Two Cases of Chloromethylisothiazolinone and Methylisothiazolinone-associated Toxic Lung Injury

Previous animal studies have not conclusively determined the association between exposure to humidifier disinfectants (HDs) containing 5-chloro-2-methyl-4-isothiazolin-3-one (CMIT) and/or 2-methyl-4-isothiazolin-3-one (MIT) and development of HD-associated lung injuries. Nonetheless, patients exposed to HDs containing only CMIT and/or MIT showed clinically similar lung injuries to those exposed to HDs containing polyhexamethylene guanidine (PHMG) or oligo (2-[2-ethoxy]ethoxyethyl) guanidinium chloride (PGH). Here, we report twin sisters with lung injuries associated with exposure to CMIT/MIT-containing HDs. At 6 months of age, a younger twin sister presented with the 3-day history of cough, sputum, and respiratory difficulty. Chest radiography revealed multiple patchy consolidation and ground-glass opacities with pneumothorax and pneumomediastinum. Thoracostomy was performed due to pneumothorax at admission and she was discharged at 11 days of hospitalization. At 5 years of age, multiple tiny nodules and faint centrilobular ground-glass opacities were observed with the small pneumatocele. The elder sister visited a tertiary hospital due to dyspnea at 12 months of age. Chest radiography showed consolidation, pneumomediastinum, and pulmonary interstitial emphysema. There was no response to the administration of immunosuppressant drugs and antifibrotic agents. At 5 years of age, chest CT revealed ground-glass opacity and multiple tiny centrilobular ground-glass opacities nodules in both lungs with exercise intolerance.

A study of the use of home mechanical ventilator and medical insurance

PURPOSE: Use of a home mechanical ventilator can shorten the hospitalization duration of children with chronic respiratory failure requiring long-term use of a mechanical ventilator. In this study, the researchers analyzed patients who had used a home mechanical ventilator. METHODS: From January 2009 to July 2014, we retrospectively investigated 15 patients under 18 years of age, from 2 hospitals, and their use of home mechanical ventilators. RESULTS: The median age of the patients was 55 months. Ten children were male, and 5 were female. As for the type of mechanical ventilators, 10 used a pressure type, 3 used a volume type, and 2 used a volume-mask type. Analysis of underlying diseases revealed that 10 children had neuromuscular disease, 3 had pulmonary disease, and 2 suffered from hypoxic ischemic encephalopathy. The number of patients who were discharged from the hospital with a home mechanical ventilator was 13. One child died of sepsis irrespective of the mechanical ventilator. Six patients had health insurance. But 9 did not. The group with insurance had the possibility of being discharged earlier than the group without. On readmission, the length of hospitalization was also reduced in patients who had used a home mechanical ventilator. CONCLUSION: Use of a mechanical ventilator at home is helpful in patients who need long-term use of a mechanical ventilator due to neuromuscular disease, chronic pulmonary diseases, and accidents because complications are rare and insurance coverage is feasible.

The cause of hemoptysis according to age and the amount of hemoptysis in children

PURPOSE: Studies on hemoptysis is rare because hemoptysis is an uncommon symptom in children. The aim of this study was to identify the causes of hemoptysis in children. METHODS: Medical chart review of patients with hemoptysis was retrospectively conducted at 2 tertiary hospitals from November 2008 to December 2014. Patients were divided into 3 groups according to age. The amount of hemoptysis was categorized as mild (<20 mL/day), moderate (20–99 mL/day), and massive (≥100 mL/day). RESULTS: A total of 59 patients were identified, and their mean age was 11.0±5.6 years. Among the causes of hemoptysis, respiratory tract infection was most common. Other causes included vasculitis syndrome, neoplasm in the airway, idiopathic pulmonary hemosiderosis, cardiac disease, and bronchiectasis. According to age, a significant difference was identified between the age groups in children with pneumonia (<6 years vs. 12–18 years, P=0.001). Differences were verified between the age groups in children with tuberculosis (<6 years vs. 12–18 years and 6–11 years vs. 12–18 years, P=0.023). According to amounts of hemoptysis, no significant difference was identified regardless of the causes. CONCLUSION: This study showed that the causes of hemoptysis in children were heterogeneous and the respiratory tract infection was most common. In children with hemoptysis, the age of onset and the amount of hemoptysis are needed to be considered for more precise diagnosis and more proper management of the underlying cause of hemoptysis.

