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Brain abscess due to Klebsiella pneumoniae in liver-transplanted children
A66
Abstracts / Digestive and Liver Disease 39 (2007) A49–A87
their potentially very severe complications, like enteric bleeding or bowel obstruction. doi:10.1016/j.dld.2007.07.092 PP 30 EOSINOPHILIC OESOPHAGITIS AND COELIAC DISEASE: IS THERE AN ASSOCIATION? L. Quaglietta, P. Coccorullo, E. Miele, F. Pascarella, R. Troncone, A. Staiano Department of Pediatrics, University of Naples “Federico II”, Naples, Italy Objective. We report a series of 17 children affected by eosinophilic oesophagitis (EoE). Six of them also received a diagnosis of celiac disease (CD). Methods. Seventeen children with history of dyspeptic symptoms were investigated. Results. Six patients (M/F 2/4; mean age ± S.D. 5.6 ± 1.3 years, range 4–7 years; Group A) affected by EoE also received a diagnosis of CD. The other 11 children (M/F 10/1, mean age ± S.D. 7.5 ± 2.3 years, range 4–10 years, Group B) were affected solely by EoE. All children underwent a change in dietary regimen. Group A received a gluten-free diet. Group B attempted dietary restriction based on allergy testing results. After 6 months follow-up, all patients in Group A showed a complete disappearance of symptoms and three of them, who underwent upper GI endoscopy, showed histologic remission. Patients from Group B had moderate clinical improvement and in seven of them (63.6%) a repeated upper GI endoscopy showed a statistically significant reduction in eosinophilic infiltration. Conclusions. This is the first reported group of patients with an association between CD and EoE. To date, it is not possible to exclude that in a subgroup of children with CD the oesophageal eosinophilic infiltration could be caused by CD itself. doi:10.1016/j.dld.2007.07.093 PP 31 BRAIN ABSCESS DUE TO KLEBSIELLA PNEUMONIAE IN LIVERTRANSPLANTED CHILDREN S. Lenta a , N. Di Cosmo a , M. Esposito a , F. Caranci b , G. Crispino a , E. Sokal c , P. Vajro a a
Departments of Pediatrics University of Naples “Federico II”, Italy Neurological Sciences-Neuroradiology, University of Naples “Federico II”, Italy c Department of Pediatrics, Catholic University of Louvain - Hospital SaintLuc, Bruxelles, Belgium b
Introduction. Neurological complications represent a large cause of morbidity and mortality especially in short-term follow-up after liver transplantation. Brain abscesses are quite rare (0.6–1%); and the diagnosis may be difficult because imaging resembles that of central nervous system (CNS) lymphoma (Selby R et al., Arch Surg, 1997). Most reported cases are due to fungal infections, particularly Mycelia (Candida and Aspergillus) whereas bacterial infections are less common (Nocardia). We report the first case of cerebral abscess due to Klebsiella pneumoniae occurring during long-term follow-up of a liver transplanted child. Case report. S.D. underwent orthotopic liver transplantation at 10 months for biliary atresia. At age of 12.5 years, he was admitted for headache and asthenia. At this time physical examination was unremarkable. Routine laboratory tests resulted all negative. Chest X-rays, abdominal ultrasounds and fundus oculi were normal. Head X-rays showed a chronic maxillary sinusitis and treatment with amoxicillin was started. Four days later the patient was newly admitted for increasing weakness and behaviour changes (sad and melancholic). Neurological examination showed marked left lower limb hypostenia. EEG showed focal irritation of right anterior temporal–parietal region. CT revealed a voluminous not homogeneous lesion
on the right temporal-parietal lobe with multiple cystic-like areas and surrounding oedema, which caused a right ventricular dislocation, suggesting a CNS lymphoma diagnosis. Mannitol i.v. was started. Differently from CT scan, MR imaging showed a unique multilobate lesion with a heterogeneous solid–liquid content suggesting an infectious nature. This lesion caused a mass effect on the median line and on the ventricles. Microbiological studies on the purulent material obtained by stereotactic drainage revealed Klebsiella pneumoniae, sensitive only to ciprofloxacin and meronem. A treatment with these drugs was continued for 4 months. Follow-up revealed clinical symptoms resolution and imaging improvement. Conclusions. Appearance of neurological symptoms during long-term follow-up of immunosuppressed patients should alert clinicians to consider a brain abscess in differential diagnosis also in the absence of overt clinical/laboratoristic infectious signs. Our case due to Klebesiella pneumoniae demonstrates the possible pathogenetic role of bacteria other than Nocardia. doi:10.1016/j.dld.2007.07.094 PP 32 LONG-TERM COURSE OF MACRO-ASPARTATE AMINOTRANSFERASE (MACRO-AST) IN CHILDREN M. Caropreso a , G. Fortunato b,c , N. Di Cosmo a , S. Lenta a , M. Esposito a , S. Maddaluno a , I. De Napoli a , R. Iorio a , P. Vajro a a
