Acute Progressive Visual Loss in a Case of Acute Myeloid Leukemia: Challenges in the Utility of Molecular Tests in Early Diagnose of Cytomegalovirus Retinitis

Cytomegalovirus (CMV) retinitis is one of the rare but debilitating presentations of the CMV infection in children with leukemia. Herein, we report a 12-year-old boy with acute myeloid leukemia complicated by rapid progressive visual loss during relapse of leukemia. The definite diagnosis of CMV retinitis was made after vitreous aspiration. Despite prompt treatment and ophthalmologic intervention, he died because of AML relapse. Viral infections, especially cytomegalovirus infection, may present with vague clinical pictures during any time of chemotherapy, which may not be easily distinguishable from bacterial or fungal retinitis and also chemotherapy-induced retinopathies. Clinician should consider CMV retinitis in seropositive patients especially those without detectable viremia

Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit

Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU

Cyclosporine in the Treatment of a Case of Fulminant and Refractory Acute Disseminated Encephalomyelitis

Background: Acute disseminated encephalomyelitis (ADEM) is rare, monophasic, demyelinating disease of the CNS which sometimes could be refractory to traditional treatment. Case Presentation: We present a case of fulminant ADEM which is treated with combination of corticosteroid, intravenous immunoglobulin and cyclosporine. Conclusion: Immunosuppressive agents such as cyclosporine may be effective especially in fulminant form of the disease

Status Epilepticus as a Presenting Sign of Reversible Posterior Leukoencephalopathy Syndrome in a Liver Transplant Recipient

Background: Reversible posterior leukoencephalopathy syndrome (RPLE) is an increasingly recognized disorder, most commonly associated with immunosuppressive and cytotoxic agent, malignant hypertension and toxemia of pregnancy. Neurological symptoms are headache, mental and visual disturbance, and seizures. Brain MRI findings are symmetrical bilateral hyper intense areas of occipital and parietal lobes in T2-weighted magnetic resonance (MR) images. This finding is reversible with prompt successful treatment which may take days to weeks for full reversal. Case Presentation: We observed a case of status epilepticus which occurred 32 days after liver transplantation in a patient on regimen consisting of Tacrolimus (FK 506). He had no history of neurologic disease or metabolic abnormalities. Typical findings of RPLE were present on brain MRI. The recurrence of seizures terminated after a few hours with adding Na-valproate to Phenytoin, Phenobarbital and Midazolam. The radiological finding of brain MRI gradually diminished after several weeks. Conclusion: A physician should be alert of seizures during early post transplant period of liver transplantation. He should bear in mind the diagnosis of RPLE and consider discontinuation of immunosuppressive drugs

Improved Kaplan-Meier Estimator in Survival Analysis Based on Partially Rank-Ordered Set Samples

This study presents a novel methodology to investigate the nonparametric estimation of a survival probability under random censoring time using the ranked observations from a Partially Rank-Ordered Set (PROS) sampling design and employs it in a hematological disorder study. The PROS sampling design has numerous applications in medicine, social sciences and ecology where the exact measurement of the sampling units is costly; however, sampling units can be ordered by using judgment ranking or available concomitant information. The general estimation methods are not directly applicable to the case where samples are from rank-based sampling designs, because the sampling units do not meet the identically distributed assumption. We derive asymptotic distribution of a Kaplan-Meier (KM) estimator under PROS sampling design. Finally, we compare the performance of the suggested estimators via several simulation studies and apply the proposed methods to a real data set. The results show that the proposed estimator under rank-based sampling designs outperforms its counterpart in a simple random sample (SRS)

Generalized exfoliative skin rash as an early predictor of supratherapeutic voriconazole trough levels in a leukemic child: A case report

