The Change of IgG Antibody Titer to Measles, Mumps and Rubella According to Age / 소아감염

PURPOSE: We investigated the change of antibody titer to measles, mumps and rubella according to age after vaccination. METHODS: The IgG antibody titers to measles, mumps and rubella were tested on the residual serum from patients aged 7-20 years old after routine laboratory testing in the hospital with informed consent from the parents. RESULTS: Antibody to measles was present in 275 cases out of 408 cases with a positive rate of 67.4%, the mean IgG titer was 2.77+/-1.18 Index. Antibody to mumps was present in 112 cases out of 408 cases with a positive rate of 27.5%, the mean IgG titer was 2.08+/-1.29 Index. Antibody to rubella was present in 367 cases out of 408 cases with a positive rate of 90.0%, the mean IgG titer was 60.46+/-63.47 IU/mL. CONCLUSION: It is important to maintain a high rate of vaccination coverage in order to prevent an outbreak of measles, mumps, or rubella. It is also important to stress the maintenance of vaccination records for further reference.

Korean Guidelines for Diagnosis and Treatment of Tuberculosis in Children and Adolescents / 소아감염

Tuberculosis is a disease with high morbidity and mortality in children worldwide. Despite the decrease in the incidence of tuberculosis in Korea, more than 30,000 new patients are diagnosed each year. Active tuberculosis is less frequent in children compared to adults but the risk of miliary tuberculosis and CNS tuberculosis is much higher. The diagnosis of tuberculosis in children and adolescents is difficult due to the nonspecific symptoms upon presentation. Diagnostic work up is based on the confirmation of tuberculosis infection by tuberculin skin test, abnormal radiologic findings, and contact with an adult with active tuberculosis. Anti-tuberculosis medications are prescribed according to the drug susceptibility of the index patient. Latent tuberculosis infection plays an important role in adult tuberculosis by reactivation. Thus, it is critical to accurately diagnose latent tuberculosis in children to prevent reactivation in adulthood. Korean guidelines for diagnosis and treatment of tuberculosis in children and adolescents provide evidence based recommendations in the optimal diagnosis and treatment for active and latent tuberculosis in children and adolescents based on the current Korean situation.

Recommendation for the use of newly introduced Tdap vaccine in Korea / 소아과

Pertussis is an acute respiratory infection characterized by paroxysmal cough and inspiratory whoop for over 2 weeks. The incidence of pertussis has decreased markedly after the introduction of DTwP/DTaP vaccine, but the incidence of pertussis has increased steadily among young infant and among adolescents and adults in many countries. Td vaccine was used in this age group but the increase in pertussis has lead to the development of a Tdap vaccine. The Tdap vaccine is a Td vaccine with a pertussis vaccine added and is thought to decrease the incidence and transmission of pertussis in the respective age group. In Korea, two products are approved by the KOREA FOOD & DRUG ADMINISTRATION, which are ADACEL(TM) (Sanofi-Pasteur, Totonto, Ontario, Canada) and BOOSTRIX(R) (GlaxoSmithKline Biologicals, Rixensart, Belgium) for those aged between 11-64. This report summarizes the recommendations approved by the Committee on Infectious Diseases, the Korean Pediatric Society.

Recommendation for use of the newly introduced pneumococcal protein conjugate vaccines in Korea / 소아과

Streptococcus pneumoniae remains a leading cause of invasive infections including bacteremia and meningitis, as well as mucosal infections such as otitis media and pneumonia among children and adults. The 7-valent pneumococcal conjugate vaccine (PCV7) was licensed for use among infants and young children in many countries including Korea. The routine use of PCV7 has resulted in a decreased incidence of invasive pneumococcal disease (IPD) by the vaccine serotypes among the vaccinees and substantial declines in IPD among unvaccinated populations such as older children and adults as well. In addition, there are increasing evidences to suggest that routine immunization with PCV7 is changing the epidemiology of pneumococcal diseases such as serotype distribution of IPD, nasopharyngeal colonization, and antibiotic resistance patterns. In contrast, there is an increase in the number of IPDs caused by nonvaccine serotypes, though it is much smaller than overall declines of vaccine serotype diseases. Several vaccines containing additional serotypes have been developed and tested clinically in order to expand the range of serotypes of Streptococcus pneumoniae. Recently two new pneumococcal protein conjugate vaccines, 10-valent pneumococcal conjugate vaccine (PCV10) and 13-valent pneumococcal conjugate vaccine (PCV13), have been approved for use in several countries including Korea. This report summarizes the recommendations approved by the Committee on Infectious Diseases, the Korean Pediatric Society.

