2012, Vol 8, No 2
Chronic cough in children – diagnostic and therapeutic problem
Pediatr Med rodz Vol 8 Numer 2, p. 97-100
Coughing is a physiological defence mechanism against irritants that stimulate respiratory mucosa. On the other hand, it can be the first symptom of a disease. Depending on symptoms duration we distinguish acute cough, subacute and chronic cough. Cough can be paroxysmal, characteristic to asthma and pertussis or “barking” with inspiratory dyspnea occurring in croup (laryngitis subglottica); it can be also dry or productive. A particular type of cough is a postinfectious cough resulting from damage of respiratory mucosa, increased sensitivity of cough receptor and bronchial hyperresponsiveness. There is also psychogenic cough, cough accompanying allergic diseases and provoked by some drugs. Diagnosis of chronic cough include a detailed clinical history, physical examination and additional diagnostic tests. Among infectious agents, that predispose to long‑term cough, there are viruses, particularly human respiratory syncytial virus (RSV), atypical organisms – Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila, and bacteria, especially Bordetella pertussis. Apart from infectious diseases, the analysis of causes of cough in young children include the presence of gastroesophageal reflux, allergic diseases (especially asthma), chronic sinusitis, aspiration of foreign material, congenital structural abnormalities of the respiratory system and chronic respiratory diseases, including cystic fibrosis or primary ciliary dyskineswia. A cardiac causes of cough should also be considered. Often cough characteristics and accompanying symptoms may indicate its cause. In the treatment of cough we can use casual treatment and symptomatic medications among which there are antitussives and mucoactive drugs. It is permissible to use butamirate and levodropropizine in persistent dry cough. Administration of opioid agonists and preparations containing promethazine should be avoided. Mucoactive drugs include expectorants, mucolytic, mucoregulatory and mucoregulatory medications.
Keywords: cough, children, aetiology, diagnosis, treatment
Factors affecting the effectiveness of aerosol therapy in children
Pediatr Med rodz Vol 8 Numer 2, p. 101-106
Aerosol therapy is one of the most important administration routes in the treatment of many pulmonary
diseases in childhood. The basic advantage of aerosol therapy is that drugs are directly targeted at the diseased site in the lung, which warranties a more rapid therapeutic effect and possibility to lower doses of drug application. Effectiveness of inhalation is dependent on anatomical build and action of child’s respiratory system, proper drug application, droplet size, used aerosol delivery devices. Integral part of the aerosol treatment is also patients’ good education in childhood. The aerosol administration method should be focus on those inhalers which are easiest to use, correctly matched to the different age groups of children and do not require a large number of training needed to achieve the correct technique. Systems of aerosol therapy differ from each other in terms of construction, way of producing aerosol stream, optimal inhalation technique and difficulties of using. In paediatric pulmonary diseases four different systems to inhale drugs are used: pMDI (pressurized metered‑dose inhaler), pMDI with spacer, DPI (dry powder inhaler) and nebulizer apparatus. In young children who breath usually through the nose a difficulty with establishing cooperation may arise, therefore we use a face mask. Regardless of the choice the most important thing is proper and repeated education by demonstration of a breathing technique and of the inhalationprocess control. Analysis of the needs of the child with pulmonary changes is an important element of the well done inhalation treatment.
Keywords: aerosol therapy, nebulizer treatments, inhalations in children, systems of aerosol therapy, inhalation technique
Sore throat – when local treatment is enough?
Pediatr Med rodz Vol 8 Numer 2, p. 107-110
Sore throat is one of the most frequent reason of visiting physician. The essence of a sore throat is inflammation on the growing surface infection. Viral infection are the cause of pharyngitis and tonsillitis in 70‑85% in children and in 90‑95% in adults. Usually these are rhinoviruses, coronaviruses, adenoviruses, Epstein‑Barr virus, Coxsackie, herpes simplex and influenza and parainfluenza viruses. Bacterial sore throats are usually caused by beta‑hemolytic group A streptococcus, mainly Streptococcus pyogenes. Regardless of aetiology, the infection occurs by respiratory droplets and by contact with nasopharyngeal secretions of the diseased person. Diagnosis of a sore throat based on carefully collected data from medical history and physical examination. Sometimes it is necessary to perform a quick test or laboratory tests in the direction of streptococci. Distinguishing bacterial from viral infections is important because of the significantly increasing antibiotic resistance and a worldwide tendency to antibiotics overuse. First, the treatment should be symptomatic. It is advisable to use anti‑inflammatory drugs, analgesic and local treatment with painkillers and substances that reduce the inflammation (e.g. benzydamine hydrochloride, flurbiprofen, choline salicylate, chlorquinaldol). In case of the bacterial aetiology, first‑line antibiotic is penicillin, alternatively first generation cephalosporin or amoxicillin and in the case of allergic reactions – macrolides.
