Approach to pediatric hip pain: what to expect?

IP Universitatea de Stat de Medicină și Farmacie ”Nicolae Testemițanu”, IMSP Institutul Mamei și CopiluluiDurerea de șold debutată subit la copil, reprezintă deseori un obstacol de diferențiere diagnostică multidisciplinară clinică și paraclinică. Printre principalele diagnostice presumptive la copilul primar debutat cu durere în articulația șoldului în țările în curs de dezvoltare cu rată endemică sporită se enumeră și tuberculoza extrapulmonară articulară. Tuberculoza extrapulmonară este mai frecventă în cazul copiilor mici. Odată instalată, este deobicei monoarticulară, afectând în special articulațiile mari. Sinovita tuberculoasă izolată este paucisimptomatică, cu limitarea mișcării, fiind diagnosticată tardiv. Artrita tuberuloasă se asociază cu un grad de osteită, amiotrofie progresivă a grupelor musculare adiacente și distrucție ireversibilă a articulației. Diagnosticul este stabilit în funcție de stadiul clinicoradiologic, examenul bacteriologic pentru Mycobacterium tuberculosis din lichidul sinovial sau examenul histopatologic din biopsia sinovială asociate cu IDR pozitivă la tuberculină. Evoluția este favorabilă sub tratament antituberculos asociat cu imobilizarea articulației. Studiul de caz curent marchează importanța diagnosticării precoce prin metode specifice și nespecifice, diagnostic diferențial cu maladiile reumatice din copilărie, a afectării articulare tuberculoase la copiii din grupele de risc

Renoparenchymal hypertension in a child with reactivated viral hepatitis B

Nicolae Testemitanu" State University of Medicine and Pharmacy, Department of Pediatrics, Mother and Child Institute, Congresul consacrat aniversării a 75-a de la fondarea Universității de Stat de Medicină și Farmacie „Nicolae Testemițanu” din Republica Moldova, Ziua internațională a științei pentru pace și dezvoltareIntroduction. The pathology of the renal parenchyma is the most common cause of drug-resistant malignant hypertension, being 5-10%. HBV-associated nephropathy is the most common extrahepatic clinical manifestation of HBV, the main pathogenetic mechanism being that mediated by circulating immune complexes. Purpose. Highlighting the difficulties of diagnosis of the cause of hypertension in a child with reactivated occult viral hepatitis B and renal impairment. Material and methods. The authors present the clinical case of a 1-year-old patient diagnosed with renoparenchymal malignant hypertension and reactivated occult viral hepatitis B, with very high viremia and extrahepatic affecting (cardiovascular, renal and cerebral). Results. The patient was hospitalized with clinical manifestations of toxic and infectious syndrome and blood pressure up to 200/120 mmHg. The clinical and paraclinical investigations have estimated stage I hypertensive retinopathy, leukocytosis with neutrophilia, increased acute phase reactants, hypoproteinemia, hypoalbuminemia, nephritic syndrome, marked hepatocytolysis and quantitative HBV DNA with extremely high values. The echocardiography revealed signs of cardiac remodeling and LV myocardial hypokinesia. Selective aortography ruled out the renovascular cause of hypertension. MRI revealed inflammatory changes in the bilateral renal parenchyma (Fig.2) and diffuse abdominal lymphadenopathy. Conclusions. The holistic approach of the patient allowed the identification of the possible cause of hypertension and inflammatory changes in the bilateral renal parenchyma as well as the premise for starting antiviral therapy

Hipertensiunea arterială renoparenchimatoasă la un copil cu hepatită virală B ocultă reactivată

