2016, Vol 12, No 2
RSV infection and recurrence of respiratory tract obstruction in children
Pediatr Med Rodz 2016, 12 (2), p. 118–125
DOI: 10.15557/PiMR.2016.0010

Viruses, including the respiratory syncytial virus, are the most common aetiological factor of respiratory infections in children. The disease most often occurs between November and April in the northern climate zone, with a peak incidence in January and February. A total of 90% of children up to 2 years of age become infected with respiratory syncytial virus. The virus is recognised as the most common pathogen causing bronchiolitis and pneumonia in children up to 2 years old. Respiratory syncytial virus infection is the cause of 17–20% of all infantile hospitalisations. It stimulates both humoral and cellular responses of the immune system, which involves a number of cells (neutrophils, eosinophils) and inflammatory mediators (IL-1, IL-5, IL-6, IL-11, TNF-α, MIF-1a, IL-8, RANTES). It is assumed that apart from its effects on the immune system, respiratory syncytial virus also affects the neurogenic regulation of respiratory smooth muscle tension, resulting in bronchial contraction. Respiratory syncytial virus infection leads to lymphocyte Th1/Th2 imbalance with the dominance of Th2, which can indicate a further relationship with asthma. The correlation between early respiratory syncytial virus infection and the recurrence of post-infection wheezes and asthma development later in life constitutes a subject of numerous discussions. Long-term research demonstrated a relationship between respiratory syncytial virus infections and obstructive ventilatory impairment in the first decade of life. However, no clear causal relationship was found. It is assumed that respiratory syncytial virus infection can only manifest in children with genetic predisposition to this type of response.

Keywords: RSV, bronchial asthma, obstruction, bronchiolitis, viruses
Melatonin – a pleiotropic hormone
Pediatr Med Rodz 2016, 12 (2), p. 127–133
DOI: 10.15557/PiMR.2016.0011

Melatonin, a tryptophan derivative, is synthesised in mammals mainly in the pineal gland. It coordinates the biological clock by regulating the circadian rhythm. Its production is dependent on light and its concentrations change with age. Thanks to its specific chemical structure, melatonin is capable of crossing all biological barriers in the organism and affecting other tissues and cells, both in indirect and direct ways. Its mechanism of action involves binding with membrane receptors, nuclear receptors and intracellular proteins. Melatonin shows antioxidant activity. Moreover, its immunomodulatory and antilipid effects as well as its role in secreting other hormones, such as prolactin, luteinizing hormone, follicle-stimulating hormone, somatotropin, thyroliberin, adrenocorticotropin hormone or corticosteroids, are essential. In the recent years, research studies have been mainly focussed on the potential influence of melatonin on the aetiology and development of various disease entities, such as sleep disorders, gastrointestinal diseases, cancers, psychiatric and neurological conditions, cardiovascular diseases or conditions with bone turnover disorders. Indications for melatonin use in paediatrics are being discussed more and more frequently. Among others, authors debate on its use in dyssomnias in children with neurodevelopmental disorders, such as attention deficit hyperactivity disorder, supportive treatment in febrile seizures and epilepsy as well as potential use in paediatric anaesthesia. The molecular mechanism and broad-spectrum action of melatonin have not been sufficiently researched and its clinical relevance is often underestimated. This hormone is a promising link in achieving alternative therapeutic solutions.

Keywords: melatonin, circadian rhythm, melatonin use
A new look at the etiopathogenesis of adolescent idiopathic scoliosis
Pediatr Med Rodz 2016, 12 (2), p. 134–140
DOI: 10.15557/PiMR.2016.0012

Adolescent idiopathic scoliosis is the most common form of spinal deformity in children. The aetiology of the condition has not been elucidated. Currently, the multifactorial theory seems to be the most probable. Certain authors propose that melatonin should be considered as a causative factor of adolescent idiopathic scoliosis. Their assumption is supported by a range of research studies conducted on animal models with removed pineal gland, which induced scoliosis. Melatonin has been proven to exert direct and indirect effects on the development of the skeletal system. The role of calmodulin or osteoprotegerin seems equally important. In patients with this condition, the levels of platelet calmodulin and calmodulin in the specimens of the paraspinal muscles on the convex side of the curve have been shown to rise. Osteoprotegerin, in turn, modifies osteoclastic and osteoblastic differentiation. These substances have a direct influence on the cellular calcium and phosphate metabolism and can be potentially responsible for spinal deformity in adolescents. The role of oestrogens is being investigated. Moreover, the role of growth factors or thrombospondins still remains obscure. Additionally, molecular tests have revealed a number of genes that can predispose to adolescent idiopathic scoliosis. It still needs to be determined which of the musculoskeletal disorders occur first in the development of scoliosis and which are secondary to the deformity. The identification of the aetiological factor and factors responsible for scoliosis progression determines the manner of treatment.

