|
THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
|
Vol.128, No.4, April 2024
|
Original Article
Title
Multicentered Study on Prolonged Symptoms Following COVID-19 Immunizations in Children
Author
Yuho Horikoshi1) Takayuki Yamanaka2)3) Yuta Aizawa3) Yukitsugu Nakamura4) Takayo Shoji5) Toshihiko Okumura6) and Yoshiaki Cho7)
1)Division of Infectious Diseases, Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center
2)Department of Pediatrics, Niigata City General Hospital
3)Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences
4)Department of Pediatrics, St. Marianna University School of Medicine
5)Division of Pediatric Infectious Diseases, Shizuoka Children's Hospital
6)Department of General Pediatrics, Aichi Children's Health and Medical Center
7)Division of Pediatric Infectious Diseases, Department of Pediatrics, Nanbu Medical Center & Children's Medical Center
Abstract
Backgrounds & Objective: Although adverse events following immunization for COVID-19 vaccines could include various prolonged symptoms such as immunization stress-related reactions, it has not been well-described in Japan. The aim of our study is to describe characteristics of prolonged symptoms following COVID-19 immunization.
Methods: Patients with prolonged symptoms following COVID-19 immunization were included at 7 pediatric institutions in Japan between June 2021 and March 2023. Medical charts were reviewed retrospectively for age, sex, comorbidities, diagnosis, any influences on daily life and its duration, and prognosis.
Results: A total of 46 patients were identified. The age range was 6-17 (average 13.1, Standard Deviation 2.0) years. Girls were comprised of 43%. Among them, 45% had comorbidities which were allergy (19%), pervasive developmental disorder (13%), mental retardation (6%) and psychiatric disorder (6%). Diagnoses were chronic headache (28%), psychosomatic disorder (26%), dissociative neurological symptom reaction (DNSR) (17%), idiopathic chest pain (17%), orthostatic dysregulation (17%), psychogenic pyrexia (6%) and complex regional pain syndrome (CRPS) (4%). Among them, 76% of patients had influences on their daily life, which were school absenteeism (63%) and motor disorder (6%) for a median of 4 (interquartile range 5-7) months. Prognoses were resolution (37%), remission (22%), improvement (4%), and no improvement (37%).
Conclusion: Most of the diagnoses were ones commonly seen in adolescents, but DNSR and CRPS were also observed. To maintain vaccine confidence, it is critical to evaluate and care for those symptoms following immunizations.
|
|
Case Report
Title
Infantile Pyknocytosis in Two Siblings
Author
Makoto Nakamura Yuriko Watanabe Yuto Sunaga Koichi Makino Kinuko Saito Atsushi Nemoto and Satoru Kojika
National Health Insurance Fujiyoshida Municipal Hospital
Abstract
Infantile pyknocytosis (IP) is a rare cause of neonatal jaundice associated with transient hemolytic anemia. Occasionally, frequent red blood cell (RBC) transfusions are required, but its etiology has not been determined. The diagnosis is based on cytological examination revealing numerous distorted, contracted, and densely stained RBCs with spiny projections, namely pyknocytes, and excluding other causes of hemolytic anemia. We describe the case of two sisters with IP who presented with jaundice and hemolytic anemia shortly after birth. The older sister's symptoms lessened after phototherapy was performed up to 3 days of age. The younger sister fully recovered after phototherapy was conducted up to 20 days of age, and packed RBC transfusions were performed four times up to 26 days of age. No abnormalities of the RBCs were identified on the blood films of both patients after the age of 4 months, suggesting spontaneous remission. The small and hyperdense RBCs of the sisters lacked the characteristic morphologic appearances of IP, such as projections and distortions. However, their clinical courses and the flow-cytometric osmotic fragility test (FCM-OF) of the younger sister confirmed IP. In addition to the evaluation of the morphology of the RBCs, the osmotic fragility and eosin-5-maleimide binding tests should be performed for cases of neonatal-onset hemolytic anemia. In some patients with IP, including the two current cases, it is difficult to detect the pyknocytes on blood films. Therefore, establishing supporting diagnostic methods, such as FCM-OF and detection of RBCs with Heinz bodies, is essential for improving IP diagnosis rates.
