Fluconazole administration leading to anaphylactic shock in a preterm newborn.

Preterm infants, born with immature innate immunity, are less likely to develop anaphylaxis. Fluconazole prophylaxis during the first six weeks of life decreases invasive candidiasis in very low birth weight infants. Adverse effects of fluconazole are very rare. In this study, we report a newborn (a male, 26 weeks gestation and 900 g birth weight) who developed anaphylaxis after fluconazole administration. Hypotension and erythematous rash were present. We believe this to be the first anaphylaxis case in newborns caused by fluconazole in literature. Clinicians should be aware of the possibility of this potentially fatal adverse effect occurring with intravenous fluconazole.

Levetiracetam-induced anaphylaxis in a neonate.

BACKGROUND: Neonatal seizures are often refractory to treatment with initial antiseizure medications. Clinicians turn to agents such as levetiracetam despite the paucity of published data regarding its safety, tolerability, or efficacy in the neonatal population. PATIENT PRESENTATION: We describe a neonate who developed anaphylactic shock developing after receiving intravenous levetiracetam. RESULTS: This is the first neonate to develop anaphylactic shock due to intravenous administration of levetiracetam. CONCLUSION: Clinicians should be aware of this potentially fatal adverse effect occurring with intravenous levetiracetam in newborns.

Anaphylactic shock due to vitamin K in a newborn and review of literature.

Newborn infants are born with an immature innate immunity. They are less likely to develop anaphylaxis since their immune system is weaker than older infants and children. There are only a few reports of side effects after vitamin K injection in neonates although prophylaxis against hemorrhagic disease of the newborn with this drug has been in routine practice in all over the world for many years. We herein report a case of anaphylactic shock developing after the intramuscular administration of vitamin K1 in a newborn. To our knowledge, this patient is the first case of neonatal anaphylactic shock developing due to intramuscular administration of vitamin K1. We suggest the clinicians should be aware of this possibility of potentially fatal adverse effect occurring with intramuscular administration of vitamin K1.

Foot Skin Ischemic Necrosis following Heel Prick in a Newborn.

There are only a few reports on side effects after heel prick in neonates although heel prick has been performed all over the world for many years. The medicine staff had obtained only a drop of blood by pricking the baby's heel using a lancet without compressing the heel or foot to measure his blood glucose level 3 hours after birth. However he developed a severe and hemorrhagic skin reaction on his entire left foot, beginning 30 minutes after obtaining the drop of blood by pricking the baby's heel using a lancet. The lesion, which was treated with topical mupirocin and povidone-iodine solution daily, slowly decreased in size and had almost fully resolved within 3 weeks. He was healthy and 9 months old at the time of writing this paper. We herein report a case of foot skin ischemic necrosis following heel prick in a newborn. To our knowledge this patient is the first case of foot skin ischemic necrosis due to heel prick in newborns.

Treatment of hyperinsulinemic hypoglycemia because of diffuse nesidioblastosis with nifedipine after surgical therapies in a newborn.

Recent studies have demonstrated a role for calcium channel blocking agents in the treatment of persistent hyperinsulinemic hypoglycemia of newborns. We report a newborn infant with persistent hyperinsulinemic hypoglycemia whom we successfully treated with oral nifedipine alone after surgical therapies. A 4-day-old male infant was referred with intractable hypoglycemia and seziures. Normoglycaemia could be maintained only by the intravenous infusion of glucose at a rate of 20 mg/kg per minute. Persistent hyperinsulinemic hypoglycemia of newborn was diagnosed from an inappropriately raised plasma insulin concentration (44 mU/L) at the time of hypoglycemia. Medical treatments led to only a mild reduction in the intravenous glucose requirement; an 85-90% pancreatectomy was performed and histological "diffuse nesidioblastosis" was confirmed. However, despite all the medical treatments after the first pancreatectomy, the hyperinsulinemic hypoglycemia persisted and a second 95% pancreatectomy was performed. After the second pancreatectomy, persistent hyperinsulinemic hypoglycemia was treated with somatostatin and diazoxide, but led to no reduction in the intravenous glucose requirement. We report the case of an infant who had persistent hypoglycemia after two subtotal pancreatic resections but subsequently became normoglycemic on treatment with nifedipine (2 mg/kg per day). The patient was discharged home on oral nifedipine. Calcium channel blocking agents cuold be used with efficacy and safety in recurrent persistent hyperinsulinemic hypoglycemia.