Keywords: sore throat, virus, Streptococcus pyogenes, local treatment, antibiotics
Azithromycin in outpatient setting
Pediatr Med rodz Vol 8 Numer 2, p. 111-119
Introduction: Azithromycin, broad spectrum macrolide antibiotic with familiar therapeutic schedule has been
commonly used in outpatient clinical practice in patients over 2 years. The aim of the study was to gain the
data of azithromycin preparations usage, focusing on the causes resulting in final therapeutic decisions.
Material and method: Project had been realized as a retrospective survey based on documented cases
of azithromycin therapies realized in outpatient setting. The demographic and anamnestic data were collected, as: diagnosis made, therapeutic schedule, causes of such decisions, eventually recommended control visit and patient’s therapeutic adherence. Data obtained were statistically analysed with Statistica 9.0 PL software. Results: The 27 850 cases of azithromycin usage in patients over 2 years were analysed. The main indications for azithromycin therapy were the respiratory tract infections, probability of bacterial aetiology. The decisions were made mostly upon clinical examination. In about 20% of cases azithromycin was used as a second one antibiotic. One third of cases were not recommended the control visit, but from the rest only about 70% were realized. Almost 96% of patients did not realized the treatment according to recommended schedule despite the mostly well treatment tolerance. Conclusions: 1) In outpatient clinical practice azithromycin is used mainly as an antibiotic of first choice, mostly in respiratory tract infections, despite epidemiological data suggesting their mainly viral aetiology. 2) The common practice is an empirical azithromycin recommendation, judged as a highly effective therapy. 3) Except of good tolerance and familiar treatment schedule, almost all of patients did not realized the treatment completely. 4) The knowledge of rational antibiotics usage should be widely propagated in Polish community.
Keywords: azithromycin, retrospective study, outpatient setting, empirical antibiotic therapy, therapeutic adherence
Small intestinal bacterial overgrowth in children with abdominal pain
Pediatr Med rodz Vol 8 Numer 2, p. 120-123
Although little bacteria colonize upper part of alimentary tract, its microflora is very diverse. In normal conditions intestinal bacteria remain in balance, they constitute barrier, protecting us from infections. Qualitative as well as quantitative disturbance of the microflora has a negative influence on digestion and absorption. Small intestine bacterial overgrowth (SIBO) is defined as an increased number of nonpathogenic bacteria – over 105 organisms in 1 ml of small intestine content. The aim of the study is to assess the frequency of SIBA among children with abdominal symptoms. Material and methods: The study consisted of 83 children (43 girls and 40 boys) aged 4‑17 (mean 11±3.56 years). After excluding organic disorders, hydrogen breath test with lactulose (administered per os) was established among them. Expired air was analysed using Gastrolyzer by Bedfont. Results: Gastrointestinal symptoms were analysed. It appeared that abdominal pain was the most common symptom among 47 (54%) children (among them 27 girls and 20 boys). Eighteen (21%) patients presented additional symptoms that coexisted with abdominal pain. HBT result was positive among 59 (71%) patients – 32 (74%) girls and 27 (68%) boys. Conclusions: Among patients with abdominal pain about 70% presented positive result of HBT.
Keywords: small intestine bacterial overgrowth, hydrogen breath test, bacterial intestine microflora, abdominal pain, children
Efficacy and tolerance of chronic pain treatment with modified extended‑release ketoprofen in osteoarthritis
Pediatr Med rodz Vol 8 Numer 2, p. 124-129
Introduction: Modified, extended‑release ketoprofen formulations are commonly used in the treatment
of osteoarthritis. The aim of the study was the evaluation of efficacy of chronic pain treatment with modified
extended‑release ketoprofen in monotherapy or polytherapy in osteoarthritis and the monitoring of possible
adverse events. Material and methods: Twenty‑three thousand two hundred and forty patients treated with
extended‑release ketoprofen for 3±2 weeks because of pain associated with osteoarthritis participated in post‑marketing survey. Pain intensity was assessed in a 10‑point visual analogue scale (VAS). Results:
The intensity of pain in patients treated with extended‑release ketoprofen preparations at a dose of 154±41 mg and other analgesics (32.7% of respondents) was 5.28±1.97 points. During a subsequent visit, previous treatment was maintained in 66.8% patients, including 51.8% patients on ketoprofen monotherapy and 15.0% treated with additional anti‑inflammatory agent. Daily dose of ketoprofen was increased in 27.9% patients, while in 7.7% of patients an increase or the use of another anti‑inflammatory drug was recommended. Twelve point four percent of patients reported at control visit discontinued the treatment with ketoprofen. A more marked reduction of pain intensity was observed in patients with increased (by an average of 60 mg) extended‑release ketoprofen dose (‑60.7%), than in those with increased dose or use of another anti‑inflammatory drug (‑44.0%). Adverse events was reported by 11.67% responders. Ketoprofen therapy was discontinued by 29.5% of patients who experienced an adverse drug reaction and by 10.2% of patients without any side effect. Non‑occurrence of adverse drug reaction was associated with a 3.69‑fold greater chance of treatment continuation. Conclusions: 1) Extended‑release ketoprofen preparations in monotherapy allow a satisfactory pain control in half of patients with osteoarthritis. 2) Adverse drug reactions associated with the use of ketoprofen preparations cause discontinuation of treatment in every third patient.
