gakkaizashi


THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY

Vol.124, No.11, November 2020


Original Article
1. Possibilities of Early Diagnosis and Decreased Cases of Incomplete Kawasaki Disease Due to Revision of Diagnostic Guidelines
2. End-of-life Care and Planning at the Osaka Developmental Rehabilitation Center
Case Report
1. Chronic Bilirubin Encephalopathy Due to Persistent Perioperative Hypoalbuminemia in an Extremely Premature Infant
2. Asymmetric Septal Hypertrophy of a Newborn Exposed to Maternal Amphetamines
3. Infective Endocarditis Complicated with Meningitis by Methicillin-Susceptible Staphylococcus aureus
4. Central Nervous System Dysfunction Concomitant with Adenovirus Type 7 Pneumonia
5. Group A Beta-hemolytic Streptococcus Osteomyelitis of a Thoracic Vertebral Spinous Process Detected on Repeat MRI
6. Gastroesophageal Reflux Disease Treated Without Surgical Intervention Owing to the Introduction of Base Rice Blenderized Foods by Nasogastric Tube
7. Two Cases of Flunitrazepam Ingestion Diagnosed by Blue Tongue
Brief Report
Clinical Characteristics of 10 Children with COVID-19 in Our Hospital


Original Article
Title
Possibilities of Early Diagnosis and Decreased Cases of Incomplete Kawasaki Disease Due to Revision of Diagnostic Guidelines
Author
Takeshi Koga Nozomi Ikeda Satomi Ohtaki Moe Yoshimura Katsuhiko Tabata Yuko Akioka Akira Ohtake and Kenichi Tokuyama
Department of Pediatrics, Saitama Medical University Hospital
Abstract
The diagnostic guidelines for Kawasaki disease were revised in May 2019. The major modifications are as follows: the duration of febrile days is no longer relevant, BCG scar erythema is considered as one of the principal symptoms, and confirmed diagnosis of incomplete Kawasaki disease. These changes may influence the time of diagnosis, illness onset, and treatment strategies. We reviewed cases of children diagnosed with and treated for Kawasaki disease using the 5th edition of the diagnostic guidelines, and these cases were reclassified using the 6th edition. We then compared these cases before and after reclassification. In total, 291 patients, with a mean age of 2.6±2.2 years, were included in this study. After reclassification, the mean number of principal symptoms upon admission increased from 4.4±1.3 to 4.9±1.2. The proportion of patients diagnosed with incomplete Kawasaki disease decreased from 17.5% to 13.4%. The duration of illness before initial treatment was reduced from 5.5±1.7 days to 4.8±1.5 days. Meanwhile, the patients' Kobayashi score increased from 3.4±2.4 points to 3.9±2.7 points, and the proportion of children with ≥5 points increased from 95 (32.6%) to 109 (37.5%). Hence, the use of the revised guidelines resulted in early diagnosis, effect on treatment strategies, and a decreased proportion of patients with incomplete Kawasaki disease.




Original Article
Title
End-of-life Care and Planning at the Osaka Developmental Rehabilitation Center
Author
Masahisa Funato Kiyoshi Takemoto Hiroshi Wada Yoshitaka Iijima Waka Hatano Masumi Fujiwara and Tamami Katayama
Department of Pediatrics, Osaka Developmental Rehabilitation Center
Abstract
Aim. Our medical care team discussed with legal representatives of family members about advance care planning (ACP) and end-of-life care, in consideration of the best interests of the subjects. We present these cases and their outcomes.
Subject and Method. Subjects of these 10 cases had severe motor and intellectual disabilities for which we made an ACP through shared decision-making. The ACP was revised according to the family's wishes, and the consent form signed by the family was finally approved by the ethical committee.
Results. Subjects in 8 cases died after making the ACP, and 2 subjects remain alive. Shared decision-making was incorporated by the family and medical care team in 5 cases, with the addition of physicians from the primary hospital and/or local clinic in 3 cases. In 2 of the cases, decision-making was carried out by only the medical care team. Opportunities for discussion of the ACP were triggered by several serious conditions. The invasive intervention that families wished to avoid was cardio-pulmonary resuscitation in 10 cases. Support of daily life care, end-of-life care, and grief care were provided for the subjects and their family members.
Conclusion. ACP-making provides an opportunity to consider the best total care for subjects who cannot speak for themselves, together with their families.