Antimeasles antibodies in preterm infants during early infancy in Turkey.

AIM: To measure maternally derived measles antibodies in sera of premature infants at birth and seropositivity rates in early infancy in a rural area of central Turkey. METHODS: 65 premature and 24 full-term infants born in Erciyes University Hospital and their mothers were recruited to a longitudinal, prospective study. The infants were divided into three groups by gestational age: group A, <33 weeks; group B, 33-37 weeks; group C, >37 weeks. For specific analyses, the groups were subdivided into groups Al, B1 and C1 (infants of naturally immunised mothers) and A2, B2 and C2 (infants of vaccinated mothers). Blood samples were obtained from mothers and infants after delivery. The infants were re-evaluated at 2, 4 and 6 months of age. RESULTS: Of 25 mothers, 20.3% were seronegative for measles antibodies. Twenty of the mothers had not been vaccinated. The percentages of seronegative infants at birth were 24.2% (n=8), 12.5% (n=4) and 0% (n=0) in groups A, B and C, respectively. No infants were seronegative at birth in Al, B1 or C1. Mean levels of antimeasles antibodies in all naturally immunised mothers were significantly higher than in vaccinated mothers. Antibody levels in all infants decreased rapidly with increasing age. Gestational age at birth [beta=0.179, t=3.359, 95% confidence interval (CI) 0.0001-0.0001, p<0.05], birthweight (beta=0.637, t=9.691, 95% CI 0.057-0.086, p<0.05) and maternal naturally immunised status (beta=0.168, t=2.825, 95% CI 0.002-0.014, p<0.05) were significantly associated with antibody levels after birth. In all groups of naturally immunised mothers, the percentages of seronegative infants were significantly lower than in vaccinated mothers at birth and at 2, 4 and 6 months of age. CONCLUSION: The current recommendation to immunise all infants at 9 months of age might require revision for premature infants, especially those whose mothers have vaccination-induced immunity.

Onychomycosis in a premature infant caused by Candida parapsilosis.

We report onychomycosis caused by Candida parapsilosis in a 35-day-old premature infant. To our knowledge, this represents the youngest instance of an isolated lesion of the nail plate without involvement of glabrous skin, caused by C. parapsilosis in this age group to be reported in the literature.

Adrenal haemorrhage with cholestasis and adrenal crisis in a newborn of a diabetic mother.

The large hyperaemic foetal adrenal gland is vulnerable to vascular damage. This may occur in the neonatal period as a consequence of difficult labour, or its aetiology may not be apparent. The spectrum of presentation is considerable, ranging from asymptomatic to severe life-threatening intra-abdominal haemorrhage. The presentation of adrenal insufficiency may be delayed but the regenerative capacity of the adrenal is great, and most adrenal haemorrhage is not associated with significantly impaired function. Some reports showed that cholestatic hepatopathy with congenital hypopituitarism reversed by hydrocortisone treatment is considered in the context of the endocrine syndrome, probably as a consequence of the adrenal failure. We describe a case of bilateral adrenal haemorrhage with hepatitis syndrome and persistent hypoglycaemia in a newborn male with striking features of neonatal cholestasis and adrenal crisis.

The relationship between birth weight leptin and bone mineral status in newborn infants.