Diffuse panbronchiolitis in an adolescent female

Diffuse panbronchiolitis (DPB) is a progressive inflammatory respiratory disease of unknown cause mainly occurring in East Asian people. Studies on causes of the disease point to a genetic predisposition unique to Asians, but the cause remains unknown. If untreated, DPB progresses to bronchiectasis, respiratory failure, and death. The age of patients at onset of the disease varies from young to elderly people with a peak at 40-60 years. A few cases of DPB have been reported in Korean adults since 1992; however, the case of DPB in children is uncommon. Herein, we describe a 16-year-old girl with DPB who presented with chronic cough and sputum.

Erratum: Acknowledgments Correction. The cause of hemoptysis according to age and the amount of hemoptysis in children

Acknowledgments section for grant support was misprinted unintentionally.

A Case of Galloway-Mowat Syndrome with Classic Clinical Triad in the Neonatal Period / 대한주산의학회잡지

Galloway-Mowat syndrome (GMS) is a rare autosomal recessive disorder comprising of early-onset nephrotic syndrome and central nervous system involvement including microcephaly, seizure and developmental delay. Although hiatal hernia is no longer considered essential findings for diagnosis, clinical triad of GMS included nephrotic syndrome, neurological manifestations, and hiatal hernia in the original description. We experienced a case of newborn with GMS presenting these clinical triad in neonatal period. A male infant weighing 2,250 g was born at gestational week 39+3 by cesarean section. The patient revealed mild dysmorphic facial features and microcephaly. On day 7, Nissen fundoplication was done because of hiatal hernia with gastric volvulus. At the age of 2 weeks he developed nephrotic syndrome with proteinuria and hypoalubuminemia. This is the first case of GMS that three classic findings were present in neonatal period in Korea.

Characteristics of pediatric noniatrogenic pneumomediasinum

PURPOSE: Pneumomediastinum is rare in children and adolescents, and its causes have not yet been clearly determined. We aimed to identify the causes, clinical manifestations and prognosis of noniatrogenic pneumomediastinum in children. METHODS: From February 2007 to June 2014, we retrospectively investigated 121 patients with pneumomediastinum under 18 years of age in 2 hospitals. Eighteen patients with pneumomediastinum after thoracotomy and 35 patients with iatrogenic pneumomediastinum were excluded. RESULTS: Sixty-eight patients were divided into 4 age groups: those under 1 year of age (n=9, 13.2%), those 1 to 5 years of age (n=9, 13.2%), those 6 to 10 years of age (n=17, 25.0%) and those over 11 years of age (n=33, 48.5%). Chest pain (n=43, 63.2%) was the most common initial complaint and subcutaneous emphysema was identified in 18 patients (26.5%). Chest x-ray was diagnostic in all except 9 patients (13.2%). Predisposing causes of pneumomediastinum were idiopathic (n=26, 38.2%), respiratory tract infection (n=23, 33.8%), asthma exacerbation (n=4, 5.9%), trauma (n=4, 5.9%), endobronchial foreign body (n=2, 2.9%), interstitial lung disease (n=5, 7.4%), and neonatal respiratory disease (n=4, 5.9%). Chest pain (P<0.001) and idiopathic cause (P=0.001) were shown to linearly increase with age. On the contrary, tachypnea (P<0.001), dyspnea (P=0.016), and interstitial lung disease (P=0.008) were shown to have a decreasing linear association with age. The length of hospital stay was significantly increased in patients with interstitial lung disease (P=0.042), those with pneumothorax (P=0.044), and those without chest pain (P=0.013). CONCLUSION: According to age groups, there were significant differences in causes and clinical manifestations. In particular, pneumomediastinum that developed in younger patients with interstitial lung disease showed unfavorable outcomes, such as dyspnea, pneumothorax, and increased length of hospital stay. Therefore, precise evaluation of predisposing causes and careful management are needed for children with pneumomediastinum.