Departments of Pediatrics University of Naples “Federico II”, Italy Biochemistry and Medical Biotechnology, University of Naples “Federico II”, Italy c CEINGE- Advanced Biotechnologies scarl, Naples, Italy b
Objectives. To investigate prevalence, association with clinical conditions, and long-term follow-up of paediatric macro-aspartate aminotransferase (macro-AST), a still poorly characterized cause of isolated elevation of serum AST. Methods. From 1990 to 2006 we observed 44 consecutive children with persistent isolated increase of serum AST, as compared with normal values of 150 age- and gender-matched controls. Macro-AST was studied by electrophoresis (gold standard) and by % polyethylene glycol (PEG) precipitable activity (%PPA). A clinical and laboratory follow-up was planned. Results. At entry all patients were clinically healthy; their AST values were significantly higher than those of controls (142.8 ± 181.0 vs. 27.8 ± 6.3 IU/l; p < 0.001). Seventeen patients (38.6%) were macro-AST positive. Their AST values were higher than those of the macro-AST negative patients (229.5 ± 271.3 IU/l vs. 88.2 ± 29.9 IU/l; p = 0.001). PEG test was highly suggestive of macro-AST when % PPA was >78.5 (sensitivity 82%, specificity 100%), with a grey area in the 70–78.5% range. Thirty-eight patients (14 with macro-AST) underwent a long-term clinical and laboratory follow-up (4.7 ± 3.8, range 1–16 years). All remained symptoms-free, and in both macro-AST negative and positive groups repeated AST measurements showed a decrease in enzyme activity, which was statistically significant only in the former one (p = 0.006). In nine macro-AST positive patients further macro-AST evaluation after 6 ± 4.1 years (range 1.2–10.5 years) showed that the phenomenon persisted only in six. Conclusions. In this series of children with isolated increase of AST serum levels, macro-AST is present in more than one-third of cases. Our data suggest that it is a clinically benign phenomenon which may have a transient course. Although macro-AST is generally characterized by high serum enzyme activity, it must be taken into account also in cases with slightly abnormal AST values. The PPA cut off of 78.5% consents to identify the presence of the macroenzyme with good sensitivity and excellent specificity. For values of % PPA ranging from 70 to 78.5, it is necessary to confirm PEG results with electrophoresis. doi:10.1016/j.dld.2007.07.095
Abstracts / Digestive and Liver Disease 39 (2007) A49–A87
their potentially very severe complications, like enteric bleeding or bowel obstruction. doi:10.1016/j.dld.2007.07.092 PP 30 EOSINOPHILIC OESOPHAGITIS AND COELIAC DISEASE: IS THERE AN ASSOCIATION? L. Quaglietta, P. Coccorullo, E. Miele, F. Pascarella, R. Troncone, A. Staiano Department of Pediatrics, University of Naples “Federico II”, Naples, Italy Objective. We report a series of 17 children affected by eosinophilic oesophagitis (EoE). Six of them also received a diagnosis of celiac disease (CD). Methods. Seventeen children with history of dyspeptic symptoms were investigated. Results. Six patients (M/F 2/4; mean age ± S.D. 5.6 ± 1.3 years, range 4–7 years; Group A) affected by EoE also received a diagnosis of CD. The other 11 children (M/F 10/1, mean age ± S.D. 7.5 ± 2.3 years, range 4–10 years, Group B) were affected solely by EoE. All children underwent a change in dietary regimen. Group A received a gluten-free diet. Group B attempted dietary restriction based on allergy testing results. After 6 months follow-up, all patients in Group A showed a complete disappearance of symptoms and three of them, who underwent upper GI endoscopy, showed histologic remission. Patients from Group B had moderate clinical improvement and in seven of them (63.6%) a repeated upper GI endoscopy showed a statistically significant reduction in eosinophilic infiltration. Conclusions. This is the first reported group of patients with an association between CD and EoE. To date, it is not possible to exclude that in a subgroup of children with CD the oesophageal eosinophilic infiltration could be caused by CD itself. doi:10.1016/j.dld.2007.07.093 PP 31 BRAIN ABSCESS DUE TO KLEBSIELLA PNEUMONIAE IN LIVERTRANSPLANTED CHILDREN S. Lenta a , N. Di Cosmo a , M. Esposito a , F. Caranci b , G. Crispino a , E. Sokal c , P. Vajro a a
Departments of Pediatrics University of Naples “Federico II”, Italy Neurological Sciences-Neuroradiology, University of Naples “Federico II”, Italy c Department of Pediatrics, Catholic University of Louvain - Hospital SaintLuc, Bruxelles, Belgium b