Background. The pathology of the renal parenchyma is the most common cause of drug-resistant malignant hypertension, being 5-10%. HBV-associated nephropathy is the most common extrahepatic clinical manifestation of HBV, the main pathogenetic mechanism being that mediated by circulating immune complexes. Objective of the study. Highlighting the difficulties of diagnosis of the cause of hypertension in a child with reactivated occult viral hepatitis B and renal impairment. Material and Method. The authors present the clinical case of a 1-year-old patient diagnosed with renoparenchymal malignant hypertension and reactivated occult viral hepatitis B, with very high viremia and extrahepatic affecting (cardiovascular, renal and cerebral). Results. The patient was hospitalized with clinical manifestations of toxic and infectious syndrome and blood pressure up to 200/120 mmHg. The clinical and paraclinical investigations have estimated stage I hypertensive retinopathy, leukocytosis with neutrophilia, increased acute phase reactants, hypoproteinemia, hypoalbuminemia, nephritic syndrome, marked hepatocytolysis and quantitative HBV DNA with extremely high values. The echocardiography revealed signs of cardiac remodeling and LV myocardial hypokinesia. Selective aortography ruled out the renovascular cause of hypertension. MRI revealed inflammatory changes in the bilateral renal parenchyma and diffuse abdominal lymphadenopathy. Conclusion. The holistic approach of the patient allowed the identification of the possible cause of hypertension and inflammatory changes in the bilateral renal parenchyma as well as the premise for starting antiviral therapy. Introducere. Patologia parenchimului renal este cea mai frecventă cauză a hipertensiunii arteriale maligne farmacorezistente, constituind 5-10%. Nefropatia asociată HVB reprezintă cea mai frecventă manifestare clinică extrahepatică a HVB, principalul mecanism patogenetic fiind cel mediat de complexele imune. Scopul lucrării. Evidențierea dificultăților de diagnostic al cauzei HTA la un copil cu hepatită virală B ocultă reactivată și afectare renală. Material și Metode. Autorii prezintă cazul clinic al unei paciente în vârstă de 1 an, diagnosticată cu hipertensiune arterială malignă renoparenchimatoasă și hepatită virală B ocultă reactivată, cu viremie foarte înaltă și afectare extrahepatică (cardiovasculară, renală și cerebrală). Rezultate. Pacienta a fost internată cu manifestări clinice ale sindromului toxic și infecțios și tensiunea arterială de până la 200/120 mmHg. Investigațiile clinico-paraclinice au estimat retinopatie hipertensivă stadiul I, leucocitoză cu neutrofilie, reactanții fazei acute sporiți, hipoproteinemie, hipoalbuminemie, sindrom nefritic, hepatocitoliză marcată și ADN VHB cantitativ, cu valori extrem de mari. Examenul ecocardiografic a decelat semne de remodelare cardiacă și hipokinezia miocardului VS. Prin aortografia selectivă a fost exclusă cauza renovasculară a HTA. RMN a relevat schimbări inflamatorii la nivelul parenchimului renal bilateral și limfadenopatie abdominală difuză. Concluzii. Abordarea holistică a pacientei a permis identificarea cauzei posibile a hipertensiunii arteriale și a modificărilor inflamatorii la nivelul parenchimului renal bilateral, precum și analiza inițierii terapiei antivirale

Связь между гранулёматозом с полиангиитом, носительством золотистого стафилококка и острыми инфекциями у детей – клинический случай

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, IMSP Institutul Mamei şi CopiluluiBackground: Granulomatosis with polyangiitis (GPA) is a chronic vasculitis involving small- to medium-sized arteries. It is characterized by granulomatous infl ammation of the upper and lower respiratory tracts; necrotizing, pauci-immune glomerulonephritis; and vasculitis that frequently involves other organs. Staphylococcus aureus is thought to play a crucial role in onset and flares of GPA. Method and materials: We report a clinical case of a patient with granulomatosis with polyangiitis complicated with infective endocarditis due to Staph. aureus. Results: At the onset of the disease patient complaint on persistent fever, anorexia, nausea and vomiting. Laboratory assays revealed increased acute phase reactants. X-ray revealed signs of sinusitis and pulmonary infection. Septic workup revealed repeated positive blood cultures for staph. aureus. In spite to adequate antibiotic treatment child’s condition gradually worsened. Nasal crusting and epistaxis was reported by patient. An repeated X-ray of the chest showed multiple nodules and cavities in the lungs. She was suspected to have GPA. Lung biopsy was taken and the diagnosis of GPA was confirmed. Imunnosupresive therapy was started with no expected clinical improvement. In the meanwhile patient developed a new murmur. On heart ultrasound vegetations were revealed. The diagnosis of infective endocarditis was made. The patient was treated with a 4 weeks regimen of vancomycin. Her condition markedly improved. After the treatment of active infection, an alternative regimen of GPA treatment was chosen. No relapse of lung disease was reported in 3 months follow-up. Conclusions: The case reported above highlights the importance of high index of suspicion of GPA in patients with staph. aureus infections who do not respond to conventional therapy. Nasal crusts biopsy can aid differential diagnosis and promote early diagnosis.Введение: Гранулёматоз с полиангеитом (ГПА) является хронической формой васкулита с поражением мелких и средних сосудов. Это заболевание характеризуется гранулёматозным воспалением верхних и нижних дыхательных путей, малоимунным гломерулонефритом и васкулитом, который может поражать различные органы. Методы и материалы: Мы докладываем случай пациентки с гранулёматозом Вегенера (ГПА), осложненный стафилококковым инфекционным эндокардитом. Результаты: 10-летняя девочка поступила в больницу с жалобами на повышенную температуру, анорексию, тошноту и рвоту. Лабораторные данные указывали на повышение белков острой фазы. Рентгенологическое исследование указывали на принаки синусита и лёгочной инфекции. В гемокультуре – присутствовал золотистый стафилококк. Несмотря на лечение в соответствии с антибиограммой, состояние ребенка ухудшалось. Появились носовые кровотечения и корки. На повторном рентгене лёгких – множественные очаги и полости. На основании этих данных был заподозрен гранулёматоз с полиагиитом. После биопсии легкого диагноз был подтвержден и была инициирована иммуносупрессивная терапия, без ожидаемого эффекта. Также, у пациентки появился сердечный шум. На эхо-сердца выявилось присутствие вегетаций на трёхстворчатом клапане. Был поставлен диагноз инфекционного эндокардит и начат 4-х недельный курс ванкомицина. Клиническое состояние ребенка улучшилось. После завершения антибиотерапии была начата альтернативная схема лечения ГПА с положительной динамикой. Выводы: Данный клинический случай подчёркивает важность дифференциального диагноза с ГПА у пациентов с стафилококковыми инфекциями, которые не отвечают на конвенциональную терапию. Биопсия назальных корок может поспособствовать ранней диагностике