Cause and incidence of eosinophilia in children: a single center study in one year

PURPOSE: Eosinophilia may be associated with various primary and reactive conditions. However, studies on the cause and incidence of eosinophilia in Korean children are rare. This study aimed to evaluate the cause and incidence of eosinophilia in patients at a single university hospital. METHODS: We studied 8,285 pediatric patients under the age of 18 years who had eosinophilia at Pusan National University Hospital. Premature and newborn infants were excluded. Eosinophilia was defined as an absolute eosinophil count greater than 450/microL. Eosinophilia was categorized as mild (450-1,500/microL), moderate (1,500-5,000/microL), and severe (>5,000/microL). The underlying conditions of eosinophilia were retrospectively investigated. RESULTS: Of 8,285 patients who had a hematology profile, 497 (5.9%) were found to have eosinophilia. Of patients with eosinophilia, 333 patients (67.0%) had identifiable and possible causes. The major causes of eosinophilia were allergic diseases (61.3%), infectious diseases (19.8%), immunologic diseases (9.0%) and hemato-oncologic disease (5.1%). Immunological disease such as Idiopathic hypereosinophilic syndrome, drug induced hypersensitivity syndrome and Graft-versus-host disease was the common condition with moderate to severe eosinophilia in which eosinophil count in peripheral blood was more than 1,500/microL. CONCLUSION: The most common cause of eosinophilia was allergic disease. Immunological disease was the common condition with moderate to severe eosinophilia.

Clinical features of necrotizing pneumonia in children

PURPOSE: Necrotizing pneumonia (NP) is a complication of invasive pneumonia. Few studies have reported on the clinical features of NP in children. METHODS: Nineteen patients with NP who were admitted to Pusan National University Hospital and Pusan National University Children's Hospital between December 2008 and March 2013, were studied in terms of sex, age at diagnosis, clinical characteristics, detected organisms, radiologic findings, treatments and clinical outcomes. RESULTS: Twelve patients (63.2%) were males and seven patients (36.8%) were female. Eight patients (44.4%) were younger than 5 years of age, seven patients (38.9%) were at 6-10 years of age and four patients (21.1%) were older than 11 years of age. Most patients had fever and cough at the time of diagnosis. Minorganism were identified in 9 cases (47.4%): Mycoplasma pneumonia in 4 (21.1%), Streptococcus pneumonia in 1 (5.3%), Staphylococcus aureus in 1 (5.3%), G+cocci in 1 (5.3%), and M. pneumonia + S. pneumoniae coinfection in 2 (10.5%). The diagnosis of NP was established by computerized tomography. Cavitary necrosis was shown in all patients, and pleural effusion was shown in 15 patients (78.9%). Six patients (31.6%) presented local atelectasis and 2 patients (10.5%) presented pneumothorax. Five patients (26.3%) treated with only antibiotics were cured completely. Invasive treatment was needed by 14 patients (73.7%): 10 patients (52.6%) needed chest tubing, and 5 patients (26.3%) needed surgery. Only one patient (5.3%) expired. CONCLUSION: NP is a rare complication of pneumonia in children and has a good prognosis, typically resolving completely with medical treatment alone. However, patients who present with the worsening of clinical status or pleural complications despite the use of appropriate antibiotics should be evaluated for surgical indications.

A Study on Clinical Manifestations of Pulmonary Tuberculosis and Tuberculosis Contact Investigation in School-Age Children and Adolescents at Two Centers / 소아감염

PURPOSE: The aim of this study was to evaluate the clinical manifestations, contact history, and status of tuberculosis contact investigations in school-age children and adolescents with pulmonary tuberculosis (TB) at two centers. METHODS: This study was conducted with 54 patients in the age ranging from 10 to 18 years, who were diagnosed with pulmonary TB at the Pusan National University Hospital and Pusan National University Children's Hospital, January 2008 to December 2012. We retrospectively reviewed the medical records of the patients. RESULTS: The median age of the patients was 16 years old; 11 patients were aged 10 to 14 and 43 patients were aged 15 to 18. Among 54 patients, 19 had history of contact with pulmonary TB, 10 had contact with house members (household), and remaining 9 had contact with classmates (non-household). One out of 10 patients who had household contacts and 6 out of 9 patients who had non-household contacts were evaluated with contact investigation after the exposure to pulmonary TB. Among 7 patients who were evaluated with contact investigation, 3 were diagnosed with active pulmonary TB, 1 had latent tuberculosis infection (LTBI), and 3 had no evidence of TB or LTBI. The median period of diagnosis after the exposure to active pulmonary TB was 2 years in patients with household contacts and 0.23 years in patients with non-household contacts. CONCLUSION: This study suggested that if the contact investigation conducted properly, it would be helpful for early diagnosis and prevention of pulmonary TB.