Background and Purpose: Skin rashes, mostly seen in children and adolescents, are considered among the most common side effects of azole antifungals. Although therapeutic concentrations of voriconazole (VCZ) have been documented for infected skin, there is no evidence specifying whether specific dermatologic side effects could predict high VCZ serum concentration, especially in high-risk leukemic children. Case report: Herein, we report a unique skin side effect of VCZ in a 5-year-old boy with T-cell acute lymphoblastic leukemia (ALL) referred to Amir Medical Oncology Center in Shiraz, Iran. The patient experienced erythroderma and macular rashes shortly after VCZ consumption, leading to generalized exfoliative skin rashes. Concurrent to these skin manifestations, VCZ serum concentration reached the supratherapeutic levels despite the recommended VCZ doses. As a result, VCZ was withheld, and the patient was treated with caspofungin. The lesions were resolved gradually within 2 weeks, and the patient successfully completed his treatment course with caspofungin. Conclusion: The unique case presented in this study emphasizes the need for a high index of suspicion for VCZ toxicity in any patient with atypical dermatologic manifestations, especially generalized exfoliative skin rashes. Based on this report, VCZ supratherapeutic concentration could be predicted early in the course of treatment. Additional therapeutic dose monitoring should be considered to establish a confirmatory diagnosis. It is required to further investigate the toxic effect of high VCZ concentration on the skin epithelium

Virulence Factors and Antibiotic Resistance in Uropathogenic and Commensal Escherichia coli Isolates

Background: Urinary Tract Infections (UTIs), including cystitis and pyelonephritis, are the most common infectious diseases in childhood. Aim and Objectives: Escherichia coli (E. coli) account for as much as 90% of the community-acquired and also 50% of nosocomial UTIs. Therefore, the identification of E. coli strains and antibiotic resistance patterns is important for both clinical and epidemiological implications. Material and Methods: To characterize uropathogenic strains E. coli, we studied 100 strains recovered from both urine samples of children aged less than 7 years with community-acquired UTIs and stool samples of healthy children, respectively. Results: We assessed Virulence Factors (VFs) and drug sensitivities of E. coli isolates. Drug sensitivities of the isolates were 94% (amikacin), 90% (nitrofurantoin), 66% (gentamicin), 56% (cefixime), 40% (nalidixic acid) and 28% (cotrimoxazol). Laboratory tests showed that the prevalence of virulence factors ranged from 18% for hemolysin and P-fimbriae to 2% for type1-fimbriae. Most drug resistance was cotrimoxazole and amikacin was the lowest. P-fimbriae and hemolysin in uropathogenic E. coli were more frequent than non-pathogen type of E. coli. Conclusion: Although amikacin appeared to be the first choice for UTI in children, but nitrofurantoin seems to be practical and could be considered as the selective choice for uncomplicated lower UTIs

Current strategies against invasive fungal infections in patients with aplastic anemia, strong power and weak weapon, a case report and review of literature

We report an 18 year old boy with Aplastic anemia complicated by serious fungal rhinosinusitis. Despite prompt treatment and early repeated surgical debridements, he died after about more than 6 weeks of hard challenges with fungal infections. Current strategies against invasive fungal infections (IFIs) in patients with Aplastic anemia may be inadequate for the management of serious complications. Antifungal prophylaxis is highly recommended in pre-transplant period for severe form of Aplastic anemia

Potential voriconazole associated posterior reversible leukoencephalopathy in children with malignancies: Report of two cases

The fungal infection has become severe morbidity amongst patients with malignancy. Voriconazole, a new generation of triazole, has shown excellent results in treating invasive fungal infections. Herein, we report two cases of posterior reversible encephalopathy syndrome (PRES), which induced after voriconazole exposure. Magnetic resonance imaging, and the serum level of voriconazole were investigated in both patients to assess toxicity. The role of methotrexate, as one of the possible causes of PRES, is weakened significantly through precise assessing diffusion-weighted images on magnetic resonance imaging. These unique cases emphasize that voriconazole can induce PRES even at therapeutic levels. Therefore, in the case of neurotoxicity, PRES must be considered, and voriconazole should discontinue. The prognosis seemed promising when voriconazole stopped immediately after clinical suspicion