Hand, Foot, and Mouth Disease in Children: Clinical Characteristics of an Outbreak in Novi Sad, Serbia.

Hand, foot, and mouth disease (HFMD) is a relatively common mild viral infection that usually affects young children, mainly occurring during the late spring, early summer, and fall months. It is most commonly caused by members of the human enterovirus (HEV) genus. Recently, HFMD has received renewed attention because of evidence that this disease could have clinical, epidemiological, and etiological characteristics different from those initially associated with it. HFMD may be associated with neurologic or cardiopulmonary complications and can, rarely, lead to death. Our study was a retrospective analysis on 83 children (<18 years of age) who were clinically diagnosed with HFMD at the Department of Dermatology of the Institute for Child and Youth Health Care of Vojvodina, in a single, tertiary-care university hospital in Novi Sad, Vojvodina province, Serbia, for the time period from January 2016 to December 2017. During the study period, HFMD was diagnosed in 83 children. Our results suggest that the outbreak of HFMD occurred in younger children (average age 3.10 years), who seem to be the most susceptible age group for HFMD infection. Taking into account that the diagnosis of HFMD is usually clinical, we believe that it is important for health professionals to be well-informed about the clinical features and the course of the disease. Good personal hygiene and the implementation of a surveillance system can help stop the spread of the disease and prevent outbreaks.

Multifocal Infantile Hemangioma - Presentation of 4 Cases and Review of the Selected Literature.

BACKGROUND: Multifocal infantile hemangiomas (IHs) are focal cutaneous lesions affecting more than 1 anatomic site. The multifocal distribution pattern is the rarest form of IH manifestation, accounting for only 3-4% of all affected infants. This type of cutaneous IHs may be a marker for extracutaneous disease, with the liver being the most frequently affected organ. METHODS: We investigated the clinical and epidemiological characteristics of a small case series of infants with multifocal IHs presenting with different clinical patterns, all diagnosed and treated in a regional tertiary-care pediatric clinic. RESULTS: Four infants with multifocal IHs were included in the analysis. There were 3 girls and 1 boy. Three out of 4 infants were prematurely born (2 of them very preterm), while only 1 was full-term. Clinical patterns in all cases were quite different, but more than 20 cutaneous IHs were present in each of the patients. Two infants had multifocal liver hemangioma, but without complications. In 3 out of 4 patients, systemic propranolol therapy was introduced, with excellent response in two cases (both with liver involvement). CONCLUSION: With the increase in the number of cutaneous IHs, the probability of internal organ involvement, most often the liver, also increases. Evaluation for extracutaneous lesions is indicated in infants with 5 or more cutaneous IHs. Treatment of infants with multifocal IHs should be individualized and consider all relevant risk factors, including prematurity.

Infantile Hemangiomas with Minimal or Arrested Growth - Do They Occur More Often in Premature Infants Than It Seemed?

Infantile hemangiomas with minimal or arrested growth (IH-MAGs) are a subtype of infantile hemangiomas (IHs), characterized by absent or minimal (equal or less than 25% of the total IH surface area) proliferation. They are less conspicuous than classical IHs, but can also be complicated by ulceration or can be misdiagnosed as capillary malformations. The literature on IH-MAGs is scarce, but with increasing interest in the literature. We investigated the clinical and epidemiological characteristics of IH-MAGs in a retrospective series of cases found in a regional tertiary-care pediatric clinic during a 7-year period. Eleven infants with 14 IH-MAGs were included in the analysis. There were 7 girls and 4 boys. Unlike the majority of other authors, we have found 7 premature and 4 full-term infants in our case series. Most of the IH-MAGs were classified as focal (78.57%), were present at birth (72.72%), and were located on the lower body, below the waist line (71.42%). In almost all infants, erythematous background as well as vasoconstricted patches and/or halos were present, while fine or coarse telangiectasias were observed mainly in full-term infants. A subtle proliferative component was observed in only one case on follow-ups. There were no ulcerations. The therapy - topical and oral beta-blocker - was introduced in two cases of IH-MAGs in the face region. Clinical characteristics of IH-MAGs in our case series were similar to those found in other studies on this subject. However, we found a significantly higher percentage of premature infants with IH-MAGs than in any available reference.

Iatrogenic Anetoderma of Prematurity: A Series of 5 Clinical Cases and Literature Review.