|
|
Case Report
Title
Fulminant Myocarditis with Symptoms Like Multisystem Inflammatory Syndrome in Children Following COVID-19 Vaccination
Author
Kohei Yamada1)2) Yoichiro Ishii1) Kunihiko Takahashi3) Muneyuki Takeuchi2) Yusuke Matsuda4) and Hisaaki Aoki1)
1)Department of Pediatric Cardiology, Osaka Women's and Children's Hospital
2)Department of Pediatric Intensive Care Unit, Osaka Women's and Children's Hospital
3)Department of Pediatrics, Toyonaka Municipal Hospital
4)Department of Pediatrics, Kanazawa University Hospital
Abstract
Although some cases of multisystem inflammatory syndrome in children (MIS-C) after a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported, reports of similar symptoms after the COVID-19 vaccination are rare. We encountered a case of a 15-year-old girl who presented with MIS-C-like symptoms and developed fulminant myocarditis after COVID-19 vaccination. She had a fever and a skin rash one week after receiving the vaccine. Three days after the illness, she experienced bulbar conjunctival hyperemia and visited a local hospital. The patient was treated with antibiotic therapy without improvement. She was diagnosed with fulminant myocarditis based on the findings of elevated creatine kinase and cardiac dysfunction. The patient was administered a catecholamine injection, high-dose immunoglobulin therapy, and steroid pulse therapy. Cardiac catheterization performed on day seven after an illness showed a left ventricular ejection fraction of 38% and a left ventricular end-diastolic pressure of 32 mmHg, indicating severe systolic and diastolic dysfunction. A myocardial biopsy revealed loss of myocardial fibers and fibrosis, suggestive of myocarditis. Cardiac function recovered gradually. The patient was discharged 24 days after hospitalization. Despite ruling out viral infections and autoimmune disease, the patient fulfilled the diagnostic criteria for MIS-C. Furthermore, the cytokine profile showed a pattern of elevated interleukin-18 and soluble tumor necrosis factor receptors 1 and 2, unlike Kawasaki disease and systemic juvenile idiopathic arthritis. The COVID-19 vaccination may induce MIS-C-like symptoms in some individuals, necessitating vigilant monitoring for complications such as fulminant myocarditis.
|
|
Case Report
Title
A Case of Lupus Podocytopathy Diagnosed in a Female Adolescent Following Asymptomatic Hematuria and Proteinuria Detected by a Urine Test at School
Author
Tatsuya Nishimura1) Takaya Iida1) Yuzaburo Inoue2) Kanako Mitsunaga2) Chie Naito2) Yuki Naruke3) and Masataka Hisano1)
1)Department of Nephrology, Chiba Children's Hospital
2)Department of Allergy and Rheumatology, Chiba Children's Hospital
3)Department of Diagnostic Pathology, Chiba Children's Hospital
Abstract
Lupus nephritis is a well-known kidney manifestation in systemic lupus erythematosus (SLE), typically associated with immune-complex deposition. However, several cases of lupus podocytopathy (LP) have been reported recently. LP characteristically presents with nephrotic syndrome (NS), without immune-complex deposition. We report a pediatric case of LP, diagnosed following the development of NS subsequent to initially asymptomatic urine irregularities.
A 14-year-old girl was referred to our hospital due to hematuria and proteinuria detected by a urine test at school. She had severe proteinuria, not causing NS, and positive antinuclear antibody. A kidney biopsy examination showed mesangial proliferation, and immunofluorescence detected mild IgG and C3 mesangial deposits, but not in the capillary wall. Electron microscopy revealed foot process effacement across more than 90% of podocytes. While she met the diagnostic criteria for SLE clinically, she was followed up with no treatment as unknown nephritis since the histological findings were atypical for lupus nephritis. However, she developed NS after eight months and was diagnosed with LP. Moreover, she was diagnosed with lupus enteritis based on the presence of chronic digestive symptoms and enhanced CT findings. She responded to immunosuppressive agents including steroids and we observed improvements in digestive symptoms and urine findings.