Reemergence of mumps / 소아과

The mumps virus is a single-stranded, non-segmented, negative-sense RNA virus belonging to the Paramyxoviridae family. Mumps is characterized by bilateral or unilateral swelling of the parotid gland. Aseptic meningitis is a common complication, and orchitis is also common in adolescents and adult men. Diagnosis is based on clinical findings, but because of high vaccination coverage, clinical findings alone are not sufficient for diagnosis, and laboratory confirmation is needed. Mumps is preventable by vaccination, but despite high vaccination coverage, epidemics occur in several countries, including Korea. Many hypotheses are suggested for these phenomena. In this review, we investigate the reason for the epidemics, optimal methods of diagnosis, and surveillance of immunization status for the prevention of future epidemics.

Causative Organisms of Community Acquired Urinary Tract Infection and Their Antibiotic Susceptibility at a Secondary hospital in Korea / 소아감염

PURPOSE: We investigated the causative organism and its antibiotic susceptibility of community acquired urinary tract infection (UTI) in children at a secondary hospital to test the adequacy of the current guidelines. METHODS: Children diagnosed with UTI at the Department of Pediatrics, Kwandong University Myongji Hospital by pyuria and bacterial growth of greater than 1.0x10(5) CFU/mL on clean catch midstream urine from January 2005 to December 2008 were studied retrospectively. The epidemiologic data, causative organism, and the antibiotic susceptibility were analyzed. RESULTS: Sixty two children were diagnosed with sixty four cases of UTI's. Two bacteria were isolated in one case and thus data on 65 urine cultures were analyzed. The male:female ratio was 1.6:1 and 78.1% were less than 12 months of age. Escherichia coli was the predominant cause consisting of 53 cases (82.8%) of the cases. K. pneumoniae (5), Enterobacter (4), Enterococcus (1), beta-streptococcus (1), Diphtheroides (1) were isolated. The antibiotic resistance of E. coli were as follows; ampicillin 69.8%, cefotaxime 1.9%, gentamicin 15.1%, amikacin 0.0%, levofloxacin 1.9%, and trimethoprim/sulfamethoxazole 26.4%. Only one case of the E. coli was extended spectrum beta-lactamase (ESBL) positive. CONCLUSION: Compared to prior reports from other tertiary hospitals in Korea, E. coli was the predominant cause in childhood UTI and the rate of ESBL positivity was low. The antibiotic resistance was also different compared to prior reports. We conclude that a difference in the cause and antibiotic resistance of childhood UTI exists between centers and this should be taken into consideration when prescribing antibiotics for childhood UTIs.

Early Onset Renal Failure in Congenital Nephrotic Syndrome associated with Congenital Diaphragmatic Hernia by WT1 Gene Mutation

We experienced a female neonate with congenital nephrotic syndrome (CNS) associated with congenital diaphragmatic hernia (CDH). Because of the rare combination of two conditions, we report this case with literature review. CDH was found immediately after birth and emergency operation was done for hernia repair. But on the next day, generalized edema and oliguria(0.59 mL/kg/hour) was found and her blood chemistry showed hypoalbuminemia (1.6 g/dL), increased BUN (27.7 mg/dL) and serum creatinine( 1.8 mg/dL) along with heavy proteinuria (4+). We started albumin infusion with a bolus of intravenous furosemide. We suspected the neonate had congenital nephrotic syndrome and her 24hr urine protein was 1,816 mg/day. In spite of immunosuppressive therapy, the nephrotic syndrome and renal failure progressed. We started peritoneal dialysis on the day of life 22 but it was not satisfactory. She was complicated by intracranial hemorrhage and multi-organ failure and expired at 34 days of age. Kidney necropsy was performed which showed diffuse mesangial sclerosis (DMS). Her chromosome study revealed 46, XX and her gene study revealed a heterozygous missense mutation, Arg366His, in Wilms tumor suppressor gene (WT1). This case deserves attention on account of the 4th case of CNS with CDH revealing the Arg366His mutation in the WT1 gene andG the 1st case of early onset renal failure without male pseudohermaphroditism and Wilms tumor with CNS, CDH and the Arg366His mutation in the WT1 gene. So, this report gives support to the hypothesis that Arg366His mutation in the WT1 gene can result in CNS and CDH.

