Amoebic liver abscess – a cause of acute respiratory distress in an infant: a case report

<p>Abstract</p> <p>Introduction</p> <p>The usual presentation of amebic liver abscess in children is extremely variable and unpredictable. It presents with a picture of common pediatric illness that is fever, lethargy, and abdominal pain, and can go on to develop into a rare complication of rupture into the pleura to cause acute respiratory distress, which is another common pediatric illness. In our patient, diagnosis was not made or suspected in these two stages.</p> <p>Case presentation</p> <p>This is the report of a 2-year-old male infant who presented with a 2-week history of anorexia, fever, and abdominal pain. A few hours after admission, he suddenly developed acute respiratory distress; chest X-ray demonstrated massive right pleural effusion that failed to response to tube thoracostomy. Limited thoracotomy revealed a ruptured amebic liver abscess through the right cupola of the diaphragm. The content of the abscess was evacuated from the pleural cavity, which was drained with two large chest tubes. Serological examination confirmed the diagnosis of ruptured amebic liver abscess. Postoperative treatment with antibiotics including metronidazole continued until full recovery.</p> <p>Conclusion</p> <p>Diagnosis of such a rare disease requires a high degree of suspicion. In this patient, the diagnosis was only made postoperatively. The delay in presentation and the sudden onset of respiratory distress must be emphasized for all those physicians who care for children.</p

Childhood sarcoidosis: A rare but fascinating disorder

Childhood sarcoidosis is a rare multisystemic granulomatous disorder of unknown etiology. In the pediatric series reported from the southeastern United States, sarcoidosis had a higher incidence among African Americans. Most reported childhood cases have occurred in patients aged 13–15 years. Macrophages bearing an increased expression of major histocompatibility class (MHC) II molecules most likely initiate the inflammatory response of sarcoidosis by presenting an unidentified antigen to CD4+ Th (helper-inducer) lymphocytes. A persistent, poorly degradable antigen driven cell-mediated immune response leads to a cytokine cascade, to granuloma formation, and eventually to fibrosis. Frequently observed immunologic features include depression of cutaneous delayed-type hypersensitivity and a heightened helper T cell type 1 (Th1) immune response at sites of disease. Circulating immune complexes, along with signs of B cell hyperactivity, may also be found. The clinical presentation can vary greatly depending upon the organs involved and age of the patient. Two distinct forms of sarcoidosis exist in children. Older children usually present with a multisystem disease similar to the adult manifestations, with frequent hilar lymphadenopathy and pulmonary infiltrations. Early-onset sarcoidosis is a unique form of the disease characterized by the triad of rash, uveitis, and arthritis in children presenting before four years of age. The diagnosis of sarcoidosis is confirmed by demonstrating a typical noncaseating granuloma on a biopsy specimen. Other granulmatous diseases should be reasonably excluded. The current therapy of choice for sarcoidosis in children with multisystem involvement is oral corticosteroids. Methotrexate given orally in low doses has been effective, safe and steroid sparing in some patients. Alternative immunosuppressive agents, such as azathioprine, cyclophosphamide, chlorambucil, and cyclosporine, have been tried in adult cases of sarcoidosis with questionable efficacy. The high toxicity profile of these agents, including an increased risk of lymphoproliferative disorders and carcinomas, has limited their use to patients with severe disease refractory to other agents. Successful steroid sparing treatment with mycophenolate mofetil was described in an adolescent with renal-limited sarcoidosis complicated by renal failure. Novel treatment strategies for sarcoidosis have been developed including the use of TNF-alpha inhibitors, such as infliximab. The long-term course and prognosis is not well established in childhood sarcoidosis, but it appears to be poorer in early-onset disease

Disorders of intestinal rotation and fixation (“malrotation”)

Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46708/1/247_2004_Article_1279.pd

Prevention of acute kidney injury and protection of renal function in the intensive care unit

Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention