Imaging of pyelonephritis.

OBJECTIVE: Accurate diagnosis of pyelonephritis using clinical and laboratory parameters is often difficult, especially in children. The main aims of this prospective study were to compare the value of different imaging techniques [renal sonography, cortical scintigraphy with technetium-99m dimercaptosuccinic acid (99mTc DMSA) and computed tomography (CT)] in detecting renal involvement in acute urinary tract infections and to determine the sensitivity of DMSA scans for permanent renal scars 6 months later. MATERIALS AND METHODS: Between February 1992 and January 1993, 55 children admitted to our pediatric unit with febrile symptomatic urinary tract infections were eligible for analysis. Ultrasonography (US), DMSA scanning and micturating cystourethrography were performed in every case. Only 18 children underwent CT. A second DMSA scan was performed in 48 children a mean of 7.5 months after the first. RESULTS: US abnormalities were found in 25 children (45 %). The first DMSA scan showed a parenchymal aspect suggestive of pyelonephritis in 51 patients (93 %). Among the 18 patients studied by CT, 14 had abnormalities. Normal US findings did not rule out renal parenchymal involvement. Scintigraphy appeared to be more sensitive than CT for renal involvement. The frequency and degree of initial renal parenchymal damage seemed to correlate with vesicoureteral reflux, but the most severe initial parenchymal defects were not associated with marked clinical or laboratory manifestations. Repeat DMSA scans, performed on 45 kidneys with abnormalities at the first examination, showed resolution in 19, improvement in 16, persistence in 8 and deterioration in 2. The prevalence of vesicoureteral reflux was not higher in patients with renal scarring on the second DMSA scan than in patients whose scans showed an improvement. CONCLUSION: DMSA scans should be considered as a reference in the detection and follow-up of renal scarring associated with acute urinary tract infection as this technique is more sensitive than US and CT, the latter being unsuitable because it entails radiation exposure and sedation of patients.

[Citrullinemia: management and clinical course. Apropos of a familial case]. / La citrullinémie: prise en charge et évolution. A propos d'une observation familiale.

The authors report two cases of citrullinemia in siblings which add to 68 observations from the literature. They overview the clinical presentation, diagnosis and therapeutic management of the disease. The prognosis of severe neonatal form remains poor but an early adequate management may contribute to an acceptable outcome.

[Evaluation of urinary calcium/creatinine ratio in premature and full-term newborn infants]. / Evaluation du rapport calcium/créatinine urinaire chez le nourrisson et le nouveau-né à terme et prématuré.

Urinary calcium/creatinine ratio (U Ca/creat) was studied in infants, term and preterm newborn babies. In 31 1.5-24 months old healthy infants, the median U Ca/creat was 0.16 mmol/mmol (range 0.013-1.17) and was similar to the value obtained in children older than 4 years. In 55 healthy full-term newborns studied in the first week of life, the median U Ca/creat was 0.12 mmol/mmol. However the range of values was extremely wide (0.0006-4.75), suggesting that the U Ca/creat ratio is of little interest to screen for hypercalciuria during the neonatal period. In 31 premature newborns, the median U Ca/creat was 1.08 mmol/mmol, a value significantly higher than in the two other groups (P < 0.001); as in the term newborns there was a very wide range of values (0.057-6.83). However after excluding the premature babies with elevated serum 25 OHD level, this difference was not statistically significant.

[Intracranial venous sinus thrombosis in nephrotic syndrome]. / Thrombose des sinus veineux intracrâniens au cours d'un syndrome néphrotique.

A 3-year old child was admitted for a third relapse of nephrotic syndrome associated with intracranial hypertension related to dural sinus thrombosis (tomodensitometry). The treatment consisted in the association of low dose heparin and fresh frozen plasma. After a 3 year-follow-up, there was no neurologic sequelae, and the nephrotic syndrome was on complete remission. The radiologic features and the management of sinus thrombosis are discussed.

[Iron deficiency in infants and children]. / Carence martiale chez le nourrisson et l'enfant.

A study of the incidence of iron deficiency and its risk factors was carried out in 90 hospitalized or outpatient children and infants, 4 to 48 months old. Iron deficiency (serum iron concentration less than 10 mumol/l) was found in 70% of them and microcytosis (mean corpuscular volume less than 70 fl) in 10%. A good correlation was observed between hemoglobin concentration or mean corpuscular volume, and serum iron or ferritin concentrations. When risk factors were studied, 20% of the children were found to have insufficient meat or vegetable intakes. Only 45% of 6 month-old and 20% of 1 year-old infants received iron fortified milk formulas. However no significant correlation was found between the nutritional factors and the hematological data. Anemia and microcytosis were significantly more frequent in children born from immigrant parents as compared with native children, but there was no difference between these two groups for isolated iron deficiency. These results indicate that there is a need for a better prevention of iron deficiency in French infants and young children; a larger use of iron fortified milk formula until the age of 12 months is to be recommended.