Keywords: ketoprofen, extended‑release formulations, pain, osteoarthritis, efficacy, tolerance
Clinical examination of young athlete – sports cardiologist’s point of view
Pediatr Med rodz Vol 8 Numer 2, p. 130-136
The meaning of physical activity for maintenance of a healthy life, normal growth and development of children and adolescents is well known. A regular sport training causes favourable functional changes including improvement in cardiopulmonary or metabolic status. Despite these benefits, vigorous physical exertion may trigger mechanisms leading to sudden death in athletes with unrecognized cardiac disorders. That’s why the regular cardiovascular screening in all young competitive athletes in needed. Complete medical examination of young athletes (including a medical personal and family history and physical examination) should give information about functional status of cardiovascular system. Physical examination should include auscultation in supine, seated and upright position, palpation of peripheral pulses, accurate measurement of blood pressure and looking for findings of Marfan syndrome. Physical examination may reveal signs of cardiovascular effects of adaptation to long‑term sport activity, i.e., enlargement of the heart (increase of dimensions, wall thickness and mass of left ventricle) and a slow pulse rate at rest as a result of vagal tone increase.Another target of cardiovascular examination of young athletes is to identify underlying heart disease (especially in aspect of prevention of sudden cardiac death) requiring the extension of diagnostic workup. The main aim of this paper is to give for paediatricians and family doctors some practical information helpful in proper interpretation of physiological, adaptive circulatory changes in relation to long‑term physical activity and identification of cardiac pathologies threatening of sudden death in association with sporting activity.
Keywords: cardiovascular system, medical history, physical examination, young athletes, sudden cardiac death
Electrical stimulation – modern treatment of heart rhythm and conduction disorders. Management of patient with pacemaker and implantable cardioverter‑defibrillator
Pediatr Med rodz Vol 8 Numer 2, p. 137-147
Electrical stimulation is an undisputable, effective and wide‑spreading method of treating heart rhythm disorders. Currently there are 5 millions people living with implantable heart pacemakers. Electrical stimulation initializes electric activity in case of the absence of heart’s own activity. Basic pacemakers are single or dual chamber and also it is possible to program very specific parameters of stimulation. The number of people living with implanted cardioverter‑defibrillator (ICD) increases recently, in cases of primary or secondary prevention of sudden cardiac death. ICD recognizes brady‑ and tachyarrhythmias, terminates ventricular arrhythmias by means of cardioversion or defibrillation, ICD is able to stimulate cardiac rhythm and also enables the ECG recording during arrhythmia. The main clinical problems associated with pacemaker or ICD are function disorders of the device, infective complications, damage caused by the electromagnetic field and anxiety disorders. The patient qualified to implantation pacemaker or ICD should gain detailed information about indications for electrical stimulation, benefits but also restrictions connected with the therapy. It is very important to stay under the care of specialized medical unit, undergo necessary controls and be aware of basic rules in daily life, such as avoiding exposure on electromagnetic interferences, because they may influence the pacemaker or ICD. There is no doubt in effectiveness and legitimacy of implanted cardioverters‑defibrillators, but still exists the problem of the patient’s intolerance for hurtful, unpleasant interventions witch may achieve high energy. The patient’s anxiety should be reduced by precise and reliable information and permanent cooperation between doctor and patient.