Lupus podocytopathy should be considered in patients with SLE with kidney involvement but lacking immunoglobulin and complement deposition on immunofluorescence microscopy. Even though the present proposed diagnostic criteria for LP require the presence of NS, we should recognize that patients in the early stages of LP may only present with asymptomatic hematuria and proteinuria.
|
|
Case Report
Title
Scrofuloderma after Bacille Calmette-Guérin Vaccination
Author
Akihiko Shimizu1) Mariko Shimizu2) and Shigeru Nomura2)
1)Department of Infectious Diseases, Gunma Children's Medical Center
2)Department of Allergy and Rheumatology, Gunma Children's Medical Center
Abstract
Bacille Calmette-Guérin (BCG) vaccine is effective in preventing tuberculosis meningitis or miliary tuberculosis in children and has been used as a routine immunization in Japan. Although lymphadenitis or subcutaneous abscesses are sometimes observed as adverse reactions after BCG vaccination, scrofuloderma, a form of true cutaneous tuberculosis, is rarely reported. Herein, we report a case of a 7-year-old girl who developed scfuloderma after BCG vaccination. The patient developed induration and abscess at the site of the vaccination and ulcerated two years and seven months after the vaccination. She received antibiotics and steroid ointment, then incision drainage was performed. The patient was referred to our hospital because she repeatedly experienced exacerbations. Mycobacterium tuberculosis complex was detected at the previous hospital, and was identified as BCG by genetic analysis. We diagnosed her condition as scrofuloderma. She was treated with a combination of riampicin and isoniazid, and the local findings improved. A genetic screening for congenital immunodeficiency syndrome revealed no known genetic mutations. True cutaneous tuberculosis, including scrofuloderma, is a rare adverse reaction after BCG vaccination. In cases of refractory ulcers with negative bacterial cultures, BCG should be listed as a causative organism. Delayed diagnosis and treatment may lead to unnecessary treatment and cosmetic sequelae.
|
|
Case Report
Title
Diagnosis of Congenital Tracheal Stenosis and Tracheal Bronchus Using Abnormal Chest Radiographs in an Infant
Author
Hiroki Okamoto1) Yugo Takaki1) Syungo Yamamoto1) Yuki Takanarita2) Tadashi Hatakeyama2) Tomohiko Imamura3) and Katsuki Hirai1)
1)Department of Pediatrics, Kumamoto Red Cross Hospital
2)Department of Pediatric Surgery, Hyogo Prefectural Kobe Children's Hospital
3)Department of Pediatrics, Kumamoto City Hospital
Abstract
Recurrent wheezing in infants has multiple differential diagnoses, one of which is congenital tracheal stenosis. In patients with recurrent wheezing, respiratory failure may be rapidly triggered by infection or other conditions, leading to a fatal course. Therefore, early diagnosis is critical. We report a case of a male infant (aged 1 year and 6 months) with tracheal bronchus and congenital tracheal stenosis, whose diagnosis was based on abnormal shadows on chest X-ray. He was referred to our hospital for detailed examination of recurrent pneumonia that started 11 months after birth. The patient had biphasic stridor accompanied by retractive breathing, with wheezing heard from both the lung fields. Upon chest X-ray, a hyperlucent area in the right upper lung field and a hypolucent area were noted, suggesting pneumonia in the right lower lung field. Upon plain chest computed tomography, right tracheal bronchus was detected, and lobar emphysema was observed in an area corresponding to the segmental branches of the right tracheal bronchus. Moreover, part of the trachea, caudal to the bifurcation of the right tracheal bronchus, was narrowed. Bronchoscopy revealed that the right tracheal bronchus and a part of the trachea, caudal to the bifurcation of the right tracheal bronchus, formed complete cartilage rings, and the patient was diagnosed with congenital tracheal stenosis. We retrospectively checked his chest X-ray images and confirmed the bifurcation of the right tracheal bronchus. Since our diagnosis, his respiratory status improved by medical treatment, and he has not developed respiratory failure after subsequent infection. If a patient recurrently has biphasic stridor or if their chest X-ray images repeatedly show changes in lucency of the lung fields, air tracheograms should be carefully interpreted. Therefore, detailed examination should be performed, and congenital complications, including those of the respiratory tract, should be considered for differential diagnoses.
|
|
|
Back number
|
|