BACKGROUND: The positive relationship between fat mass, bone mass and leptin has been shown in fetal mouse cartilage/bone. It has been shown that umbilical venous leptin predicts both the size of the neonatal skeleton and its estimated volumetric mineral density. AIMS: This study investigates how birth weight and bone mineralization correlate with leptin levels. In addition, we aimed to determine the predictive value of anthropometrics measurements and gender on variability in bone mineral status. METHODS: Umbilical cord venous blood samples were obtained at the delivery from 100 term newborn infants. Forty of the newborn infants had birth weights appropriate for gestational age (AGA), 30 were small for gestational age (SGA) and 30 were large for gestational age (LGA). Data were acquired using the whole body dual energy X-ray obsorptiometry scanner in the first 24 h after birth. RESULTS: Leptin concentrations were higher in LGA (36.6 +/-12.0 ng/ml; p < 0.0001), but lower in SGA (11.7 +/- 5.6 ng/ml; p < 0.001) than in AGA infants (20.3 +/- 7.6 ng/ml). Whole body bone mineral density and whole body bone mineral content were higher in LGA babies (0.442 +/- 0.025 g/cm(2), 71.6 +/- 9.0 g, p < 0.01, p < 0.001, respectively) but lower in SGA (0.381 +/- 0.027 g/cm(2), 29.1 +/- 9.1 g, p < 0.001, p < 0.001, respectively) than in AGA babies (0.426 +/- 0.022 g/cm(2), 53.7 +/- 9.6 g, respectively). The percentage of whole body bone mineral content was lower in SGA (1.3 +/- 0.3) than in AGA (1.6 +/- 0.2, p < 0.001) and LGA (1.7 +/- 0.2, p < 0.001). In stepwise linear regression analyses models; leptin is not found related to the bone indices. CONCLUSION: Our study does not provide support for the hypothesis that leptin may play a major role in the regulation of bone metabolism in the developing skeleton.

Influence of maternal smoking on neonatal aortic intima-media thickness, serum IGF-I and IGFBP-3 levels.

Epidemiological studies have reported associations between a range of cardiovascular risk factors such as smoking and intima-media thickness (IMT). Some reports indicate that the maternal tobacco smoking causes disturbances of the endocrine status of the foetus. There are several potential mechanisms by which insulin-like growth factor I (IGF-I) could modify atherosclerotic processes either locally or in a systemic manner. The aim of this study was to investigate the influence of maternal smoking on neonatal aortic IMT (aIMT), serum IGF-I and IGF-binding protein-3 (IGFBP-3) levels. Aortic intima-media thickness was measured in 28 neonates whose mothers smoked during the pregnancy and 28 control neonates. Mean and weight-adjusted aIMT were significantly greater in the neonates whose mothers smoked (0.455 +/- 0.009 mm and 0.151 +/- 0.005 mm/kg, respectively) than in controls (0.403 +/- 0.029 mm and 0.118 +/- 0.014 mm/kg, respectively). Birth-weight of newborns whose mothers smoked was less than that of the controls. The decreases in serum IGF-I and IGFBP-3 observed in the infants whose mothers smoked were non-significant. Mean aIMT was negatively associated with birth-weight and IGF-I level. In conclusion, neonates whose mothers smoked have significantly increased aIMT. It might play a role in the pathogenesis of atherosclerosis in adult life.

Aortic intima-media thickness and lipid profile in macrosomic newborns.

Macrosomia is associated with alterations in lipoprotein composition and concentration at birth. Exposure to diabetes in utero has been established as a significant risk factor for some of the components of metabolic syndrome. The aim of this study was to investigate the effect of macrosomia on lipid metabolism, aortic intima-media thickness (aIMT) and subsequent atherogenic risk in newborn infants. Aortic intima-media thickness was measured in 40 macrosomic neonates of diabetic mothers (group A), 30 macrosomic neonates of healthy mothers (group B) and 30 healthy neonates (group C). Lipid profile was determined in all infants and their mothers. Mean aIMT was significantly higher in macrosomic neonates of diabetic and healthy mothers (0.56+/-0.06 and 0.49+/-0.03 mm respectively) than in controls (0.39+/-0.03 mm). Weight-adjusted aIMT in macrosomic neonates of diabetic mothers (0.129+/-0.013 mm/kg) was significantly higher than in groups B and C (0.114+/-0.008 and 0.113+/-0.011 mm/kg respectively). There were significant alterations of total serum, high-density lipoprotein (HDL), very low-density lipoprotein (VLDL) cholesterols and triglyceride levels in the macrosomic neonates of diabetic mothers compared with controls. Macrosomia was associated with increased lipid concentrations. Macrosomic neonates of diabetic mothers have significantly higher aIMT with lipid alterations. This may play a role in the pathogenesis of atherosclerosis in adult life.