GIANT OVARIAN MUCINOUS CYSTADENOMA

The authors described a well documented observation of a giant (24.8x18.3x12.6 cm) ovarian mucinous cystadenoma (MCA). A review of the literature on the frequency, classification, features of diagnosis and surgical treatment of giant MCAs is presented

Терапевтическая гипотермия у новорождённых с гипоксически-ишемической энцефалопатией

IMSP Institutul Mamei şi Copilului, Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Departamentul PediatrieThe goal of the study is to understand the action mechanisms of therapeutic hypothermia to set selection criteria for newborns requiring hypothermia, protocols description and improving the management of neonatal therapeutic hypothermia induction. Materials and Methods: The study included 55 children born at 37-43 gestational weeks within the period of 2013- 2016 years, divided into 2 groups. Thus, the first group included 30 newborns with no therapeutic hypothermia, the second group - 25 children who were induced in therapeutical hypothermia. For statistical analysis was used statistical program 8.0 [Stat Soft, Inc.2007, USA]. Differences were considered significant if p <0.05. Results: We observed benefits inducing hypothermia in infants with severe asphyxia. Length of stay to respiratory support VAP, shows a better indicator in group II: group I - 5.7 days vs group II - 4.5 days. Another demonstrative factor is acid-base balance, it normalized faster in group II – 9 hours vs group I - 24 hours. Pulmonary hypertension is down from 36.6% to 24% in group II (p <0.05). Convulsive syndrome was detected in 43.3% in the first group and 28% in group II (p <0.05). Intracranial hemorrhage occurred 23.3% in first group and 8% in group II (p <0.05). NEC was reduced from 26.6% in group I to 12% in group II (p <0.05). Conclusion: Induced hypothermia significantly reduce the morbidity and mortality in asphyxiated infants. However, many of those who survive remain with varying degrees of sequelae on follow-up program, which demonstrates the need to improve the neuroprotective mechanisms. In this study were elucidated the benefits of hypothermia induction in infants with severe encephalopathy.Цель исследования: заключается в понимании механизмов действия терапевтической гипотермии, c целью определения критериев отбора новорожденных, требующих охлаждения; описание протоколов, возможных осложнений и улучшения оказания помощи новорожденным, требующим индукции терапевтической гипотермии. Материалы и методы: В исследование были включено 55 детей, родившихся при сроке 37-43 недели беременности в состоянии тяжёлой асфиксии в период 2013-2016 годы, разделенных на 2 группы: I группа состояла из 30 новорожденных, которым не проводилась терапевтическая гипотермия, II группа - 25 детей, которым была индуцирована гипотермия. Для статистического анализа использовали программу 8.0 [StatSoft, Inc.2007, США]. Различия считались значимыми, если р <0,05. Результаты: Мы наблюдали положительный эффект данного метода лечения у новорожденных с тяжелой асфиксией. Среднея продолжительность пребывания на ИВЛ была меньше во II группе – 4,5 дней против 5,7 дней в I группе. Другим важным фактором являлось время нормализации кислотно-щелочного балансса, которое быстрее корригировалось во II группе, в среднем через 9 часов против 24 часов в I группе. Легочная гипертензия отмечалась меньше во II группе 24% против 36,6% (р <0,05). Судорожный синдром был выявлен у 43,3% в первой группе и 28% в II группе (р <0,05). Удельный вес внутричерепных кровоизлияний выше в первой группе 23,3% против 8% во II группе (р <0,05). Некротически язвенный энтероколит чаше встречался в I группе - 26,6% против 12% во II группе (р <0,05). Вывод: Tерапевтическая гипотермия значительно снижает заболеваемость и смертность детей, родившихся в асфиксии. Тем не менее, многие из тех, кто выживает остаются с разной степенью осложнений, что свидетельствует о необходимости сочетания гипотермии с нейропротекторными методaми