Evaluation of Usefulness of the Panel Test Composed of Malaria Non-specific Tests As a Surrogate Marker / 대한진단검사의학회지

BACKGROUND: Although malaria-specific antibody or antigen test is useful for the diagnosis of malaria infection, its cost-effectiveness has to be concerned in the area where malaria prevalence is very low. We created a panel test composed of malaria non-specific parameters, namely hematology autoanalyzer-derived results with or without addition of HDL-cholesterol data, and evaluated its usefulness in comparison with malaria-specific antibody test. METHODS: For 395 patients tested for malaria smear, the hematology parameters such as platelet count, NRBC (%) and VCS (volume, conductivity, scattering) parameters of WBC, and HDL-cholesterol data were analyzed. Statistical significance of each parameter and that of panel test with or without addition of HDL-cholesterol were evaluated. RESULTS: Malaria antibody test showed sensitivity of 97.1% and specificity of 99.1%. Each parameter of platelet count, NRBC (%), D parameter and HDL-cholesterol showed sensitivity of 86.8%, 41.2%, 81.8%, and 70.6%, and specificity of 85.9%, 96.3%, 72.3%, and 81.7%, respectively. Panel test without including HDL-cholesterol showed sensitivity of 91.2% and specificity of 81.6%, and that including HDL-cholesterol showed sensitivity of 91.2% and specificity of 86.2%. CONCLUSIONS: The malaria non-specific panel test composed of hematology autoanalyzer-derived parameters showed relatively good, but slightly lower sensitivity than that of malaria-specific antibody test. It might be used as a screening test for the diagnosis of malaria infection, and addition of HDL cholesterol improved little the usefulness of the panel test.

Antibody prsistence after Haemophilus influenzae type b (Hib) primary vaccination and response to boosters in Korean children / 소아과

PURPOSE: Antibody persistence after primary series of Haemophilus influenzae type b (Hib) vaccine and responses to boosters are seldom studied in Korean children. We performed this study to evaluate the antibody titer in relation to booster immunization of Hib vaccine in Korean children. METHOD: One hundred forty four children aged 12-23 months were enrolled in three university hospitals. The immunogenicity of boosters with Hib vaccine was assessed in children previously primed with Hib vaccine. Antibody persistence was also assessed in children who had received 3 doses of Hib vaccine without a booster. Anti-polyribosylribitol phosphate (PRP) IgG antibody levels and bactericidal titers were determined by enzyme immunoassay and bactericidal assay at the Center for Vaccine Evaluation and Study, Medical Research Institute, Ewha Womans University. RESULTS: Prior to a booster in the second year of life, geometric mean antibody concentrations were 2.39 microgram/mL and the percent of subjects who had a anti-PRP antibody level > or =1 microgram/mL was 68.6%. After boosting, antibody concentration was 19.09 microgram/mL and the percent of subjects who had a anti- PRP antibody level > or =1 microgram/mL was 96.5%, which reflects previous immune priming. In subjects who had finished primary immunization only, the bactericidal titer was 3,946 and in subjects who had a booster, it was 11,205. Anti-PRP antibody level was correlated with serum bactericidal titer. CONCLUSION: Many children aged 12-23 month old still had protective antibodies after recommended primary immunization only. A booster dose seemed to induce good anamnestic antibody responses in Korean children.