Iatrogenic anetoderma of prematurity (IAOP) represents a benign iatrogenic dermatosis characterized by focal, well-demarcated areas of atrophic skin in preterm infants. We present the cases of 5 infants diagnosed with IAOP during a 3-year period in a tertiary-care university hospital. Skin atrophy patches were absent at birth in all presented infants, and there was no family history of anetoderma. All of the infants were born with very low gestation and birth weight, with a clinical course that was complicated with several serious prematurity-related complications with consequent long periods of unstable vital functions and the need for continuous monitoring. Skin defects consistent with IAOP were located on the previous ECG electrode sites. IAOP changes in all the infants were in the form of oval patches of skin atrophy in the middle chest region, with an additional few small, round patches bellow the nipple on both sides in one girl. Diagnosis of IAOP was based on characteristic clinical findings. IAOP is rare, benign, but permanent skin injury in the most immature of infants, with a potential for considerable aesthetic and psychological burden. Due to the constant increase in survival of very and extremely preterm infants, more often without major developmental consequences, milder complications like IAOP will become more and more important.

Major risk factors for chronic venous disease development in women: is childbirth among them?

Many studies have reported that Chronic venous disease (CVD) occurs more in females than males, due to pregnancy. The study was conducted over the period 2014-2015 at the Dermatovenereological clinic, Novi Sad, Serbia. We performed a cross-sectional study of 554 women. According to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) staging, the sample was divided into three groups: Mild CVD (classes 1-3 by CEAP) - n = 72; Severe CVD (classes 4-6 by CEAP) - n = 122 and a Control (no CVD) - n = 360 patients. The age range of participants was 18 to 93 years (average 54.92 years). Most important CVD risk factors were examined in detail. Out of 554 examinees, 22.03% had severe CVD, and 12.99% had mild CVD. Bivariate analyses showed a significantly higher proportion of women who had deliveries in the severe CVD and mild CVD groups, compared with the control group. Other significantly related factors were older age, family history of varicose veins, standing job position and hypertension. After performing multiple logistic regression analysis, older age, standing job position and family history of varicose veins remained significant, while childbirth lost its significance. Our results suggest that childbirths are not associated with the occurrence of CVD.

Frequency of Peripheral Arterial Disease in Patients With Chronic Venous Insufficiency.

BACKGROUND: It is estimated that about 15% (10% - 30% in most of the studies) of the total adult population has some aspects of the Chronic Venous Insufficiency (CVI). Frequency of the Peripheral Arterial Disease (PAD) in the adult population is 3% - 4%. Studies dealing with etiopathogenesis of leg ulcers show that between 10% and 18% of all ulcers are of mixed, arterial-venous origin. OBJECTIVES: The purpose of this study was to find out if there is a higher frequency of PAD among CVI patients in comparison with the control group, as well as to discover some common risk factors for CVI and PAD. PATIENTS AND METHODS: This cross-sectional descriptive study was conducted at the dermatovenereological clinic, clinical center of Vojvodina, Serbia. A total of 162 examinees were included. All patients were examined for the existence of CVI and staged according to CEAP (Clinical, etiology, anatomy and patophysiology) classification. In this way, 3 groups were formed: Patients with the mild forms of CVI (stage 1 - 4 by CEAP classification), 57 patients; patients with the severe forms of CVI (stage 5 and 6 by CEAP classification), 55 patients; control group (no CVI), 50 patients. Also, the Ankle Brachial Pressure Index (ABPI) was assessed in all subjects, and its value of ≤ 0.9 was set as criteria for diagnosis of PAD. The same sample was divided according to the presence of PAD into two groups. The most important risk factors for CVI and PAD were identified for each patient through complete examination, medical record and appropriate questionnaire. RESULTS: Our results showed that the risk factors for CVI were high Body Mass Index (BMI), hypertension, predominantly standing position during work and positive family history for CVI. In the same sample it was found that 28 (17.28%) patients had PAD. Relevant risk factors for PAD in the present study were: high BMI, hypertension, diabetes and a positive family history for PAD. Comparison of frequency of PAD among patients with severe forms of CVI and control group showed that this difference was statistically significant (P = 0.0275; OR 3.375; 95% CI 1.125 - 10.12). After multivariate analyses, adjusted odds ratio OR was still statistically significant. CONCLUSIONS: The peripheral arterial disease is more frequent in patients with the severe form of CVI, than in patients without CVI. Concomitant risk factors for CVI and PAD were high BMI and hypertension. In each patient with severe CVI it is necessary to determine the ABPI, in order to exclude the presence of PAD.