Keywords: idiopathic scoliosis, aetiology, melatonin, calmodulin, osteoprotegerin
Streptococcal tonsillopharyngitis – principles of diagnosis and treatment
Pediatr Med Rodz 2016, 12 (2), p. 141–149
DOI: 10.15557/PiMR.2016.0013

Tonsillopharyngitis is one of the main causes of medical appointments. In fact, a seemingly simple diagnosis and treatment causes various problems and is the reason of many problems and errors, including antibiotic misuse or overuse. The most frequent aetiological agents of pharyngitis relate to viruses. A carefully taken medical history and physical examination can help distinguish patients in whom bacterial (streptococcal) aetiology should be suspected. However, signs and symptoms themselves do not usually allow the correct diagnosis to be established. A clinical suspicion of bacterial infection must be confirmed microbiologically. The best practice is a throat culture. Rapid tests for the presence of Streptococcus pyogenes antigen are a convenient alternative. They are characterised by high sensitivity and specificity. The first-line treatment in streptococcal tonsillopharyngitis is phenoxymethylpenicillin used for 10 days. Streptococcus pyogenes is uniformly sensitive to this antibiotic. Cefadroxil is reserved for patients with non-immediate hypersensitivity to penicillin and Streptococcus pyogenes carriers. Macrolides, in turn, should be used only if immediate hypersensitivity occurs. In this case, 3–5-day treatment with azithromycin is a convenient alternative to clarithromycin. It is important to use its high, double doses – the standard dose is ineffective. Treatment of streptococcal tonsillopharyngitis with amoxicillin, amoxicillin with clavulanic acid and cefuroxime axetil is considered inappropriate and harmful. These are relatively broad-spectrum antibiotics, but their overuse is conductive to the spread of pneumococci of reduced penicillin sensitivity.

Keywords: Streptococcus pyogenes, pharyngitis, penicillin
Zika virus infection – a new epidemic threat
Pediatr Med Rodz 2016, 12 (2), p. 150–156
DOI: 10.15557/PiMR.2016.0014

Zika virus, like dengue and yellow fever viruses, is an RNA virus of the Flaviviridae family. The virus is transmitted by Aedes mosquitoes. On February 1, 2016, the World Health Organization declared Zika virus a Public Health Emergency of International Concern, similarly as in the case of Ebola virus in 2014 and bird flu virus in 2009. Although the Zika virus commonly causes a mild flu-like illness, it can cause congenital infections in the foetus. Based on the recommendations of the International Health Regulations Emergency Committee, the World Health Organization confirmed the possible relationship between the increase in the incidence of Zika virus infections and an increased number of infants with microcephaly. The incidence of microcephaly in Brazil in 2015 was 10–20 times higher than in previous years. A total of 691 cases of travel-related Zika infections have been reported in the United States of America, including 206 pregnant women – with 11 cases of sexually transmitted infection; Guillain–Barré syndrome complication was identified in 2 cases. There is an emphasis on measures to prevent mosquito bites and eliminate mosquito breeding sites in the countries affected by the epidemic. Due to both, Zika virus isolation from sperm and the growing number of sexually transmitted infections, measures to prevent sexual transmission of Zika virus have also been taken. There is an ongoing research to develop vaccine against the Zika virus, however, the estimated time of vaccine development is several years.

Keywords: ZIKV, horizontal infection, microcephaly, vector-borne disease, public health emergency
The effects of syncope on serum tau protein levels in adolescents
Pediatr Med Rodz 2016, 12 (2), p. 157–163
DOI: 10.15557/PiMR.2016.0015

