. When compared to AST, ALT showed longer period of morbidity and resolution and the peak value was also higher in ALT. The male and female ratio showed significant value of 1.63:1. The morbid and resolution periods of AST and ALT between males and females were longer periods in males. The most prevalent disease entities were respiratory and gastrointestinal infections. Between the respiratory and the gastrointestinal diseases, the highest level of AST and ALT was observed in the respiratory disease. CONCLUSION: NRH is a common disease that occurs in 2.84% of the admitted pediatric patients. However, the pathogenesis and the progress of the disease have not been well known due to the lack of generalized information. Further research is necessary in the future.

Perianal Ulcerative Hemangioma Treated with a Colostomy

Hemangioma is the most common benign tumor of infancy. Greater than 60% of hemangiomas occur on the head and neck, and have an uncomplicated course. In contrast, most complicated hemangiomas develop in the urogenital or anogenital areas. These lesions are frequently associated with pain, bleeding, recurring infections, and ulcerations. Sometimes, perianal ulcerative hemangiomas are difficult to treat with multiple therapies, such as laser and steroid therapy. We managed a case of a severe perianal ulcerative hemangioma in a male newborn who did not respond to conservative management. He was successfully treated after a colostomy.

A Prospective Study of the Epidemiology of Out-of-Hospital Pediatric Cardiopulmonary Arrest / 한국역학회지

PURPOSE: Data regarding out-of-hospital pediatric cardiopulmonary arrest have been limited to the retrospective study. This study was performed to analyze the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest(CPA) with the international consensus in a single hospital. METHODS: Children less than 15 years old who entered emergency department with CPA, between 1st March 2004 and 31st July 2007, were included this study. Data were recorded prospectively following Utstein's template. The characteristics and outcomes of patients were analyzed. RESULTS: Cardiopulmonary arrests occurredin total of 37 of 21,339 children presented to emergency department during 41 months study period. 15 out of 37 with CPA had return of spontaneous circulation (ROSC) after resuscitation, 4 survived to be discharged from the hospital. The rate of ROSC in the respiratory arrest is higher than the cardiac arrest. Trauma was the most common cause of out-of-hospital pediatric cardiopulmonary arrest. No children who had more 20 minutes of cardiopulmonary resuscitation (CPR) or took more than 3 doses of epinephrine survived. CONCLUSIONS: The 10.4% survival rate after out-of-hospital pediatric CPA is poor. The respiratory arrest is more favorable. Education of basic life support for publics is needed to increase the rate of ROSC and survival from out-of-hospital pediatric cardiopulmonary arrest.

Infantile Type Choledochal Cyst with Biliary Atresia: Report of two cases

Choledochal cysts in neonates and young infants take two forms: the choledochal cyst associated with biliary atresia (CCBA) and the choledochal cyst in the absence of biliary atresia (CC). Infants in both groups usually have similar clinical symptoms at presentation, but management and prognosis are different. While early portoenterostomy is required for CCBA, cyst excision with hepaticojejunostomy or choledochojejunostomy is usually performed for CC. The former shows a relatively poor prognosis, and the latter shows a better prognosis. Two infants who presented with clinical features of neonatal cholestasis, and clinically suspected to have choledochal cysts, were found on imaging studies and surgery to have extrahepatic bile duct atresia in association with choledochal cysts.

A case of multicystic dysplastic kidney and cystic adenomatoid malformation of the lung identified as incidental findings / 소아과

Multicystic dysplastic kidney and congenital cystic adenomatoid malformation of the lung are independent disorders, but both result from abnormal morphogenesis during embryogenesis. Congenital cystic adenomatoid malformation of the lung is associated with renal anomalies as well as other extrapulmonary anomalies and almost all cases with these anomalies are stillborn. We report a case of a 21-month-old male who was admitted with the impression of acute infectious gastroenteritis; multicystic dysplastic kidney with congenital cystic adenomatoid malformation of the lung was detected incidentally during evaluation.

A Study of Epstein-Barr Virus, and Human Leukocyte Antigen Typing in Children with Acute Infectious Mononucleosis

PURPOSE: The Epstein-Barr virus(EBV), gamma herpesvirus, is an important pathogen that is widespread around the world. The EBV causes various diseases depending on the geographic location, and on the immunity or the premorbid condition of the person exposed to EBV. To evaluate EBV typing may be the most important step to figure out the pathogenesis of EBV associated diseases, and we need to re-evaluate the pathologic role of human leukocyte antigen(HLA) in developing Epstein-Barr virus associated acute infectious mononucleosis by using newly developed methods. METHODS: This study included 24 children(age range : 6 to 13 years), serologically confirmed with acute infectious mononucleosis. The control group for the HLA type consisted of 200 age-matched healthy children. To classify HLA I, modified ARMs-PCR was used, while modified PCR-SSOP was utilized in typing of HLA II. Also, we performed EBV typing in study patients by using a one-step PCR. RESULTS: The results of HLA types : In HLA class I, HLA-A24 was positive in 69 of 200 healthy children and positive in 14 of 24 patients in the study group(relative risk : 3.5724, chi-square; 5.26, P<0.05). In HLA class II, HLA-DRB1*07 was detected in 18 of 200 healthy children, and eight of 24 patients in the study group(relative risk; 506173, chi-square; 9.73, P<0.01). The results of EBV types : In the research group, 20(83.8%) of 24 patients were shedding type A virus, while 4(16.7%) were type B. CONCLUSION: We conclude that development of infectious mononucleosis may be associated with HLA types, and these results suggest that acute infectious mononucleosis could have hereditary traits. And we confirm that type A EBV is highly prevalent in patients with acute infectious mononucleosis in Korea. Also, our results suggest that further large scale studies, including adult groups, regarding the association between pathogenesis of EBV with HLA-DP or HLA-DQ will be warranted.

Causative Organisms in Children with Bacterial Meningitis(1992-2002)

PURPOSE: This study was performed to assess the difference of organisms causing bacterial meningitis according to time. METHODS: We analyzed retrospectively 40 medical records of bacteriologically proven meningitis from 1992 to 2002. We divided them into two groups; neonate's group(14 cases), and children's group(26 cases). The results of the neonate's group were compared with those of previously reported articles in Korea, in 1970s-1980s. The causative agents of the children's group were analyzed according to the stage before and after the introduction of H. influenza type b(Hib) vaccine. RESULTS: In neonates, Group B streptococci(GBS) was the most common cause of bacterial meningitis. There was a trend in Korea that major causative agents of neonatal bacterial meningitis have changed from gram negative bacteria including E. coli to gram positive bacteria including GBS. In children, H. influenzae was isolated in six out of 11 cases(55%) in 1992-95, before the introduction of Hib vaccine, while two out of seven(29%) were isolated in 1999-2002, after the introduction of the Hib vaccine. CONCLUSION: Our study showed that the most common agent of neonatal bacterial meningitis was GBS. There was a trend that after the introduction of Hib vaccine, the incidence of H. influenza meningitis decreased in children.

A Case of Neonatal Submandibular Abscess

Suppurative sialadenitis is rare in the neonate and usually involves the parotid glands. Isolated suppurative submandibular sialadenitis in the neonatal population is extremely rare. There are only 11 cases found in the literature of suppurative submandibular sialadenitis occurring as an isolated lesion. We describe a case of isolated submandibular sialadenitis progressing to submandibular abscess requiring incision and drainage in a term neonate. Pus culture yielded methicillin-resistant Staphylococcus aureus (MRSA). A brief review of literature is included.