Drug-related pityriasis rubra pilaris with acantholysis.

INTRODUCTION: Acantholysis is rarely reported histological feature of Pityriasis rubra pilaris (PRP), recently recognized as having diagnostic specificity for differentiating PRP from psoriasis. CASE REPORT: Adult male patient one week after the introduction of simvastatin had experienced pruritic erythemo-squamous eruption on head and upper trunk that in a month progressed to erythrodermia, with islands of sparing. Histological picture combined pemphigus-like acantholysis with alternating hyper- and parakeratosis, follicular plugs and dermal inflammation, and confirmed the clinical diagnosis of classic adult type 1 PRP. Acitretin therapy resulted in a resolution of skin disease. Patch test with simvastatin was negative, scratch test was positive, and it was estimated that potential risk of oral challenge with simvastatin outweighed actual need for it. Drug triggering PRP episode is the most likely explanation for temporal relation between the start of simvastatin treatment and skin eruption. CONCLUSION: In management of rare inflammatory skin disease, such as PRP, we have to carefully observe and evaluate not only diagnostic features but possible external influences on its course also.

Epidemiological and clinical features of erythema infectiosum in children in Novi Sad from 2000 to 2009.

BACKGROUND/AIM: Erythema infectiosum (EI) is a common childhood illness, caused by human parvovirus B19. It occurs sporadically or in epidemics and is characterized by mild constitutional symptoms and a blotchy or maculopapular lacy rash on the cheeks (slapped-cheek) spreading primarily to the extremities and trunk. The aim of our study was to analyse the epidemiological and clinical characteristics of erythema infectiosum in children. METHODS: This study included 88 children observed in the Department of Dermatology of the Institute for Child and Youth Health Care of Vojvodina, in Novi Sad, during the period January 2000-December 2009. We compared the data about the clinical characteristics during and after the outbreak of EI observed from December 2001 to September 2002. The data were retrieved from the hospital database. RESULTS: During the study period, EI was detected in 88 children (44 females and 44 males), 0.213% of the total number of 41,345 children observed in the Department of Dermatology. An outbreak of erythema infectiosum was observed from December 2001 to September 2002, with the peak frequency in April and May 2002 and 39 diagnosed cases, and stable number of cases from 2005 to 2009 (a total of 49 diagnosed cases). The average age of infected children was 7.59 +/- 3.339. Eleven (12.5%) children were referred from primary care pediatricians with the diagnosis of urticaria or rash of allergic origin. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of the cases, followed by 89.77% of cheek erythema. Pruritus was present in 9.09% of the children, mild constitutional symptoms in 5.68% and palpable lymph glands in 3.41% of the children. In all the cases the course of the disease was without complications. CONCLUSION: The results of this study confirm the presence of EI (the fifth disease) in our area with a mild course in the majority of patients. Since the diagnosis of EI is usually based on clinical findings, continuing medical education of primary health care pediatricians is essential for reducing the number of misdiagnosed cases.

Recurrent infections and cows-milk hypersensitivity in a 2-year-old girl with hyper immunoglobulin E syndrome.

The hyperimmunoglobulin E syndrome is a rare complex primary immunodeficiency characterized by high serum IgE levels, eczema, and recurrent infections. We present a case of 2-years-old girl with eczema and repeated bacterial skin and lung infections since the period of infancy. The patient also had eosinophilia, high serum levels of IgE, and cows-milk hypersensitivity. We describe the case, in order to illustrate the difficulty of establishing the diagnosis hyper-immunoglobulin E syndrome in a toddler.

Vitiligo and thyroid dysfunction in children and adolescents.

The link between vitiligo and thyroid disease has been proved in adult patients. The aim of our study was to assess the prevalence of thyroid dysfunction in children and adolescents with vitiligo and to identify any predisposing factors of this association. This retrospective study included 75 children and adolescents with vitiligo: 47 (62.66%) females and 28 (37.33%) males. Physical examination, thyroid ultrasonography and laboratory parameters of thyroid disease were performed in all study subjects. Various degrees of thyroid parameter alterations were found in 19 (25.33%) of 75 patients. Hashimoto's thyroiditis associated with non-segmental vitiligo was present in 11 (14.66%) patients. The most common site of vitiligo onset in patients with Hashimoto's thyroiditis were upper limbs, which was significantly more frequent compared with patients without Hashimoto's thyroiditis (χ(2); P<0.05). Since vitiligo usually appears before the development of thyroid disease, it may be useful to screen the children and adolescents with vitiligo for thyroid autoantibodies.