Case Report
Title
Chronic Bilirubin Encephalopathy Due to Persistent Perioperative Hypoalbuminemia in an Extremely Premature Infant
Author
Takuma Deguchi1) Daisuke Hitaka1) Yayoi Miyazono1)2) Motomichi Nagafuji1) Syusuke Takeuchi1) Yu Kanai1) Saki Saeki1) Takashi Enokizono1) and Hidetoshi Takada1)2)
1)Department of Pediatrics, University of Tsukuba Hospital
2)Department of Child Health, Faculty of Medicine, University of Tsukuba
Abstract
Chronic bilirubin encephalopathy (CBE) results from bilirubin neurotoxicity. Its clinical diagnosis involves athetoid-type cerebral palsy, auditory neuropathy, and bilateral T2 hyperintensity of the globus pallidus on brain MRI. We report an extremely low birth weight infant with CBE who had persistent hypoalbuminemia in the perioperative period of gastrointestinal perforation and whose serum total bilirubin (TB) level was not significantly elevated. The patient was a dichorionic diamniotic twin, born at gestational age 24 weeks and 1 day, with a body weight of 630 g. The peak value of serum TB and bilirubin/albumin ratio were 9.8 mg/dL at 8 days and 3.8 (mg/g) respectively. At 10 days, the neonate underwent a laparotomy for gastrointestinal perforation. Serum albumin levels remained low (1.5 to 2.5 mg/dL) during the perioperative period despite repetitive administration of albumin solution. During the course, unbound bilirubin was not measured. Auditory neuropathy and athetoid-like movement developed at the corrected age of 2 and 10 months, respectively. Brain MRI at corrected age 10 months showed bilateral hyperintensity of the globi pallidi and CBE was diagnosed. Our case indicates that undergoing gastrointestinal operation and hypoalbuminemia during the perioperative period can increase the risk of CBE in extremely premature infants.




Case Report
Title
Asymmetric Septal Hypertrophy of a Newborn Exposed to Maternal Amphetamines
Author
Manabu Miyamoto1) Yuto Otsubo1) Itsumi Komori1) Yuya Takaiwa1) Miori Ogawa1) Go Ichikawa1) and Shigemi Yoshihara2)
1)Department of Pediatrics, Nasu Red Cross Hospital
2)Department of Pediatrics, Dokkyo Medical University
Abstract
Few reports in the available literature in Japan have described neonates exposed to maternal amphetamine or methamphetamine, which are known to cause various complications. We report a case of a female neonate weighing 3,612 g at birth, who was delivered vaginally at 39 weeks of gestation. We discovered that her mother dissolved methamphetamine in liquid tobacco and inhaled this mixture throughout her pregnancy. Urinalysis performed on day 0 revealed maternal methamphetamine use; however, the patient did not show withdrawal symptoms. Transthoracic echocardiography revealed thickening of the ventricular septal wall and the posterior left ventricular wall. Her heart function was normal, so we followed-up her cardiac complications. She was discharged on day 44. Cardiac complications are important contributors to long-term prognosis.




Case Report
Title
Infective Endocarditis Complicated with Meningitis by Methicillin-Susceptible Staphylococcus aureus
Author
Yuji Asami1) Akihiko Shimizu2) Shuhei Arai1) Kensuke Tanaka1) Kentaro Ikeda1) Shinya Shimoyama1) Hidenori Hayashi3) Takahiro Tomoyasu3) Norihiko Oka3) Yoshiyuki Yamada2) and Tomio Kobayashi1)
1)Department of Cardiology, Gunma Children's Medical Center
2)Department of Allergy, Infectious Diseases, and Immunology, Gunma Children's Medical Center
3)Department of Cardiovascular Surgery, Gunma Children's Medical Center
Abstract
Staphylococcus aureus has become one of the most common causes of infectious endocarditis (IE) in recent years. Cephazolin is usually used to treat staphylococcal IE in Japan, where anti-staphylococcal penicillin (ASP) is not commercially available. However, cephazolin should not be used for bacterial meningitis because of its low cerebrospinal fluid penetration rate. Herein, we report a case of methicillin-susceptible S. aureus (MSSA) IE complicated with bacterial meningitis.
A 12-year-old boy with atopic dermatitis visited a local hospital with chief complaints of fever and disturbance of consciousness. Lumbar puncture revealed pleocytosis with polynuclear cell dominance. MSSA was detected in the blood culture, and an echocardiogram revealed vegetation on the mitral valve and the mitral valve prolapse. IE complicated with bacterial meningitis was diagnosed and he was transferred to our hospital. The next day, he underwent resection of the vegetation. We chose cefotaxime and vancomycin as substitutes for ASP. He completed a 6-week treatment of antibiotics without any sequelae.
Mitral valve prolapse and atopic dermatitis may have caused IE in this case. Although we should have used ASP in this case, we had little choice but to use suboptimal antibiotics due to the lack of ASP in Japan. Approval of ASP and a stable supply of antibiotics are important to improve the quality of treatment for staphylococcal endocarditis and meningitis.