[Congenital tubulopathy with magnesium loss]. / Tubulopathie congénitale avec fuite de magnésium.

The authors report on a 1-year old girl who presented with transient hypotonia and polydipsia related to renal-concentrating defect. Renal magnesium and calcium wasting were noted when the subject was 3.5 years old, in association with distal tubular acidosis and nephrocalcinosis. Hypocalcemia and hypomagnesiemia persisted when the patient was 9.5 years old. About 50 cases of tubular defects with renal magnesium loss have been reported in the literature and show that magnesium loss may be either isolated or associated with potassium and/or calcium wasting. This hereditary defect may be due to an alteration in magnesium reabsorption in the thick ascending limb of the loop of Henle.

[Comparative study of 24-hour calciuria and urinary calcium/creatinine ratio in children over 4 years of age]. / Etude comparative de la calciurie de 24 heures et du rapport calcium/créatinine urinaire chez l'enfant de plus de 4 ans.

The relationship between 24 hour urinary calcium excretion (U Ca/24 h) and urinary calcium/creatinine ratio (U Ca/creat) measured for morning and evening urine samples was studied in 56 children aged 4-15 years and hospitalized for benign conditions. Depending on the length of hospitalisation, 1 to 3 determinations of U Ca/24 h and U Ca/creat ratio were carried out for each child. Mean +/- SD U Ca/24 h was 0.05 +/- 0.058 mmol/kg. Mean U Ca/Cr, expressed in mmol/mmol, was 0.368 for total 24 h urine, 0.358 for the morning sample and 0.358 for the evening sample respectively. A good correlation was found between U Ca/24 h and 24 h U Ca/Cr ratio (r = 0.89), morning U Ca/creat (r = 0.83) and evening U Ca/creat ratio (r = 0.81) respectively. It is concluded that determination of the U Ca/Cr ratio for morning or evening urine samples is an efficient means of detecting hypercalciuria.

[Endoscopic extraction of a foreign body from the distal bronchus in the middle lobe, inaccessible by usual techniques, in a 3-year old child]. / Extraction par voie endoscopique d'un corps étranger distal du lobe moyen inaccessible par les techniques habituelles chez une enfant de 3 ans.

The authors report on the extraction of a piece of peanut impacted into the antero-internal bronchus of the right middle lobe, inaccesible to rigid bronchoscopy. After 4 months, this foreign body was visualised by flexible endoscope and removed by this technique under general anesthesia. We initially used a brush to pull the foreign body out of the distal bronchus and then used a biopsy forceps to remove it. Three months later, the chest-X-ray is normal and the child is asymptomatic.

[Hemolytic uremic syndrome and febrile urinary Escherichia coli infection]. / Syndrome hémolytique et urémique et infection urinaire fébrile à Escherichia coli.

The authors report on 2 cases of hemolytic uremic syndrome in 2 infants during a febrile Escherichia coli urinary tract infection. They discuss the role of urinary tract infection in the occurrence of hemolytic uremic syndrome and the possible role of specific Escherichia coli strains.

[Serum concentrations of 25 hydroxyvitamin D in hospitalized infants. Relation to calciuria]. / Taux sériques de 25 hydroxyvitamine D chez les nourrissons hospitalisés. Rapport avec la calciurie.

In attempt to evaluate the vitamin D status of the infants of our area under the mode of prophylaxis of carential rickets actually used in France, serum 25 hydroxyvitamin D (25 OHD) levels were measured in 65 infants (age 3 - 32 months) during their hospitalisation for acute illness. Most infants were receiving vitamin D either in daily doses (1,200 - 1,600 u) or in unique loading doses (200,000 - 600,000 u every 4 - 6 months). With this prophylaxis serum concentrations of 25 OHD were elevated, i.e. above 75 nmol/l, in more than 50% of the infants, reaching 474 nmol/l in one case. Calciuria estimated by the calcium/creatinine urinary ratio tended to increase in parallel with the serum 25 OHD level. From these data it is concluded that the actual prophylaxis of carential rickets in France frequently uses excessive doses of vitamin D and that new rules have to be established.

[Familial nephrogenic diabetes insipidus with chronic hypernatremia and cerebral calcifications]. / Diabète insipide néphrogénique familial avec hypernatrémie chronique et calcifications cérébrales.

The authors report on the unusual evolution of two brothers suffering from nephrogenic diabetes insipidus after a 25-year follow-up. The polyuro-polydipsic syndrome was clinically well tolerated, without acute complications even during infancy. However, despite the lack of water restriction and the presence of thirst sensation, the children remained chronically hypernatremic. An intellectual deficiency was present, with a dysmorphic syndrome unrelated to a biochemically determined central nervous system disorder, or an X fragility. Calcifications of basal ganglia and frontal lobes were discovered on a cerebral computed tomography performed at 16 and 18 years. This syndrome may represent a specific entity.