Serotype and Antimicrobial Susceptibility of Streptococcus pneumoniae / 감염과화학요법

BACKGROUND: Pneumococcus is the most common cause of acute otitis media, community acquired pneumonia and invasive bacterial diseases in children. Ninety serotypes have been identified, and the distribution differs according to geographic area and ages. The 7 valent pneumococcal protein conjugate vaccine is used widely. To evaluate the efficacy of the vaccine, it is essential to investigate the distribution of the pneumococcal serotypes. MATERIALS AND METHODS: The serotypes and antibiotic resistance of the pneumococcus isolated from 308 patients at Shinchon Severance hospital from September of 2001 to July of 2005 were analyzed. RESULTS: The pneumococcci were isolated mostly from sputum and blood, and ear discharge in the descending order. Serotyping was possible in 265 cases, and the distribution of serotypes were 19F (16.2%), 19A (12.8%), 23F (8.7%), 6B (7.9%), and 6A (7.2%). Fifty two cases were isolated from those patients less than 16 years of age and the distribution of serotypes was 19F, 19A, 23F, 14, 6B, 6A and 4. Resistance to penicillin was 64.6% in all cases and 67.3% in children. The more common serotype showed the higher rate of penicillin resistance. Multi-drug resistance was demonstrated in 64.7%. Forty three percent of the total identified serotypes were included in the 7 valent pneumococcal conjugate vaccine. And 61.5% of the serotypes identified in children were included in the vaccine. CONCLUSION: The 7 valent vaccine may be used effetively in Korea. But, further study is needed to address serotype switching after the use of the protein conjugated vaccine, which has been reported in other countries.

Serotype and Antimicrobial Susceptibility of Streptococcus pneumoniae / 감염과화학요법

BACKGROUND: Pneumococcus is the most common cause of acute otitis media, community acquired pneumonia and invasive bacterial diseases in children. Ninety serotypes have been identified, and the distribution differs according to geographic area and ages. The 7 valent pneumococcal protein conjugate vaccine is used widely. To evaluate the efficacy of the vaccine, it is essential to investigate the distribution of the pneumococcal serotypes. MATERIALS AND METHODS: The serotypes and antibiotic resistance of the pneumococcus isolated from 308 patients at Shinchon Severance hospital from September of 2001 to July of 2005 were analyzed. RESULTS: The pneumococcci were isolated mostly from sputum and blood, and ear discharge in the descending order. Serotyping was possible in 265 cases, and the distribution of serotypes were 19F (16.2%), 19A (12.8%), 23F (8.7%), 6B (7.9%), and 6A (7.2%). Fifty two cases were isolated from those patients less than 16 years of age and the distribution of serotypes was 19F, 19A, 23F, 14, 6B, 6A and 4. Resistance to penicillin was 64.6% in all cases and 67.3% in children. The more common serotype showed the higher rate of penicillin resistance. Multi-drug resistance was demonstrated in 64.7%. Forty three percent of the total identified serotypes were included in the 7 valent pneumococcal conjugate vaccine. And 61.5% of the serotypes identified in children were included in the vaccine. CONCLUSION: The 7 valent vaccine may be used effetively in Korea. But, further study is needed to address serotype switching after the use of the protein conjugated vaccine, which has been reported in other countries.

Statistical Analysis of 1,000 Cases of Kawasaki Disease Patients Diagnosed at a Single Institute / 소아과

PURPOSE: To find the risk factors associated with coronory artery lesions, non-responsiveness to intravenous immunoglobulin(IVIG) treatment, and recurrences in Kawasaki disease patients. METHODS: We retrospectively analyzed 1,000 Kawasaki disease patients who were admitted to Yonsei University Medical Center from September 1990 to December 2003. We compared between responder and non-responder groups to IVIG treatment as well as between relapsed and non-relapsed groups, and as to the relapsed group, we also compared variables between patients in their first and second attack states. Finally, factors associated with longer-fever duration from disease onset were evaluated. RESULTS: Longer fever durations before and after IVIG treatment, male sex, lower Hgb and Hct level, higher WBC count and segmented WBC proportion, and higher CRP and Harada's score were related with coronary artery lesions. Non-responsiveness was related to higher WBC count, segmented WBC proportion, CRP, SGPT, Harada's score, and pyuria. Moderate-to-severe coronary artery dilatations and recurrences were more commonly seen among the non-responder group. No significant predictive factors for recurrence were found. In the relapsed group, lower WBC count, CRP, and shorter fever duration from disease onset were observed in their second attack state. Fever duration from disease onset showed positive correlation with WBC count, CRP, and Harada's score and negative correlation with Hgb levels. CONCLUSION: Higher WBC count, CRP, and higher Harada's score were related to both higher incidences of coronary artery lesions and non-responsiveness to IVIG treatment, and these factors were also related with longer fever duration. Non-responders to IVIG treatment showed higher recurrence rate and more moderate-to-severe coronary artery dilatations than responders.