Case Report
Title
Central Nervous System Dysfunction Concomitant with Adenovirus Type 7 Pneumonia
Author
Yuma Onagawa1) Makoto Tsutsumi1) Jinya Shiote1) Chika Muramatsu1) Yukako Yoshikane1) Reimi Tsurusawa1) Junichi Hashimoto1) Shinichi Hirose2) and Atsushi Ogawa1)
1)Department of Pediatrics, Chikushi Hospital, Fukuoka University
2)Department of Pediatrics, Faculty of Medicine, Fukuoka University Hospital
Abstract
An outbreak of adenovirus type 7 occurred in Japan in 1995, and several cases of severe or fatal pneumonia were reported. Although this outbreak ended in 2000, outbreaks of adenovirus type 7 were reported across Asia in 2010. Studies have reported an association between cytokines and the severity of adenovirus type 7 pneumonia, suggesting the effectiveness of corticosteroid therapy in this condition.
We present a case of a previously healthy 1-year-old female infant with adenovirus type 7 pneumonia concomitant with central nervous system dysfunction. She was found to have hypercytokinemia and developed status seizures with considerable delay from the onset of fever. She was given a diagnosis of acute encephalopathy based on abnormal electroencephalography and head magnetic resonance imaging findings. Cerebrospinal fluid examination was normal; however, polymerase chain reaction assay of cerebrospinal fluid yielded adenovirus. She did not respond to usual doses of corticosteroid; however, steroid pulse therapy was effective, and she was discharged without neurological sequelae. Invasion of adenovirus type 7 into the central nervous system was strongly suggested because EEG and head image findings were abnormal and adenovirus was detected in the cerebrospinal fluid. A future outbreak of adenovirus type 7 cannot be ruled out in Japan. Therefore, clinicians need to be aware and prepared for this eventuality.




Case Report
Title
Group A Beta-hemolytic Streptococcus Osteomyelitis of a Thoracic Vertebral Spinous Process Detected on Repeat MRI
Author
Haruka Tokoro1)2) Tamako Takashina1) Ai Tokunaga1)2) Natsuko Tamura1)2) Ayako Ozawa1)2) Yuji Takizawa1) Kikuko Tamura1) Kensuke Shoji3) and Shinji Oana1)2)
1)Department of Pediatrics, Nishisaitama-chuo National Hospital
2)Department of Pediatrics, Tokyo Jikei University School of Medicine
3)Department of Infectious Diseases, National Center for Child Health and Development
Abstract
A 5-year-old boy with 4 days of fever refractory to oral antibiotic treatment, right abdominal pain, and non-specific pain that worsened with inspiration was referred to our hospital; urinary tract infection was suspected. Enhanced computed tomography of the abdomen was performed but showed no evidence of infection. However, two blood cultures were positive for group A beta-hemolytic streptococcus. Gallium citrate scintigraphy was performed on day 8 of his illness and showed abnormal tracer uptake in the Th 6-8 vertebrae. Magnetic resonance imaging (MRI) of the thoracic spine on day 11 was normal. On day 25, MRI was repeated and showed high signal intensity in the Th 7 spinous process on short T1 inversion recovery and T2-weighted images. The patient was given a diagnosis of osteomyelitis of the Th 7 spinous process. Intravenous ampicillin was administered for 6 weeks, followed by oral amoxicillin for 2 weeks; the patient fully recovered without relapse or complication.
Diagnostic imaging is useful when the source of pain is difficult to identify. In this case, repeat MRI demonstrated the proper diagnosis, showed the extent of pathology, and guided appropriate treatment. If initial imaging is negative, repeat examinations should be considered.