[The role of immunosuppressive agents in the treatment of nephrosis in children]. / Place des immunosuppresseurs dans le traitement de la néphrose de l'enfant.

Good clinical results are well known with the use of immunosuppressive therapy in children with idiopathic nephrotic syndrome; more recently, biological data have enhanced immunological anomalies, concerning mainly T helper lymphocytes. The need for steroids may decrease when relapsing nephrotic syndrome is associated with steroid intoxication and is absent when corticoresistance occurs. In these cases, the use of immunosuppressive agents is justified, but limited by side effects and toxicity. In patients treated with alkylating agents and now cyclosporine, good responses are often seen in frequently relapsing children whereas the course of steroid-resistant nephrotic syndrome is not significantly modified. However, the definite appreciation of such therapeutic results has to be further precised by both histological data and multicentric studies concerning new protocols.

[Transient neonatal hypothyroidism in a neonate born of a mother with Hashimoto's thyroiditis]. / Hypothyroïdie transitoire néonatale chez un nouveau-né de mère présentant une thyroïdite de Hashimoto.

Transient neonatal hypothyroidism was found in a boy whose mother was treated for hypothyroidism due to Hashimoto's thyroiditis. During the neonatal period the infant had antithyroid microsomal and antithyroglobulin antibodies and immunoglobulins inhibiting cyclic AMP production by thyroid cells in vitro. After one year of treatment, all antibodies disappeared. Thyroid scintiscan and fixation in the neonatal period was negative and became positive 2 months after stopping treatment with normal fixation and cervical thyroid picture. The mother's serum contained the same antibodies: they crossed the placental barrier and were responsible for neonatal pathological manifestations.

[Hypoglycemia and hyperlactacidemia in relation with a new case of fructose-1,6-diphosphatase deficiency. Determination of enzymatic activity in leukocytes]. / Hypoglycémie et hyperlactacidémie en rapport avec un nouveau cas de déficit en fructose-1,6-diphosphatase. Détermination de l'activité enzymatique dans les leucocytes.

A 11.5 month-old girl with recurrent episodes of hypoglycemia and lactic acidosis was identified as having fructose-1,6-diphosphatase deficiency. The diagnosis may be realised with a simple way by an oral fructose tolerance test and the activity dosage of this enzyme in white blood cells. The fructose and sucrose-free diet and avoidance of prolonged fasting resulted in a decrease of hepatomegaly and normal values of lactate between the episodes.

[Plasma 25-OH D deficiency in Maghrebian children more than 10 years of age immigrated to France]. / Déficit plasmatique en 25 OH D chez les enfants maghrébins de plus de 10 ans immigrés en France.

From 1984 Feb 1st to April 30, 63 blood samples were collected from children more than 10 years old in the pediatric unit of CHR de St-Etienne, and analysed for 25 OH D, calcium, phosphate, magnesium and alkaline phosphatase serum concentrations. Mean 25 OH D is lower (22,6 nmol/1) in 26 migrant children (24 from Maghreb and 2 from Turkey) than in 37 European children (mean = 48,6 nmol/1; p less than 0,001). Serum concentration is under 10 nmol/1 in 3 of the 37 Europeans (8%), versus 13 of the 26 Maghrebians (50%). Mean alkaline phosphatase and phosphate are significantly higher in the 36 boys than in the 27 girls. A significative positive correlation is found between alkaline phosphatase and phosphate (r = 0,535; p less than 0,01). There is no relation between age, month of assessment, sex, height, weight, place of late holidays and any of the measured serum values.

[HLA and rheumatoid purpura with or without nephropathy]. / HLA et purpura rhumatoide avec ou sans néphropathie.

HLA profile was determined in 121 caucasoid children with rheumatoid purpura: out of those 55 developed nephropathy, of variable severity. HLA A and B were studied in all children, DR in 87. HLA BW 35 was more frequently found in total group of rheumatoid purpura (28,9%) and especially in nephropathies: 38,2% vs 20,4% in controls. However the increase is not significative even in nephropathy. On the other hand BW 35-DR 4 association is significatively higher in rheumatoid purpura with or without nephropathy than in controls. Analysis of 3 families with 2 affected sibs and 7 families with 1 affected child does not show any linkage with HLA. Determination of HLA profile does not allow to predict that the disease will be complicated by a nephropathy.

[Deficiency rickets in older children. Apropos of 2 cases]. / Rachitisme carentiel chez le grand enfant. A propos de 2 observations.

Typical rickets were observed in a 13 year old Turkish girl and in a 14 year old Moroccan girl. Hypocalcaemia was present in one case. Symptoms have easily regressed with vitamin D2. Seric 25 OH D3 was very low; seric 1-25 OH D3 was normal before treatment and increased very much with vitamin D. In the second case vitamin D deficiency was familial. Study of 15 immigrant children living in or near Saint-Etienne has shown low seric concentrations of 25 OH D3 in 9 (8 undetectable).