According to the new (2009) definition, sudden, reversible, short-lasting and spontaneously resolving loss of consciousness associated with a transient, global decrease in cerebral blood flow occurs during syncope. Syncope-associated cerebral ischaemia lasts from a few to several seconds. Near infrared spectroscopy reveals decreased oxygenated haemoglobin and increased reduced haemoglobin levels. If cerebral ischaemia is due to stroke, blood–brain barrier damage and tau protein diffusion into the cerebrospinal fluid occur. Cerebrospinal fluid tau levels can be both, a useful biomarker in the assessment of ischaemic extent and a prognostic factor. The aim of the study was to evaluate whether there is an increase in serum tau protein levels during syncope, which could correspond to a stroke model of brain injury. Material and methods: The study group included 32 patients, and the control group included 38 patients (mean age for both groups was 15 years). Syncope was induced by tilt table testing. The test was performed according to the Westminster protocol. Three blood samples were collected (at baseline as well as 6 and 24 hours afterwards) to measure tau levels. Results: No differences in tau levels were demonstrated between the study group and controls (p > 0.05). Conclusions: The extent of brain injury in adolescents with syncope is insufficient to induce significantly increased serum tau levels. However, the study should be continued to assess the levels of this marker in different types of syncope.

Keywords: tau protein, syncope, adolescent
Urolithiasis in children aged 0–3 years based on author’s own research, with reference to the coexistence of urinary tract defects and infections
Pediatr Med Rodz 2016, 12 (2), p. 164–170
DOI: 10.15557/PiMR.2016.0016

In recent years, there has been a significant increase in the number of children with urolithiasis, particularly in the youngest age group. It is estimated that metabolic disorders account for about 75% of cases of stone formation. Urinary tract infections and defects promote stone formation in children. The aim of the study was to evaluate paediatric patients aged up to 3 years, diagnosed with urolithiasis and staying under the care of our Department, with attention being paid to staghorn calculi and the coexistence of urinary tract infections and defects. Material: A total 514 children with urolithiasis, including 122 children aged up to 3 years, were staying under the care of the Department. Methods: We have performed a retrospective analysis of medical records of children hospitalised at the Department of Paediatrics, Paediatric Nephrology and Allergology of the Military Institute of Medicine between 2008 and 2014 due to urolithiasis. Results: Children in the youngest age group, i.e. up to 3 years old, including 50% of children diagnosed in their first year of life, accounted for 25% of patients with urolithiasis. Urinary tract defects and infections coexisted with urolithiasis in more than 70% of the monitored patients. Staghorn urolithiasis was diagnosed in 16.4% of patients, mostly in children with urolithiasis complicated by urinary infection and/or urinary tract defects. Staghorn urolithiasis was not related to urinary tract defects or infections in more than 30% of children.

Keywords: urolithiasis, urinary tract infection, urinary tract defects, children
Small intestinal bacterial overgrowth syndrome in children with idiopathic nephritic syndrome treated with immunosuppressive agents
Pediatr Med Rodz 2016, 12 (2), p. 171–176
DOI: 10.15557/PiMR.2016.0017

Small intestinal bacterial overgrowth syndrome is defined as an increased number of non-pathogenic bacteria over 105 microorganisms in one millilitre of intestinal contents in the initial part of the small intestine. Predisposing disorders include e.g. drug-induced hypochlorydia, congenital and acquired defects of the gastrointestinal tract, immunodeficiency, severe stress situations as well as intestinal microflora imbalance after immunosuppressive therapy. The aim of the study was to assess the incidence of small intestinal bacterial overgrowth in children receiving cyclosporine A due to idiopathic nephritic syndrome. Material and methods: The study included 20 children (11 girls and 9 boys) aged 4–16 years (mean age 8.83 ± 3.75 years), diagnosed with idiopathic nephritic syndrome and treated with cyclosporine for over 3 months. The use of antibiotics or probiotics less than 3 months prior to the study was an exclusion criterion. Serum levels of cyclosporin A were measured in all patients. Hydrogen breath test with lactulose was performed as an additional examination. The exhaled breath was analysed using Gastrolyzer (Bedfont). A minimum increase of 20 hydrogen molecules per million air molecules between the maximum value and the fasting level or values in the first hour of the test was considered as a positive test outcome, indicating small intestinal bacterial overgrowth. Results: Negative result of hydrogen breath test, excluding small intestinal bacterial overgrowth, was observed in all 20 children. Conclusions: The administration of second line immunosuppressive agents in children with idiopathic nephritic syndrome does not induce non-pathogenic bacterial multiplication in the small intestine.

