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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.127, No.5, May 2023
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Original Article
Title
Examination of Re-evaluation Methods for Congenital Hypothyroidism by Levothyroxine Dose and Thyroid Ultrasonographic Findings in Children
Author
Shiori Yazawa Takumi Shibazaki Eriko Uchida Yosuke Hara Hiroki Matsuura Fumi Mizuno Chizuko Nakamura and Yozo Nakazawa
Department of Pediatrics, Shinshu University School of Medicine
Abstract
Usually, treatment for congenital hypothyroidism (CH) is initiated before the type of CH is confirmed, to prevent irreversible intellectual sequelae. In Japan, diagnostic evaluation of CH is commonly performed at 5 to 6 years of age. CH is most commonly attributable to thyroid dysplasia. Approximately 60% of all patients with thyroid dysplasia present with ectopic thyroid, and this type of CH is frequently detected for the first time during diagnostic evaluation.
I-123 scintigraphy and the perchlorate discharge test are used for re-evaluation of the thyroid. Except during infancy, ultrasonography and TC-99m scintigraphy are preferred in patients in whom only the location of thyroid gland is to be confirmed. Therefore, distinguishing between patients with suspected thyroid dysplasia and those with other types of CH may enable prompt diagnostic evaluation using a simpler approach in contrast to a more burdensome procedure. In this study, we investigated whether patients with suspected ectopic thyroid can be identified using cut-off values of the levothyroxine dose in addition to ultrasonographic findings.
We retrospectively investigated 55 patients with CH; they were categorized into ectopic thyroid and other-CH-type groups. The levothyroxine dose was significantly higher in the ectopic thyroid group than in the other-CH-type group. The optimal cut-off value of the levothyroxine dose for diagnosis of ectopic thyroid was 2.18 μg/kg/day.
TC-99m scintigraphy may simplify re-evaluation of the thyroid in patients in cases in which thyroid dysplasia is suspected based on the levothyroxine dose and ultrasonography findings performed after infancy.
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Original Article
Title
Birth Order and Age in Months of Exanthema Subitum Onset
Author
Yoshinari Inoue1) Kazushi Tamura2) Masayuki Watanabe3) and Takeshi Tomomasa4)
1)Inoue Pediatric Clinic
2)Tamura Pediatric Clinic
3)Ichigo Pediatric Clinic
4)Pal Pediatric Clinic
Abstract
Background: We investigated whether birth order was associated with the age in months of onset of exanthema subitum (ES).
Subjects and Methods: Infants diagnosed with ES between January 2018 and December 2021 were included. Cases were retrospectively tabulated from electronic medical records, and the association of birth order with the age of onset of ES was examined, taking into account factors such as sex, birth status, and COVID-19 pandemic.
Results: A total of 433 patients (224 boys and 209 girls) were included in the study, consisting of 174 firstborns and 259 secondborns and older. The secondborns and older (12 (10-16) months) had a significantly lower (P<0.001) onset than the firstborns (17 (12-23) (median (interquartile range)) months). Subgroup analyses by factor (male vs. female, full-term baby vs. preterm baby, pre-COVID-19 vs. COVID-19 pandemic) yielded similar results. Multiple regression analysis with age at ES onset as the independent variable and birth order, sex, gestational period, and COVID-19 as dependent variables revealed that only birth order was associated with age of ES onset.
Conclusion: As age of ES onset is associated with birth order, infection from older children in the family may lead to an earlier onset of ES.
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Case Report
Title
A One-month-old Infant with Immune Thrombocytopenia with Antiplatelet Autoantibodies Defined by Serological Tests
Author
Yusuke Tokuda1) Akihiro Iguchi2) Atsushi Sakamoto2) Nozomi Hiraishi1) Yoko Imai3) Toru Miyagi4) Koichi Kashiwase4) and Akira Ishiguro1)2)
1)Center for Postgraduate Education and Training, National Center for Child Health and Development
2)Division of Hematology, National Center for Child Health and Development
3)Department of Pediatrics, Japanese Red Cross Medical Center
4)Japanese Red Cross Tokyo Blood Center
Abstract
Immune thrombocytopenia (ITP) is caused by autoantibodies against platelet glycoproteins. In early infancy, reports of ITP as an autoimmune disease have been extremely rare because of the immature immune system. We report a one-month-old infant with ITP presenting with antiplatelet autoantibodies defined by serological tests. The patient had nasal obstruction at postnatal day 42. At day 50, petechiae on the face, epistaxis, and oral mucosal hemorrhage appeared. At day 51, petechial hemorrhage spread through the entire body and the patient was examined. A low platelet count of 10,000/μL was revealed in the peripheral blood, and intracranial hemorrhage was detected by computed tomography. Concentrated platelets of maternal origin were administered, which were ineffective. There were no antiplatelet autoantibodies in the maternal serum. Antiplatelet autoantibodies against platelet glycoprotein GP IIb/IIIa were detected in the serological examination of the affected infant and a diagnosis of ITP was made. After intravenous immunoglobulin and corticosteroid treatment, platelet counts increased. When thrombocytopenia is found even in early infancy with immature immune functions, we should thoroughly distinguish autoantibodies from alloantibodies for differential diagnosis.