The relationship among intrauterine growth, insulinlike growth factor I (IGF-I), IGF-binding protein-3, and bone mineral status in newborn infants.

Insulinlike growth factors (IGFs) exert profound effects on somatic growth and cellular proliferation of many tissues and play an essential role in bone metabolism. The aim of this study was to investigate how fetal growth and bone mineralization correlate with IGF-I and IGF-binding protein-3 (IGFBP-3) levels of newborn infants and their mothers. In addition, we aimed to determine the predictive value of anthropometric measurements on variability in bone mineral status. Umbilical cord venous blood samples were obtained at delivery from 100 term newborn infants. Forty of the newborn infants had birthweights appropriate for gestational age (AGA), 30 were small for gestational age (SGA), and 30 were large for gestational age (LGA). Data were acquired using whole-body dual-energy X-ray absorptiometry scanner with a pediatric platform. Umbilical cord serum IGF-I concentrations were higher in LGA newborns ( P < 0.01), but lower in SGA newborns ( P < 0.01) than in AGA newborns. Umbilical cord serum IGFBP-3 concentrations in LGA newborns were significantly greater than in SGA and AGA newborns ( P < 0.01 and P < 0.01, respectively). Whole-body bone mineral density (WB BMD) was higher in LGA babies (0.442 +/- 0.025 g/cm2 [SD]; P < 0.01) but lower in SGA (0.381 +/- 0.027 g/cm 2; P < 0.0001) than in AGA babies (0.426 +/- 0.022 g/cm2). WB BMD and content (WB BMC) were correlated significantly with birthweight, birth height, head circumference, body mass index (BMI) of the infants; ponderal index and triceps skinfold thickness (reflecting fat stores) of the infants; cord serum IGF-I concentration, serum IGF-I concentration of the mothers; and fat mass, proportionate fat mass, weight, and BMI of the mothers. In contrast, WB BMC was also correlated positively with cord serum IGFBP-3 concentration and gestational age, and WB BMD was positively correlated with serum IGFBP-3 levels of the mothers. Umbilical cord serum IGF-I concentration of the infants was correlated significantly with the concentration of the mothers ( R = 0.232; P = 0.020). Umbilical cord serum IGF-I and IGFBP-3 concentrations were correlated significantly with the fat mass, gestational age, birthweight, birth height, head circumference, and BMI of the infants. Umbilical cord IGF-I concentration was also correlated with ponderal index and triceps skinfold thickness of the infants, maternal weight, BMI, and proportionate fat mass of the infants. Stepwise multiple regression analyses showed no significant relation between bone indices (WB BMD, WB BMC) and the infant's or mother's variations including serum IGF-I and IGFBP-3 concentrations. Birthweight and gestational age are related to bone indices. However, the present study does not provide support for the hypothesis that serum IGF-I and IGFBP-3 levels of infants and their mothers may play a major role in the regulation of bone metabolism in the developing skeleton.

The relationship between birthweight, 25-hydroxyvitamin D concentrations and bone mineral status in neonates.