A Clinical Study of Infective Endocarditis in Childhood / 소아과

PURPOSE: Advances in the treatment of congenital heart disease and a decline in the incidence of rheumatic fever has led to changes in the causative organisms and the clinical outcome of infective endocarditis(IE). We sought to analyze the clinical outcome, prognostic factors, causative organisms and corresponding antibiotic sensitivity in IE. METHODS: Retrospective analysis of medical records of 104 children diagnosed and treated with IE at Severance Hospital, Yonsei University College of Medicine from January 1986 to June 2003 was undertaken. According to the Duke criteria, 55 patients were classified into the definite group(DG) and possible group(PG). RESULTS: Thirty one cases(56.4%) fulfilled the criteria for the definite group in the Duke criteria, whereas 24 cases(43.6%) fulfilled the criteria for the possible group. The most common chief complaint on admission was fever(93%). The most common infecting organism was Staphylococcus aureus, which was found in 14 cases(48.3%). Three cases(21.4%) of this organism were methicillin- resistant S. aureus(MRSA). Other causative organisms were alpha-streptococcus(seven cases, 24.1%), Staphylococcus epidermidis(three cases, 10.3%), Citrobacter freundii(one case, 3.8%), Enterococcus faecium(one case, 3.4%) and Candida albicans(three cases, 10.3%). Penicillin-resistant organisms were found in 90.5%(19/21) of total cases and the most sensitive antibiotics were vancomycin(13/13, 100 %) and teicoplanin(12/12, 100%). One case of IE due to MRSA unresponsive to vancomycin was treated with Arbekacin. CONCLUSION: The incidence of IE caused by S. aureus, especially MRSA, is increasing. Multi-drug resistant organisms are also emerging as a frequent cause of IE. Thus, in patients strongly suspected of having IE in patients with underlying heart disease, glycopeptides such as vancomycin combined with aminoglycosides should be considered, and if fever and positive blood cultures continue despite treatment with glycopeptides, a consideration of the use of new antibiotics may improve the treatment results.

Effect of a Flavon Extracted from Artemisia absinthium on Collagen Induced Arthritis in Mice / 소아과

PURPOSE: In this study, a possible suppressive effect of a flavon extracted from Artemisia absinthium on a mouse collagen-induced arthritis (CIA) model was investigated. METHODS: DBA/1 mice were injected intradermally with emulsified chicken type II collagen. Three weeks after immunization, a flavon was introduced p.o. everyday. Clinical incidences of arthritis and arthritis index were measured. Measurement of anti-collagen antibodies and a stimulation index of the splenocytes of the mice were measured. IL-10 and TNF-alpha in the supernatants of the mice sera were measured by ELISA. mRNA expression for IL-10 and TNF-alpha in the splenocytes were tested. RESULTS: Flavon extracted from Artemisia absinthium appears to be an effective suppressor of CIA in mice. The serum anti-collagen antibody level and stimulation index of the cultured splenocytes showed no significant differences among the three experimental groups. Also serum IL-10 and TNF-alpha levels did not show any significant differences among the three experimental groups. An increased expression of mRNA for IL-10 was observed in the splenocytes treated with flavon. CONCLUSION: With these results, flavon extracted from Artemisia absinthium appears to have a suppressive effect of CIA. The mechanism of the suppressive effect of flavon extracted from Artemisia absinthium may be from a stimulation of IL-10 production.