Introduction. Neurological complications represent a large cause of morbidity and mortality especially in short-term follow-up after liver transplantation. Brain abscesses are quite rare (0.6–1%); and the diagnosis may be difficult because imaging resembles that of central nervous system (CNS) lymphoma (Selby R et al., Arch Surg, 1997). Most reported cases are due to fungal infections, particularly Mycelia (Candida and Aspergillus) whereas bacterial infections are less common (Nocardia). We report the first case of cerebral abscess due to Klebsiella pneumoniae occurring during long-term follow-up of a liver transplanted child. Case report. S.D. underwent orthotopic liver transplantation at 10 months for biliary atresia. At age of 12.5 years, he was admitted for headache and asthenia. At this time physical examination was unremarkable. Routine laboratory tests resulted all negative. Chest X-rays, abdominal ultrasounds and fundus oculi were normal. Head X-rays showed a chronic maxillary sinusitis and treatment with amoxicillin was started. Four days later the patient was newly admitted for increasing weakness and behaviour changes (sad and melancholic). Neurological examination showed marked left lower limb hypostenia. EEG showed focal irritation of right anterior temporal–parietal region. CT revealed a voluminous not homogeneous lesion
on the right temporal-parietal lobe with multiple cystic-like areas and surrounding oedema, which caused a right ventricular dislocation, suggesting a CNS lymphoma diagnosis. Mannitol i.v. was started. Differently from CT scan, MR imaging showed a unique multilobate lesion with a heterogeneous solid–liquid content suggesting an infectious nature. This lesion caused a mass effect on the median line and on the ventricles. Microbiological studies on the purulent material obtained by stereotactic drainage revealed Klebsiella pneumoniae, sensitive only to ciprofloxacin and meronem. A treatment with these drugs was continued for 4 months. Follow-up revealed clinical symptoms resolution and imaging improvement. Conclusions. Appearance of neurological symptoms during long-term follow-up of immunosuppressed patients should alert clinicians to consider a brain abscess in differential diagnosis also in the absence of overt clinical/laboratoristic infectious signs. Our case due to Klebesiella pneumoniae demonstrates the possible pathogenetic role of bacteria other than Nocardia. doi:10.1016/j.dld.2007.07.094 PP 32 LONG-TERM COURSE OF MACRO-ASPARTATE AMINOTRANSFERASE (MACRO-AST) IN CHILDREN M. Caropreso a , G. Fortunato b,c , N. Di Cosmo a , S. Lenta a , M. Esposito a , S. Maddaluno a , I. De Napoli a , R. Iorio a , P. Vajro a a
Departments of Pediatrics University of Naples “Federico II”, Italy Biochemistry and Medical Biotechnology, University of Naples “Federico II”, Italy c CEINGE- Advanced Biotechnologies scarl, Naples, Italy b
Objectives. To investigate prevalence, association with clinical conditions, and long-term follow-up of paediatric macro-aspartate aminotransferase (macro-AST), a still poorly characterized cause of isolated elevation of serum AST. Methods. From 1990 to 2006 we observed 44 consecutive children with persistent isolated increase of serum AST, as compared with normal values of 150 age- and gender-matched controls. Macro-AST was studied by electrophoresis (gold standard) and by % polyethylene glycol (PEG) precipitable activity (%PPA). A clinical and laboratory follow-up was planned. Results. At entry all patients were clinically healthy; their AST values were significantly higher than those of controls (142.8 ± 181.0 vs. 27.8 ± 6.3 IU/l; p < 0.001). Seventeen patients (38.6%) were macro-AST positive. Their AST values were higher than those of the macro-AST negative patients (229.5 ± 271.3 IU/l vs. 88.2 ± 29.9 IU/l; p = 0.001). PEG test was highly suggestive of macro-AST when % PPA was >78.5 (sensitivity 82%, specificity 100%), with a grey area in the 70–78.5% range. Thirty-eight patients (14 with macro-AST) underwent a long-term clinical and laboratory follow-up (4.7 ± 3.8, range 1–16 years). All remained symptoms-free, and in both macro-AST negative and positive groups repeated AST measurements showed a decrease in enzyme activity, which was statistically significant only in the former one (p = 0.006). In nine macro-AST positive patients further macro-AST evaluation after 6 ± 4.1 years (range 1.2–10.5 years) showed that the phenomenon persisted only in six. Conclusions. In this series of children with isolated increase of AST serum levels, macro-AST is present in more than one-third of cases. Our data suggest that it is a clinically benign phenomenon which may have a transient course. Although macro-AST is generally characterized by high serum enzyme activity, it must be taken into account also in cases with slightly abnormal AST values. The PPA cut off of 78.5% consents to identify the presence of the macroenzyme with good sensitivity and excellent specificity. For values of % PPA ranging from 70 to 78.5, it is necessary to confirm PEG results with electrophoresis. doi:10.1016/j.dld.2007.07.095