Case Report
Title
Gastroesophageal Reflux Disease Treated Without Surgical Intervention Owing to the Introduction of Base Rice Blenderized Foods by Nasogastric Tube
Author
Yusuke Nakamura1)2) Ryo Matsuoka1)2) Hirokazu Takeuchi1)2) and Naoe Akiyama1)2)
1)Department of Pediatrics, Fuji City General Hospital
2)Department of Pediatrics, The Jikei University School of Medicine
Abstract
Some gastroesophageal reflux disease (GERD) cases show severe symptoms and require surgical intervention. Here, we present a case in which surgical intervention for GERD was avoided due to the introduction of Base Rice blenderized foods.
The patient was a 19-month-old girl who vomited repeatedly and was given a diagnosis of GERD at the age of 4 months. The case was also complicated with avoidant/restrictive food intake disorder, and nasogastric feeding was initiated from then on. Moreover, infections led to worsening of frequent vomiting. She had poor weight gain from the age of 12 months.
At the age of 19 months, she was hospitalized for frequent vomiting refractory to feed thickeners and antacids. Before surgical intervention, we attempted nasogastric feeding with Base Rice blenderized foods. Thereafter, the frequency of vomiting decreased, and the patient started to gain weight.
Base Rice blenderized foods have high nutritional value, and high viscosity, and have been conventionally used primarily in gastrostomy feeding in severely handicapped individuals. In children with GERD, the strategy reduced the frequency of vomiting and improved stool quality. As the food could be administered via a nasogastric tube, a trial introduction of Base Rice blenderized foods prior to considering surgical intervention is a worthwhile treatment strategy for GERD.




Case Report
Title
Two Cases of Flunitrazepam Ingestion Diagnosed by Blue Tongue
Author
Shun Kuroda1) Takateru Ihara1) Osamu Nomura1)2) Go Inokuchi3) Yoshikazu Yamagishi3) and Kosuke Kohashi3)4)
1)Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center
2)Department of Emergency and Disaster Medicine, Hirosaki University Graduate School of Medicine
3)Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University
4)Department of Pediatrics, Matsudo City General Hospital
Abstract
The characteristic physical findings of drug intoxication are rarely reported in children, and history-taking and urine screening are sometimes unreliable.
Case 1: A 4-year-old male patient presented with a Glasgow coma scale of 13. Urine screening with TriageDOA was negative. Bluish discoloration of the oral cavity and tongue and the mother's use of flunitrazepam suggested accidental flunitrazepam ingestion. The patient was eventually discharged with no new symptoms. Case 2: A 2-year-old male patient was brought to the hospital after confessing to ingesting a drug, the amount and type of which were unclear despite history-taking. Specific symptoms were denied, and urine screening with TriageDOA was negative. Blue discoloration of the oral cavity and tongue and the mother's use of flunitrazepam suggested flunitrazepam ingestion. No new symptoms appeared during hospitalization, and he was discharged on day 2. In the above two cases, drug screening by mass spectrometry detected flunitrazepam and its metabolites. These cases demonstrated the potential for false negative results in urine screening for flunitrazepam intoxication in children. Thus, if urine screening and history-taking yield uncertain results, bright blue discoloration of the oral cavity and tongue may facilitate diagnosis.




Brief Report
Title
Clinical Characteristics of 10 Children with COVID-19 in Our Hospital
Author
Junya Take Mamoru Honda Tomoko Sato Fumi Hirose Hirokazu Oguni Chikako Kamae Noriko Nakagawa Kengo Sato and Yasutomi Kuroki
Department of Pediatrics, Self-Defense Forces Central Hospital
Abstract
We report the clinical characteristics of 10 children with COVID-19 disease in our hospital. The median age was 3 years (1-13 years). Six of the patients were boys and four were girls. Nine patients had a history of familial infection. The most common clinical signs and symptoms were fever, diarrhea, cough, nasal discharge, headache, abdominal pain, and malaise in this order. The serum troponin or creatine kinase MB levels were elevated in five patients, suggesting the presence of subclinical myocardial injury. No patient had pulmonary opacity on chest X-ray. All patients were classified as "mild" and did not require therapeutic intervention. The median time of positive to negative polymerase chain reaction testing was 7 days (4-11 days).




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