Clinical characteristics and cause of bronchiectasis in children: review in a center

PURPOSE: The study for bronchiectasis in children is rare in Korea. The aim of this study was investigate the clinical characteristic and associated etiology in pediatric patients with bronchiectasis. METHODS: We studied 29 pediatirc patients with bronchiectasis from January 2008 to December 2012 at Pusan National University Hospital. The age, sex, clinical symptoms, signs, radiologic findings, associated etiologic factors, and clinical course were investigated retrospectively. RESULTS: The median age at the time of diagnosis of bronchiectasis was 8.7 years. Chronic coughing was the most common symptom. The associated etiologies were immunodeficiency (31.0%), respiratory infection (27.6%), bronchiolitis obliterans (13.8%), interstitial lung disease (10.3%). The median age at the time of diagnosis of bronchiectasis in immunodeficient patients was 8.3 years. Post infectious bronchiectasis and severe respiratory symptom tend to occur in younger children. CONCLUSION: The risk factors of bronchiectasis in children are immunodeficiency and respiratory infection. Physicians should evaluate bronchiectasis in children with chronic cough.

Congenital Internal Hernia Presented with Life Threatening Extensive Small Bowel Strangulation / 대한소아소화기영양학회지

Internal hernia (IH) is a rare cause of small bowel obstruction occurs when there is protrusion of an internal organ into a retroperitoneal fossa or a foramen in the abdominal cavity. IH can be presented with acute or chronic abdominal symptom and discovered by accident in operation field. However, various kinds of imaging modalities often do not provide the assistance to diagnose IH preoperatively, but computed tomography (CT) scan has a high diagnostic accuracy. We report a case of congenital IH in a 6-year-old boy who experienced life threatening shock. CT scan showed large amount of ascites, bowel wall thickening with poor or absent enhancement of the strangulated bowel segment. Surgical exploration was performed immediately and had to undergo over two meters excision of strangulated small bowel. To prevent the delay in the diagnosis of IH, we should early use of the CT scan and take urgent operation.

Clinical Manifestations of Respiratory Viruses in Hospitalized Children with Acute Viral Lower Respiratory Tract Infections from 2010 to 2011 in Busan and Gyeongsangnam-do, Korea / 소아알레르기및호흡기학회지

PURPOSE: This study was performed to investigate the epidemiologic and clinical features of respiratory viruses in children with acute lower respiratory tract infection (ALRTI) in Busan and Gyeongsangnam-do, Korea. METHODS: From May 2010 to April 2011, we tested nasopharyngeal aspiration specimens in 1,520 hospitalized children with ALRTI with multiplex real time-polymerase chain reaction (RT-PCR) to identify 7 kinds of common pathogens (adenovirus [ADV], influenza virus type A [influ A], influenza virus type B [influ B], human metapneumovirus [hMPV], parainfluenza virus [PIV], human rhinovirus [hRV], respiratory syncytial virus [RSV]). We analyzed positive rates and clinical features by retrospective review of the chart. RESULTS: Virus agents were isolated from 72.5% of cases. The identified pathogens were RSV, 35.5%; hRV, 25.6%; PIV, 13.8%; ADV, 12.8%; hMPV, 7.1%; influ A, 5.0%; and influ B, 0.3%. The major period of viral ALRTI was the first year of life. Clinical diagnoses of viral ALRTI were pneumonia, 52.3%; bronchiolitis, 21.2%; tracheobronchitis, 1.0%; croup, 10.8%; and asthma, 8.8%. The most frequent case of pneumonia and bronchiolitis was RSV. Croup was frequently caused by PIV. The number of hMPV infections peaked between April and June and were primarily caused due to pneumonia. CONCLUSION: Although this study was confined to one year, this study described the features of ALRTI associated with 7 respiratory viruses in children in Busan and Gyeongsangnam-do, Korea. Additional investigations are required to define the role of respiratory viruses in children with ALRTI in this area.