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Case Report
Title
Subcutaneous Abscess Caused by Community-associated Methicillin-resistant Staphylococcus aureus Infection among Family Members
Author
Yohei Fukasawa1) Masaki Anraku2) Haruna Matsuda-Hirose3) Tomohiro Yamaguchi1) Rumi Ueno1) Yuuki Tsurinaga1) Amane Shigekawa1) Yuri Takaoka1) Yukinori Yoshida1) Ryuji Kawahara2) Yoko Kataoka3) and Makoto Kameda1)
1)Department of Pediatrics, Osaka Habikino Medical Center
2)Bacteriology Section, Division of Microbiology, Osaka Institute of Public Health
3)Department of Dermatology, Osaka Habikino Medical Center
Abstract
We present 3 recurrent cases of methicillin-resistant Staphylococcus aureus (MRSA)-induced subcutaneous abscess from a family. A 9-year-old boy contracted a subcutaneous abscess, which subsequently recurred. Three months later, a 1-year-old girl and a 37-year-old man contracted the disease. An identical strain of MRSA was detected in the collected pus samples, and sulfamethoxazole-trimethoprim was administered orally after confirming antibiotic sensitivity. There was no recurrence throughout the treatment. However, a similar MRSA strain was detected in the nasal cavity of a 37-year-old man, who remained a carrier despite undergoing treatment with oral antibiotics. He was eradicated with topical mupirocin ointment because he was a healthcare worker and was involved with compromised patients.
The strain detected was positive for leukocytolytic toxin PVL (Panton-Valentine leukocidin), and as there was no history of hospitalization, community-acquired MRSA infection (CA-MRSA) was diagnosed.PVL-positive CA-MRSA usually infects both healthy children and adults and often develops into soft tissue infections, especially abscess formations. In addition, if infection by the same organism is suspected, we should be careful about the spread of infection within the family and instruct infection control measures such as avoidance of contact with self-destructed abscesses and pus, in addition to disinfection of hands and environment. The recent trend of increased infection rates in Japan is a cause for concern.
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Case Report
Title
Neonatal Scabies with Difficult Diagnosis
Author
Masaaki Ueda1) Toshinori Minato1) Kanako Ogura2) Yukari Aida3) Yuya Tanaka4) and Masashi Kasai5)
1)Department of Pediatrics, Toyooka Hospital
2)Department of Dermatology, Kobe City Medical Center General Hospital
3)Department of General Pediatrics, Hyogo Prefectural Kobe Children's Hospital
4)Department of Allergy, Hyogo Prefectural Kobe Children's Hospital
5)Division of Infectious Disease, Department of Pediatrics, Hyogo Prefectural Kobe Children's Hospital
Abstract
Scabies, an infectious disease caused by the parasitism of itch mites in the stratum corneum of the skin, is usually classified into classical scabies and hyperkeratotic scabies according to clinical symptoms. In Japan, it is prevalent primarily in hospitals and facilities for the elderly. Although there is a strong impression that scabies affects only the elderly, it is a communicable disease and, therefore, can be transmitted to individuals of any age, including children. However, as it is not a disease that pediatricians encounter regularly, it is not recognized as a differential disease, and diagnosis is often delayed. We report the case of a 1-month-old female infant who experienced hyperkeratotic scabies after continued use of topical steroids.
From approximately 2 weeks after birth, eczema of the whole body worsened, and the symptoms could not be improved by administering steroids topically. Langerhans cell histiocytosis caused by lymphadenopathy was suspected, but skin and lymph node biopsy showed no malignant findings, and the patient was diagnosed with dermatopathic lymphadenopathy. Considering it to be an allergic symptom, the use of high steroid doses was continued. Though her symptoms initially improved, the classical scabies transitioned into hyperkeratotic scabies.
For eczema resistant to external steroids, it is vital to consider scabies as a differential diagnosis. It is essential to consult a dermatologist to ensure early diagnosis and treatment of scabies, even in neonates for rare cases.
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Case Report
Title
Transient Hepatitis B Surface Antigenemia after Hepatitis B Vaccination in Japan
Author
Koichi Ito1) Risa Takeda1) Takao Togawa1) Tokio Sugiura2) and Shinji Saitoh1)
1)Department of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences
2)Sugiura Kids Clinic
Abstract
It should be noted that the hepatitis B virus surface antigen (HBs antigen) test has a low frequency of false-positive results. We have encountered three cases of transient HBs antigenemia after HB vaccination. Case 1: A 2-month-old female infant. Screening test before skin biopsy for skin disease revealed HBs antigen level of 0.12 IU/mL (reference value < 0.03). The day before the examination, she had received her first dose of HB vaccine (Bimmugen®). Case 2: A 3-month-old male infant. A preterm infant admitted to the neonatal intensive care unit. Post-transfusion viral infection screening test showed HBs antigen of 0.04 IU/mL. She had received her first dose of HB vaccine (Bimmugen®) 2 days prior to the examination. Case 3: A 2-month-old female infant. The test was performed to find the cause of liver damage, and HBs antigen was 0.23 IU/mL. She had received her first dose of HB vaccine (HeptaVax-II®) the day before the examination. In all three cases, HBV infection was ruled out by subsequent examination, and they were judged to have transient HBs-antigenemia after HB vaccination. Although there have been many reports of transient HBs antigenemia after vaccination with HB vaccine products overseas, this is, to the best of our knowledge, the first report of transient HBs antigenemia after vaccination with HB vaccine products used in Japan. The recent HB vaccination status should be confirmed in patients with low HBs antigen positive results. HBs antigen testing should be avoided immediately after HB vaccination.