BACKGROUND: Calcium (Ca), phosphorus (P) and 25-hydroxyvitamin D (25-OHD) are the major micronutrients for fetal skeletal development. AIMS: To compare whole body bone mineral density (WB BMD) and bone mineral content (WB BMC) in different birthweights of term neonates and to determine correlations of biological criteria of bone health between neonates and their mothers. SUBJECTS AND METHODS: Serum Ca, P, alkaline phosphatase (ALP) and 25-OHD levels were measured in 30 small-for-gestational-age (SGA, group 1), 40 appropriate-for-gestational-age (AGA, group 2) and 30 large-for-gestational-age (LGA, group 3) neonates and their mothers in winter. WB BMD and WB BMC of neonates were estimated by dual-energy X-ray absorptiometry (DEXA) in the 1st 24 hrs after delivery. RESULTS: Mean (SD) serum 25-OHD levels in the mothers [8.7 (3.0), 8.6 (3.0) and 7.7 (2.8) microg/L, respectively] and their infants [6.3 (2.5), 6.0 (2.2) and 5.7 (1.8) microg/L, respectively] in groups 1, 2 and 3 were similar. Compared with the mothers, the mean 25-OHD levels of the neonates in all groups were significantly lower (p<0.05), and they were highly correlated (r=0.755, p<0.05). Ninety-three per cent of the neonates and 82% of their mothers had 25-OHD levels <10 microg/L, the lowest limit of normal. Mean (SD) WB BMD and WB BMC were higher in LGA infants [0.442 (0.025) g/cm(2), 71.6 (9.0) g, p<0.01, p<0.001, respectively] but lower in SGA [0.381 (0.027) g/cm(2), 29.1 (9.1) g, p<0.001, p<0.001, respectively] than in AGA infants [0.426 (0.022) g/cm(2), 53.7 (9.6) g, respectively]. The percentage of WB BMC was lower in SGA than in AGA and LGA infants. WB BMC and WB BMD were positively correlated with birthweight (r=0.910, p<0.05) and gestational age (r=0.707, p<0.05) but not with serum 25-OHD. CONCLUSIONS: The neonates' bone indices increased significantly with gestational age and birthweight but this was not related to serum 25-OHD levels in the infants and their mothers.

Brucellosis with pulmonary involvement in a premature infant.

Congenital brucellosis is rare. A premature infant with transplacentally acquired congenital brucellosis and pulmonary involvement is described.

Evaluation of serum cortisol levels in a relatively large and mature group of ventilated and nonventilated preterm infants with respiratory distress syndrome.

Severity of respiratory distress syndrome (RDS) and mechanical ventilation may affect the endogenous cortisol secretion in preterm infants. The aim of this study was to compare the serum cortisol concentrations of a relatively large and mature group of preterm infants with RDS who are ventilated or nonventilated and control preterm infants without RDS. Infants (group I) of comparable gestational ages without RDS served as controls. Infants with RDS who did not need ventilator support and surfactant therapy were considered to have mild RDS (group II). Those requiring mechanical ventilation and surfactant therapy were considered to have severe RDS (group III). Serum cortisol levels were determined after birth and on day 3 of life. The study groups consisted of 79 preterm infants with gestational ages ranging from 31 to 36 weeks, and birthweights ranging from 1086 to 1685 g. All preterm infants showed high cortisol levels after delivery regardless of respiratory distress (group I, n = 25, 34.1 +/- 10.7 microg/dL; group II, n = 23, 33.6 +/- 12.0 microg/dL; and group III, n = 31, 36.4 +/- 12.3 microg/dL). In group III, the cortisol levels (50.8 +/- 16.8 microg/dL) were higher than in group II (40.4 +/- 10.5 microg/dL) and in controls (22.0 +/- 7.2 microg/dL), and the cortisol levels of controls were lower than in group II on day 3 of life. Although the cortisol levels in severe and mild RDS infants increased significantly from their corresponding levels on day 1, they decreased in controls. The cortisol levels on day 3 of life were not significantly different in infants with poor outcome compared with infants with better outcome. Severity of RDS and mechanical ventilation were related to serum cortisol levels of preterm infants. Our study suggests that large and mature preterm infants who are ventilated and/or more severely ill release more cortisol than those less severely ill.

Effect of carbamezapine and valproic acid on bone mineral density, IGF-I and IGFBP-3.