Acute Hyponatremia in Pneumonia and CNS Infections of Children

PURPOSE: The option of selecting isotonic rather than hypotonic fluids for maintenance fluid in children has been advocated by some authors. Pneumonia and CNS infections are frequent clinical settings for acute hyponatremia because of nonosmotic anti-diuretic hormone stimuli in children. We conducted the present study to identify the incidence of hyponatremia in pneumonia and CNS infection of children and to determine the importance of maintenance intravenous fluid therapy regimen and other related factors. METHODS: The study included 1,992 patients admitted to the Department of Pediatrics at Pusan National University Children's Hospital between November 2008 and August 2011, who were diagnosed with pneumonia or CNS infections and checked for serum sodium concentration. Their clinical data including laboratory findings were reviewed retrospectively. RESULTS: During the study period, 218 patients were identified to have acute hyponatremia among 1,992 patients. The overall incidence of hyponatremia was 10.9%. The incidence of hyponatremia in encephalitis (37.3%) was highest and the incidence in bacterial meningitis (27.4%), viral meningitis (20.0%), bacterial pneumonia (11.1%), mycoplasma pneumonia (9.2%), and viral pneumonia (6.8%) were in descending order. The mean age was higher in hyponatremic patients than in isonatremic patients. The incidence of hyponatremia was higher in who had 0.18% NaCl in 5% dextrose (D5 0.18% NS) than 0.45% NaCl in 5% dextrose infusion (D5 1/2NS) (9.0% vs. 2.2%). SIADH was identified in 20.5% among hospital acquired hyponatremic patients after adequate evaluation for SIADH. CONCLUSION: We recommend D5 1/2NS rather than D5 0.18% NS as the maintenance fluid given to children with pneumonia or infectious CNS diseases.

Lung Abscess and Bacteremia Caused by Neisseria flavescens and Streptococcus sanguis in Patient with Idiopathic Hypereosinophilic Syndrome / 대한임상미생물학회지

Neisseria flavescens has been rarely reported as a pathogen in the literature. We experienced a case of N. flavescens bacteremia and lung abscess co-infected with Streptococcus sanguis in patient with idiopathic hypereosinophilic syndrome. A 15-year-old boy was diagnosed with idiopathic hypereosinophilic syndrome complicated with pulmonary thromboembolism. He was given systemic steroids and thrombolytics. After 8 weeks of therapy, a lung abscess appeared on the plain chest radiograph. We treated him with empirical antibiotics and carried out surgical drainage. Two types of microorganisms were cultured from both blood and pus samples, obtained in the first day of hospitalization. Pus was aspirated from the lung abscess with an aseptic technique. Neisseria species and S. sanguis were identified using traditional methods. To confirm the identity of the Neisseria species, we conducted further testing using 16S ribosomal ribonucleic acid sequencing whereupon N. flavescens was identified. This is the first case report of pulmonary infection caused by N. flavescens. We suggest that N. flavescens may act as a pathogen.

The Clinical Consideration of Tracheal Bronchus Detected by Computed Tomography Scan in Children / 소아알레르기및호흡기학회지

PURPOSE: Tracheal bronchus is an aberrant bronchus arising from tracheal wall above the carina. Most cases of tracheal bronchus are asymptomatic, so they are diagnosed incidentally. Tracheal bronchus may be associated with other anomalies. The aim of this study is to evaluate the clinical characteristics of tracheal bronchus. METHODS: This study was conducted on 19 children who were diagnosed as tracheal bronchus by the chest computed tomography from January 2000 to December 2011. Based on the medical record, clinical features, such as symptoms, radiologic findings, combined anomalies were evaluated retrospectively. RESULTS: The age at diagnosis was ranged from 2 day to 14 years (mean, 51 months). Among the 19 children, twelve children (63.2%) were boys and seven children (36.8%) were girls. Eighteen children (94.7%) had right-side tracheal bronchus and one child (5.3%) had left-side tracheal bronchus. Displaced type were fourteen children (73.7%), supernumerary type were five children (26.3%). Thirteen children (68.4%) had no respiratory symptoms, but five children (26.3%) had persistent cough and four children (21.1%) had recurrent wheezing. Combined congenital abnormalities were present in seventeen children (89.5%), including congenital cardiovascular anomaly (n=14, 73.7%), trachea-esophageal fistula (n=3, 15.8%), Down syndrome (n=2, 10.5%). CONCLUSION: The patients with tracheal bronchus had not severe respiratory symptoms, but had many combined anomalies. So, it is necessary to consider the presence of tracheal bronchus in children with respiratory symptom, like recurrent wheezing, and to evaluate clinical significance, like combined anomaly, in tracheal bronchus patients. The limitation of this study is that the study group includes many cardiovascular disease patients (84.2%).

