Thromboembolic complications in children with nephrotic syndrome in Bulgaria (1974-1996).

Over a period of 22 years, 447 children with nephrotic syndrome (NS) have been retrospectively studied for clinically apparent thromboembolic complications (TEC). The incidence of TEC is 2% (9/447); 16 clinically apparent TEC were registered in 9 children. The incidence of TEC was 1.5% among patients with steroid-sensitive NS and 3.8% among those with steroid-resistant NS. TEC were predominantly venous (81% venous vs. 19% arterial). The most commonly affected vessels were deep leg veins, followed by inferior vena cava (IVC). Rare locations of TEC were also observe--superior vena cava (SVC), mesenteric artery, IVC, and hepatic veins with the development of Budd-Chiari syndrome. Depending on the location of the TEC, imaging techniques used were: X-ray, computed tomography, and Doppler sonography. The major iatrogenic risk factor was furosemide, administered to 7 of the 9 children with TEC. In some patients additional predisposing factors were infections, dehydration, trauma, venepuncture, and immobilization. Treatment with heparin was followed by oral anticoagulation. Fibrinolytic therapy was effective in 3 of 4 patients. No new TEC occurred under oral anticoagulant prophylaxis. The outcome was a full recovery in 6 patients and a partial recovery in 1 patient. Two children died--1 with SVC thrombosis and the other with recurrent TEC affecting cerebral vessels. Although rare, TEC are among the most serious life-threatening complications in children with NS and require intensive care.

Budd-Chiari syndrome and inferior vena cava thrombosis in a nephrotic child.

We observed Budd-Chiari syndrome in a boy aged 2 years 6 months with nephrotic syndrome due to hepatic vein and inferior vena cava thrombosis, confirmed by Doppler imaging. Normal values of the routine hemostatic parameters proved that they are of little predictive value for the thrombotic state. Immediate heparin infusion was initiated. High doses of heparin up to 59 IU/kg per hour were required for efficient anticoagulation. A remission of the nephrotic syndrome was achieved with vincristine. Oral anticoagulation with a vitamin K antagonist was continued for 6 months. Doppler imaging then indicated full re-establishment of the blood flow through the affected vessels. The clinical and Doppler data in this case are compatible with acute Budd-Chiari syndrome due to incomplete outflow obstruction of the hepatic veins and inferior vena cava. The favorable outcome was due to the immediate heparin infusion and prompt remission of the nephrotic syndrome. Doppler imaging was an important tool for non-invasive diagnosis and follow-up.

[Subphrenic abscess and suppurative pericarditis as complications in children with perforated appendicitis]. / Kum vuprosa za subfrenichniia abstses i gnoiniia perikardit kato uslozhnenie pri detsa s perforativen apenditsit.

The combination of subphrenic abscess with purulent pericarditis is a rare postoperative complication of perforated appendicitis in children, with severe clinical course, difficult to diagnose and high case fatality rate. A 7-year-old child with this complication, successfully diagnosed and treated is reported. The importance of complex therapy--surgical and intensive and collaboration between pediatric surgeons, anesthesiologists, cardiac surgeons and cardiologists for the favourable outcome is emphasized.

Heart murmurs in low birth weight infants.

This study is based on 315 infants in different prematurity stages who were patients in the Special Care Unit for Preterm Infants at the First City Hospital, Sofia. Heart murmurs were observed in 98 infants. The clinical observations and investigations can be grouped as follows: 1) murmurs due to late closing or reopening of ductus arteriosus; 2) murmurs in patients with anemia; 3) murmurs in patient with anemia; and 4) accidental murmurs. The study is focused on the high percentage of heart murmurs in low-birth weight infants during the post-adaptation period.