Keywords: electrical stimulation, heart pacemaker, implantable cardioverter‑defibrillator, arrhythmia, electromagnetic interference
Bradycardia with MAS syndrome in 87 years old female patient in the course of stimulation disorders caused by mechanical damage of atrial electrode – a case report
Pediatr Med rodz Vol 8 Numer 2, p. 148-157
The rapid development of modern medicine causes the implementation of more efficient, but also more complicated forms of treatment. An important role is played by electrophysiological techniques, among which the most common are heart pacemakers or systems stimulating the heart. The number of the heart pacemakers implantation is still increasing, and the population of patient with such devices is still growing. In Poland, 16 000 such devices are implanted every year, and 60‑70% of cases are the first implantations. Indications for this form of therapy are determined by the societies of cardiology and continuously modified due to the reliable results of randomized clinical trials. The heart pacemakers are used first of all in the treatment of patients with severe, symptomatic disorders of electrical conduction system of the heart. With the more widespread access to this form of therapy, it seems to be very important to know its possible failures, such as early and late surgical complications and non‑surgical problems. This paper describes the case of a female patient who experienced bradycardia with Morgagni‑Adams‑Stokes syndrome i.e. short, frequently recurring episodes of fainting or loss of consciousness due to hypoxia of central nervous system, caused by extreme slowing or stopping the heart rhythm. These symptoms occurred in the course of stimulation disorders caused by mechanical damage of atrial electrode. Rapid and accurate diagnosis allowed to implement proper treatment. Patient underwent the damaged lead extraction and the replacement of the heart pacemaker to new dual chamber device. This form of therapy was effective, the patient was released from symptoms. Such treatment significantly improved patients prognosis.
Keywords: heart pacemaker, conduction disturbances, stimulation disorders, MAS syndrome, lead extraction
Asymptomatic angina pectoris in patient with metabolic syndrome – a modern non‑invasive tests for the diagnosis and evaluation of treatment effect
Pediatr Med rodz Vol 8 Numer 2, p. 158-164
All components of the metabolic syndrome increases the risk of cardiovascular diseases, and diabetes is considered to be a particularly strong negative prognostic factor. Patients with diabetes often deny typical angina symptoms, complaining only nonspecific shortness of breath, excessive sweating, fatigue, exhaustion. At the same time its presence is associated with a significant underestimation of coronary artery disease, later diagnosis of cardiac ischemia, suboptimal drug therapy and less frequent coronary interventions. The authors present a case of a patient with metabolic syndrome (angina symptoms denier), diagnosed due to discrete electrocardiographic abnormalities. A sequence of noninvasive imaging (nuclear exercise stress test, echocardiography with speckle tracking imaging) enabled the identification and assessment of the effect of treatment of advanced coronary artery disease. Especially valuable was the observation of delayed ST segment elevation during the recovery phase of the nuclear exercise stress test, which is a very rare phenomenon, suggesting a significant narrowing of the epicardial vessel. In presented case, the diagnosis of coronary artery disease was established with use of modern imaging techniques, which guarantee the safety of the patient. The use of these highly reliable diagnostic methods enabled the detection of critical stenosis of the right coronary artery that in the near future could result with acute coronary syndrome, as the first clinical manifestation of coronary artery disease. In case of any diagnostic doubts, especially in asymptomatic patients with high cardiovascular risk, the personalized approach and use of all available imaging tools should be recommended.
Keywords: metabolic syndrome, coronary heart disease, diabetes, coronary angioplasty, cardiovascular risk
Hereditary angioedema – patient preparation for surgery
Pediatr Med rodz Vol 8 Numer 2, p. 165-167

Hereditary angioedema (HAE) is a rare condition, first described by Quincke in 1882. Diminished levels of the C1 inhibitor protein of dysfunctional forms of the same protein are basis of this disease pathophysiology. We mark out three types of HAE. Type I, most common, is related with C1 INH insufficiency, type II – with its abnormal function. Mucous oedemas are characteristic for these diseases, including face and larynx oedema. Oedema involving larynx can be life‑threatening condition. HAE swelling can be caused by some drugs, especially from angiotensin convertase inhibitors group, stress, trauma, infections. Surgical procedures can predispose to HAE related larynx swelling. Surgery preparation can involve continuous intubation tube cuff pressure control, doubling androgen based drugs doses as well as transfusion of fresh frozen plasma. Acute HAE swelling management is recently based on cause treatment covering substitution C1 INH. We describeV46 years old patient ongoing gynaecologic surgery with prophylactic C1 INH concentrate application (Cinryze). No complications were observed during surgery, subarachnoid anaesthesia or post‑surgery period.