[Papular-purpuric gloves and socks syndrome--a case report].

INTRODUCTION: Papular-purpuric gloves and socks syndrome is a rare manifestation associated with acute seronegative arthritis and skin lesions. It is triggered by a viral infection, most commonly by Human parvovirus B19 or Coxsackie group of viruses, but precise viral diagnosis is not obtained in all cases. CASE REPORT: A 54-year old male patient experienced sudden, intense pain and swelling in the carpal area of his left hand. He also presented with unusual skin lesions, and grouped small purpuric-papules on the dorsal side of the left hand. During the next few days, both feet were similarly affected. In the next four weeks, a transient liver damage occurred, with a moderate increase in liver enzymes. Apart from elevated erythrocyte sedimentation rate and fibrinogen levels, other findings were within normal limits (complete blood and reticulocyte count, parameters of rheumatic and autoimmune diseases, abdominal ultrasound scan, radiographs of the chest and of affected hand and feet joints, urethral smears for isolation of trichomonas, yeasts and chlamydia trachomatis, and Syphilis, Borrelia, Toxoplasmosis, and Mycoplasma pneumoniae serology). Apart from positive tests for HPvB19, other viral serology tests were all negative (Coxsackievirus, Adenovirus, Influenza, Hepatitis B and C virus, HIV). The skin lesions resolved in about three weeks, the intensity of joint pain decreased, but lasted for the next 6 months. CONCLUSION: The diagnosis of papular-purpuric gloves and socks syndrome was made on the basis of the characteristic clinical picture, and confirmed by virus serology.

Erythema infectiosum in children. A Clinical study.

Erythema infectiosum is a childhood illness characterized by mild constitutional symptoms and a blotchy or maculopopular lacy rash on the cheeks (slapped - cheek) spreading primarily to the extremities and trunk. The disease is caused by human parvovirus B19. Erythema infectiosum epidemics occur in a cyclic fashion, mostly during winter and spring months. The diagnosis of erythema infectiosum is usually based on the appearance and pattern of the rash. The aim of our study was to establish the frequency and clinical characteristics of erythema infectiosum in children, in the period between 2000 and 2004 at the Institute of Child and Youth Health Care, Department of Dermatology, Novi Sad There were 0.23% of children with a clinical picture of infectious erythema. There was an outbreak of erythema infectiosum from December 2001 to September 2002. The highest number of cases was detected in April and May of 2002 from 2003 to 2004, no cases with infekctious erythema were diagnosed. The average age of injected children was 7.38. Female children were affected slightly more often than male (56.41% : 43.58%). Pruritus was detected in 10.26% of children. The most constant clinical sign was reticular exanthema on the limbs, present in 100% of cases, jollowed by 89.74% of cheek exanthema, while limb and trunk exanthema was present in 7.68% of children. Adenopathies and mild constitutional symptoms were present in 5.12% of children. No complications were recorded in any of the cases.

[Some psychological characteristics of children and adolescents with vitiligo--our results].

INTRODUCTION: Numerous studies have characterized patients with chronic skin disease as psychologically vulnerable, mainly due to the fact that their condition affects their social relations and all other aspects of life. The purpose of this work was to determine whether there are significant differences in the level of anxiety, severity of depressive symptoms, and presence of stressful life events between adolescent patients with vitiligo and healthy peers. MATERIAL AND METHODS: 33 patients with vitiligo aged 10-15 years, and a control group of 60 healthy subjects of the same age, were included in this prospective study. A clinical examination was performed to determine the clinical types of vitiligo, estimate depressive symptoms using the Birleson Depression Scale, and anxiety was evaluated by the Spielberger's scale (State-Trait Anxiety Inventory). For determination of the frequency of stressful events, the Risk Scale was used. RESULTS: Adolescents with vitiligo did not show more pronounced signs of anxiety or depression than healthy subjects; differences were not apparent in the Risk Scale either, considering stressful events. DISCUSSION AND CONCLUSION: The lack of differences between the two examined groups might be due to prepubertal age of the majority of subjects. 63.63% of all children included in this study were in the prepubertal age (10-12 years), which is the period when they are still not focused on their own body and changes to physical appearance. It is possible that early onset of vitiligo is a "protective factor", enabling the child to attain compensatory mechanisms to solve the problem of vitiligo through various interests and aspirations, which do not depend on physical appearance.