OBJECTIVE: To examine the effect of carbamezapine and valproate on bone mineral density (BMD), IGF-I and IGFBP-3 levels in children. METHODS: The effects of at least 2 years valproic acid and carbamazepine therapy on BMD were evaluated in a cross-sectional and retrospective study. All children were ambulatory, prepubertal, and had normal activity and nutritionally adequate diets. Ambulatory epileptic patients were divided into two groups. Thirty-three patients (group 1; 17 boys, 16 girls; mean age: 8.8 +/- 2.0 years) were treated with valproic acid and 33 patients were treated with carbamazepine (group 2; 20 boys, 13 girls; mean age: 9.7 +/- 1.6 years). The control group consisted of 22 healthy children (13 boys, 9 girls; mean age: 8.9 +/- 2.3 years), who were age- and sex-matched with the patient groups. Children with metabolic bone disease, growth and neurological impairment, signs of malnutrition, or any chronic disease were excluded from the study. RESULTS: BMD values at lumbar spine in both the carbamazepine (-1.69 +/- 0.85 mean L1-4 BMD z-scores, mean 35.5 +/- 12.8 months treatment, and 19,478.6 +/- 6,301.3 mg/kg cumulative dose) and valproic acid (-1.28 +/- 0.80 mean L1-4 BMD z-scores, mean 33.7 +/- 15.0 months treatment, and 22,852.4 +/- 12,477.4 mg/kg cumulative dose) groups were significantly lower than that of the control group (-0.23 +/- 0.87 mean L1-4 BMD z-score). Serum ALP and PTH levels were significantly higher in the carbamazepine-treated group (65.4 +/- 21.1 pg/ml, 767 +/- 267 U/l, respectively) than those of the valproic acid-treated (39.1 +/- 12.8 pg/ml, 561 +/- 166 U/l, respectively) and control groups (36.3 +/- 4.9 pg/ml, 487 +/- 82 U/l, respectively). Serum 25-hydroxyvitamin D of the carbamazepine-treated group (9.8 +/- 3.2 microg/l) was significantly lower than the other groups (15.1 +/- 3.5, 16.6 +/- 4.7 microg/l, respectively). There were eight and 13 patients with plasma intact PTH above reference values in groups 1 and 2, respectively. Valproic acid and carbamazepine therapy results in a hyperparathyroid state and altered vitamin D metabolism, respectively. CONCLUSION: BMD values at lumbar spine were significantly reduced in both carbamezapine and valproic acid treated groups. Valproic acid and carbamazepine therapy do not change IGF-I and IGFBP-3 levels. Altering the hepatic conversion of vitamin D may be the mechanism of carbamazepine-associated reduction in BMD, but the mechanism of decreased BMD in valproate therapy remains unclear.

Blueberry muffin syndrome owing to congenital rubella: case report.

A case of congenital rubella is reported in a 22-day-old boy presenting with a 'blueberry muffin' rash. Late-onset blueberry muffin syndrome following congenital rubella is very rare.

Increased aortic intima-media thickness is related to lipid profile in newborns with intrauterine growth restriction.

BACKGROUND AND AIM: Low birth-weight is known to be associated with an increase in cardiovascular risk similar to that seen with major environmental risk factors, such as cigarette smoking or hypertension. Much epidemiological evidence has linked low birth-weight with hypertriglyceridaemia. METHOD: We measured aortic wall thickness by ultrasonography and lipid profile in 40 newborn babies with intrauterine growth restriction and 40 controls. RESULTS: Maximum and mean aortic intima-media thickness were significantly higher in the babies with intrauterine growth retardation (0.58 +/- 0.06, 0.52 +/- 0.03 mm, respectively) than in controls (0.44 +/- 0.05, 0.40 +/- 0.03 mm, p < 0.0001, p < 0.0001, respectively), more so after adjustment for birth-weight (maximum intima-media thickness: 0.23 +/- 0.03 mm/kg vs. 0.12 +/- 0.02 mm/kg, p < 0.0001; mean intima-media thickness: 0.21 +/- 0.02 mm/kg vs. 0.11 +/- 0.01 mm/kg, p < 0.0001). Serum triglyceride levels were significantly higher in the intrauterine growth retardation group (48.9 +/- 14.8 mg/dl) compared with the control group (32.5 +/- 9.8 mg/dl, p < 0.0001). The mean body mass index, prepregnancy weight, weight gain during pregnancy, maternal LDL cholesterol level and, height of the mothers were significantly lower in the intrauterine growth retardation group compared with the control group. For maximum aIMT, significant associations included the ponderal index (p = <0.01), length (p = 0.01) and serum triglyceride levels of infants (p = 0.02). CONCLUSION: Newborn babies with growth restriction have significant maximum aortic thickening with hypertriglyceridaemia, suggesting that prenatal events might predispose to later cardiovascular risk.