Keywords: hereditary angioedema, anaesthesia, allergology, C1 inhibitors, premedication
Splenic rupture during the colonoscopy – a case study
Pediatr Med rodz Vol 8 Numer 2, p. 168-171
Introduction: Colonoscopy is routinely performed test in the diagnosis and prevention of colon diseases. Splenic rupture is a rare complication, 80 cases described so far. Case study: Patient at age 72, hospitalized with anaemia. During the colonoscopy – polypectomy of sigmoid colon polyp. In the second day after treatment: the morning syncope, hypotension, positive peritoneal signs. Additional examinations: X‑ray: no change, USG and CT scan: splenic rupture with a large hematoma, a large amount of blood in the peritoneal cavity. The patient was qualified for laparotomy by which it was found: blood in the peritoneal cavity, spleen rupture, liver capsule ruptured, stomach with a small hematoma, mesentery colon hematoma, no perforation of the colon. Discussion: Splenic rupture is a rare but serious complication of colonoscopy. Mechanisms leading to splenic rupture: direct trauma, traction system ligament, pulling adhesions between the spleen and the purse. Start of symptoms could occur as from 1 hour up to 2.5 days, usually until 24 hours after colonoscopy. Time to determine the diagnosis: as from 2 hours up to 13 days, mostly before 24‑48 hours. The most commonly used methods for the diagnosis: CT scan, USG. Conclusion: Persons performing endoscopic examination as well as patients undergoing colonoscopy should be aware of the possibility of splenic rupture. In the case of indication of the factors predisposing to complications, in asymptomatic patients an observation for 24 hours after the colonoscopy is recommended as well as USG. If symptoms of splenic rupture appeared, USG and CT should be urgently carried out.
Keywords: colonoscopy, splenic rupture, complications, mesenteric hematoma, hemoperitoneum
Peritoneally dialysed patient with pseudotumour cerebri
Pediatr Med rodz Vol 8 Numer 2, p. 172-175
Introduction: Pseudotumour cerebri (idiopathic intracranial hypertension) is diagnosed when several symptoms coexist: headaches, papilledema, increased cerebrospinal fluid pressure (without any cytologic or chemical abnormalities in it). Neuroimaging shows no pathology either. Aim: The aim of this work is to present a case of 16‑year‑old girl who has been receiving peritoneal dialysis. End stage renal disease developed on the basis of focal segmental glomerulosclerosis. Despite of many therapeutic methods used (steroids, cyclophosphamide, angiotensin convertase inhibitors, plasmapheresis), after three years she required dialysis. Few month after commencing dialysis, in ophthalmologic consultation (routine one, which was required for renal transplantation qualification), papilledema was diagnosed. The patient did not report any symptoms that could suggest intracranial hypertension. The magnetic resonance did not reveal any focal pathology. Neurologist suggested the diagnosis of pseudotumour cerebri and applied acetazolamide with increased dose of antihypertensives. The papilledema resolved after 3 months. Conclusions: Pseudotumour cerebri symptoms are rare but can be the reason for such pathology as papilledema or headaches among dialysed children. There are single cases in the literature. Poorly regulated hypertension or fluid overload can be risk factors for idiopathic intracranial hypertension.
Keywords: pseudotumour cerebri, idiopathic intracranial hypertension, peritoneal dialysis, end stage renal disease, children
Variable, clinical course of the cat scratch disease
Pediatr Med rodz Vol 8 Numer 2, p. 176-179
Cat scratch disease, i.e. an infection caused by Bartonella henselae bacteria, is an infectious disease rarely diagnosed in Poland. Around the world the infection can be found in all age categories. Children are a group of high risk due to close, frequently unsupervised, contacts with pets. An infected animal – a cat, guinea pig, rabbit, sometimes a dog– transmits the disease when it bites or scratches a person’s skin. The primary change is a lump that appears on the scratched skin surface. It gradually transforms into a scab as well as grows into a painful lymphadenopathy, which may stay for up to a few months. The collateral symptoms include: high fever, copious sweat as well as a considerable fatigue, which overall may suggest an ongoing cancerous process. In about 10% of patients there occurs an extranodal form of infection, which manifests itself by: endocarditis, encephalitis, conjunctivitis and choroiditis, hepatitis as well as erythema nodosum. This research exemplifies clinical cases of various courses of cat scratch disease, which were dependent, first and foremost, on the amount of time passed between the contact with the infected animal and the diagnosis. The paper emphasizes the importance of both: the correct anamnesis regarding the patient’s contact with pets and an early diagnosis of the disease in children as the conditions that substantially improve the results of cat scratch disease treatment. A correct diagnosis of cat scratch disease in its primary form by the pediatrician or a general practitioner decreases the trauma of the child patient that may be induced by additional diagnostic tests conducted with the view to excluding a cancerous disease.
Keywords: cat scratch disease, Bartonella henselae, child, local lymphadenopathy, infectious disease