Clinical Features of Non-A, B, C Viral Hepatitis in Children / 대한소아소화기영양학회지

PURPOSE: Non-A, B, C viral hepatitis is the name given to the disease with clinical viral hepatitis, but in which serologic evidence of A, B, C hepatitis has not been found. Little is known about the etiology and clinical features of non-A, B, C viral hepatitis in children. METHODS: A clinical analysis of 45 cases with non-A, B, C viral hepatitis who were admitted to the Department of Pediatrics, Pusan National University Hospital, from January 2001 to June 2004 was carried out retrospectively. Patients who were positive for HBsAg, anti-HAV and anti-HCV and had toxic, metabolic, autoimmune, or neonatal hepatitis were excluded in this study. RESULTS: Among 45 cases of non-A, B, C viral hepatitis, the etiology was unknown in 26 (57.8%), CMV (cytomegalovirus) in 14 (31.1%), EBV (Epstein Barr virus) in 2 (4.4%), HSV (herpes simplex virus) in 2 (4.4%) and RV (rubella virus) in 1 (2.2%). Twenty seven out of 45 (60.0%) patients were under 1 year of age. Sixteen (33.3%) patients had no specific clinical symptoms and were diagnosed incidentally. On physical examination, twenty seven out of 45 patients (60.0%) had no abnormal findings. Forty three out of 45 patients (95.6%) showed classic clinical course of acute viral hepatitis, whereas fulminant hepatitis developed in two patients. Mean serum ALT (alanine aminotransferase) level was 488.7+/-771.9 IU/L. Serum ALT level was normalized in 31 out of 45 patients (81.6%) within 6 months and all patients within 18 months. Aplastic anemia was complicated in a case. CONCLUSION: Although most patients with non-A, B, C viral hepatitis showed a good prognosis, a careful follow-up would be necessary because some of them had a clinical course of chronic hepatitis, fulminant hepatitis and severe complication such as aplastic anemia.

A Clinical Analysis of Neonatal Surgical Gastrointestinal Diseases in Daegu?Busan Area / 대한소아소화기영양학회지

PURPOSE: Perinatal mortality rates have been used as a summary statistic for evaluating child health and medical status. Neonatal mortality rates have decreased over the past 30 years in Korea. To understand the current status of neonatal surgical gastrointestinal diseases in Daegu?Busan area, we have studied about neonatal gastrointestinal diseases with their clinical features, postoperative outcome, and mortality rates. METHODS: A clinical analysis on 202 neonates who underwent neonatal surgery from January 1996 to July 2003 at Pusan National University, Kyungpook National University, Youngnam University, and Daegu Catholic University was carried out. RESULTS: The main diseases of surgical conditions were anorectal malformation (23.8%), atresia/ stenosis of midgut (13.4%) and pyloric stenosis (13.4%). The male to female ratio was 2.8:1. Thirty-five cases (17.0%) had one or more associated anomalies including congenital heart disease, cryptoorchidism, hydronephrosis, and chromosomal anomaly. Twenty cases (10.0%) were diagnosed by antenatal ultrasound. Patients with esophageal atresia had the longest hospitalization for 54.6 days. Postoperative complications occurred in 18 cases (8.9%). The main postoperative complications were wound infection (3.5%) and anastomotic leakage (2.5%). Overall mortality was 5.9%. Diaphragmatic hernia showed the highest mortality rate (37.5%), and esophageal atresia (28.6%) and omphalocele (20.0%) were followed. CONCLUSION: The current status of neonatal surgical gastrointestinal diseases in Daegu?Busan area has improved because the disease categories are various, postoperative complications and mortality rates are decreased.