[Autoantibodies in children with vitiligo]. / Autoantitela kod dece obolele od vitiliga.

INTRODUCTION: Vitiligo is an acquired, sometimes familial skin depigmentation disorder. In about half of patients it occurs before the age of twenty. The aim of this study was to investigate the incidence and significance of autoantibodies (AT) and associated autoimmune and endocrine diseases in children with vitiligo, in relation to adults with vitiligo and children without vitiligo. MATERIAL AND METHODS: The research was conducted in fifty children with clinically diagnosed vitiligo from 2 to 16 years of age. Children were compared with control groups of children with other skin diseases (aged from 2 to 16) and with adults with vitiligo. Each group comprised 30 patients. A detailed history was obtained and physical examination was performed in each patient to determine presence of autoimmune and endocrine diseases in patients with family history of vitiligo. Routine blood examination, routine urinalysis and stool were performed in all patients. We evaluated the incidence of antinuclear (ANA) and antithyroid antibodies (ATA) in each patient, as well as the incidence of antibodies to gastric parietal cell (APCA), smooth muscle (SMA), cord (ACA) and mitochondrial antigens (AMA) in 38 children with vitiligo and in control groups. RESULTS: Children with vitiligo had positive family history of vitiligo more often compared to children without vitiligo (p<.05). Presence of ANA, ATA, APCA, SMA, ACA and AMA was not considerably increased in children with vitiligo compared with their age group. ANA was more common in adults with vitiligo, in comparison with children with vitiligo (p<0.05). None of the children with vitiligo had an associated autoimmune and endocrine disease in contrast to adults with vitiligo (p<0.05). DISCUSSION AND CONCLUSION: Several studies have shown a significant incidence of positive autoantibodies in children with vitiligo, compared to children without vitiligo. However, in our series, presence of ANA, ATA, APCA, SMA, ACA and AMA was not significantly increased in children with vitiligo, compared with children without vitiligo. Further studies are necessary in this area in order to draw more conclusions. In the previous studies, it has been established that children with vitiligo were generally healthy, whereas adults with vitiligo had an increased incidence of autoimmune and/or endocrine diseases. No studies have shown this association in children with vitiligo. Our results support findings of previous studies.

[Vitiligo in childhood]. / Vitiligo u decjem uzrastu.

INTRODUCTION: Vitiligo is an acquired, sometimes familial skin depigmentation disorder due to selective destruction of melanocytes. Vitiligo is primarily a disease of the young; in about half of patients it occurs before the age of twenty. The aim of this study was to investigate some epidemiological and clinical characteristics of vitiligo in children, in relation to adults with vitiligo and children without vitiligo. MATERIAL AND METHODS: The research was conducted in fifty children with clinically diagnosed vitiligo (2 to 16 years of age). Children were compared with control groups of children with other skin diseases (age 2 to 16) and with adults with vitiligo. Each group comprised 30 patients. A detailed history was obtained and physical examination performed in each patient to determine the age of onset, clinical type (segmental or generalized), family history of vitiligo and other autoimmune and/or endocrine diseases, association with halo nevi, poliosis and Koebner phenomenon. RESULTS: Of the 50 children with vitiligo, 29 (58%) were girls and 21 (42%) boys. The mean age at first visit was 9 years and the mean age of onset was 7 years. Children with vitiligo had positive family history of vitiligo and autoimmune and endocrine diseases more often compared to children without vitiligo (p < 0.05). Children with vitiligo had poliosis, especially in cases of segmental vitiligo, more often compared to their age group (p < 0.001). Children had an increased incidence of segmental vitiligo compared to adults (p < 0.05). Halo nevi were more common in children with generalized vitiligo, in comparison with children without vitiligo (p < 0.01) and adults with vitiligo (p < 0.05). DISCUSSION AND CONCLUSION: Our results show that segmental vitiligo and halo nevi occurred significantly more often in children than adults with vitiligo.