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Case Report
Title
Late-onset GBS Infection Initially Mimicked Diaper Dermatitis in a Preterm Infant
Author
Yuka Hanaki1) Masataka Inoue1) Manao Nishimura1) Junko Fujiyoshi2) and Megumi Takemoto1)
1)Department of Pediatrics, Hamanomachi Hospital
2)Comprehensive Maternity and Perinatal Care Center, Kyushu University Hospital
Abstract
Cellulitis in the diaper area is one of the patterns of late-onset group B streptococcus (GBS) infection. The patient, a male infant, was born at 33 weeks of gestation. On day 40 of life, cutaneous erythema and swelling in the genital and inguinal areas were noted. His mother thought it to be diaper rash and cared for it at home. Three days later, the erythema and swelling rapidly extended to the abdominal wall, back and both thighs. Although he was doing well and maintained good appetite, the blood culture grew GBS. Immediate antibiotic therapy was effective, that he was discharged without complications. There has been no recurrence nor sequelae so far.
As in this case, GBS infection presenting as cellulitis in the diaper area may be difficult to distinguish from diaper dermatitis, because it lacks generalized clinical symptoms such as fever and poor feeding initially. The lesion may expand rapidly at the same time or prior to systemic symptoms appears, which may be a trigger for diagnosis. As they may firstly visit family doctors or pediatricians in their communities, the possible clinical course and potential risks should be recognized. Rapidly expanding diaper dermatitis should be treated as soon as possible considering late-onset GBS infection, even if the infant appears well.
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Case Report
Title
Decision-making Support for Invasive Respiratory Management for Patients with Severe Motor and Intellectual Disabilities
Author
Emi Kittaka1) Yoshitaka Kusama1)2) Naofumi Kitanishi3) Satoshi Fujita1) and Naoe Akiyama1)
1)Department of Pediatrics, Fuji City General Hospital
2)Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center
3)Kitanishi Clinic for Total Family Care
Abstract
Children with severe motor and intellectual disabilities often require carefully designed medical intervention and care, and their guardians are required to make many decisions. We report here a boy with hydranencephaly who required mechanical ventilation and underwent a tracheostomy for suffocation due to aggravation of adenoidal hypertrophy following a common cold. The doctor had provided the guardians multiple times with information about the necessity of invasive intervention, such as tracheostomy, however, the guardians did not consent to tracheostomy because they had a negative impression about tracheostomy. Decrease in the frequency of hospitalization for respiratory disorder after tracheostomy suggests that the child's respiratory disorder could have stabilized earlier and suffocation could have been avoided if the intervention was performed earlier. In cases requiring routine medical care, as in this case, it is important to support the guardians' informed decision-making from various viewpoints and standpoints. In Japan, the number of children requiring medical care is increasing every year and is expected to increase further with the advancement in perinatal care. On the other hand, the support system for guardians' decision-making in the pediatric field is not sufficient. In the future, it is necessary to improve the support system for guardians' decision-making in the pediatric field.
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Brief Report
Title
Acute Myocarditis after Initial mRNA COVID-19 Vaccination in a 7-year-old Boy
Author
Mioka Jitsukawa1) Michihiko Ueno1) Keiji Haseyama1) Ryo Okumura1) Shigetoshi Ogiwara1) Soichiro Wada1) Junko Oikawa1) Takuya Tamura1) Shuji Sai1) Kazuro Hamasaki2) and Kiyoshi Nagumo1)
1)Department of Pediatrics, Teine Keijinkai Hospital
2)Department of Pediatrics, Iwanai Kyokai Hospital
Abstract
Acute myocarditis after COVID-19 vaccination is generally considered to be rare and mild. A 7-year-old boy who first received the COVID-19 vaccine (COMIRNATY®) and had a fever and vomiting the next day was moved to our hospital on day five after experiencing chest discomfort and malaise for two days prior. He was diagnosed with acute myocarditis due to abnormal findings of electrocardiography, reduced percent fractional shortening on echocardiography, and increased plasma cardiac troponin I and B-type natriuretic peptide. Moreover, he was closely monitored in the critical care unit in case he required extra rigorous therapy, but he was stable and only needed diuretics. On the eleventh day after hospitalization, his symptoms and test results progressively improved, and he was discharged. In Japan, there are few reports of myocarditis following COVID-19 immunization in young children, thus more instances are needed to understand how this problem develops.
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