Keywords: small intestinal bacterial overgrowth syndrome, idiopathic nephritic syndrome, cyclosporine A, children
Level of nutrition and nutrition disorders as well as characteristics of dietary habits and physical activity among 6–13-year-old children attending selected primary schools in Opole and Silesia Provinces in Poland
Pediatr Med Rodz 2016, 12 (2), p. 177–193
DOI: 10.15557/PiMR.2016.0018

Aim of the study: Analysis of nutrition disorders, learning about eating habits and characterising physical activity among primary school children at the age of 6–13, living in the rural areas of Silesia and Opole Provinces in Poland. Material and methods: The study included the parents of children at the age 6–13 attending selected primary schools and living in rural areas of Silesia (Wielowieś, Boruszowice, Wojska, Potępa, Świerklaniec) and Opole (Kielcza) Provinces. The research group comprised 410 pupils: 217 boys (52.93%) and 193 girls (47.07%). On the basis of obtained data, BMI index was calculated and a nutritional level was assessed. Moreover, the statistical analysis of dietary habits and physical activity of studied children was also performed. Results: Nearly 38% of studied children are overweight or obese. Furthermore, 17% are malnourished. Every second child has a proper number of meals per day. Above 60% of pupils eat first and second breakfast every day. Merely 3.66% of children eat five or more portions of fruit and vegetables daily. Less than 62% of students declare to drink milk or eat dairy products. Over 83% of the respondents declare that their children eat meat several times a week. Over 28% of children have sweets or salty snacks every day. As for physical activity, about 59% of children prefer spending free time outdoors but approximately 22% of pupils practise sport regularly. Conclusion: This study revealed that students attending primary schools in selected rural areas are characterised by improper dietary habits. Their way of eating is not balanced in a right way – it is mainly based on meat and snacks like sweets. Furthermore, children eat few fruit and vegetables, highfibre products and drink little milk. Behaviours connected with physical activity are also inappropriate – children dedicate too little time to physical activity a week.

Keywords: overweight, obesity, malnutrition, school children, rural areas
Joint manifestations in children infected with Ascaris lumbricoides and Toxocara canis – single centre experience
Pediatr Med Rodz 2016, 12 (2), p. 194–200
DOI: 10.15557/PiMR.2016.0019

Joint disorders in children are a frequent cause of parents’ concern and a reason of visiting family doctors and rheumatologists. In search for the correct diagnosis, a wide differential diagnosis should be conducted, including bacterial, parasitic, but also rheumatoid or proliferative process. However, the majority of complaints reported by children are reactive in nature. Diagnosis is based on the clinical symptoms and serology tests results. Ascaris lumbricoides or Toxocara canis infection may manifest itself not only with gastrointestinal, but also musculoskeletal symptoms, depending on the period of the disease. The aim of the paper was to assess the frequency of complaints associated with the locomotor system in children with the presence of serum antibodies against Ascaris lumbricoides and/or Toxocara canis and to analyse their relationship with selected laboratory tests (eosinophilia) and the final diagnosis. Material and methods: Medical records of 86 children hospitalised in 2013–2015 at the Department of Paediatric Cardiology and Rheumatology, Medical University of Łódź, were analysed. Children with musculoskeletal symptoms and positive serum antibody titres against Ascaris lumbricoides and/or Toxocara canis were included in the study. Results: Among the infected patients, the most frequently reported complaint from the locomotor system was knee (51%) and wrist (19%) pain. Ascaris lumbricoides infection was the dominant human parasitosis (66%), while in 15 patients (17%) Toxocara canis co-infestation was detected. Rheumatoid process was the most common suspicion (36%), but the final diagnosis of juvenile idiopathic arthritis was determined in only 12 patients (14%). Conclusions: Parasitic infections often coexist with articular symptoms reported by children and should always be excluded in the differential diagnosis. In some cases, a parasitic infection may be one of the factors that initiate the rheumatoid process.

Keywords: joint complaints, children, Ascaris lumbricoides and Toxocara canis infection
Mowat–Wilson syndrome – case study
Pediatr Med Rodz 2016, 12 (2), p. 201–208
DOI: 10.15557/PiMR.2016.0020

Mowat–Wilson syndrome is a rare genetic condition characterised by a number of congenital anomalies, including facial dysmorphia, heart and kidney anomalies, Hirschsprung’s disease, intellectual disability and abnormalities of reproductive organs. In the paper, we present a case of a girl who was admitted to the Department of Paediatrics, Immunology and Nephrology at the age of 3 months, with a suspicion of tubulointerstitial nephritis. The patient had facial dysmorphia, congenital malformations of the nervous system and Hirschsprung’s disease. During hospitalisation, congenital urinary anomalies (bilateral vesicoureteral reflux) and heart defects were diagnosed. On the basis of the clinical picture, the diagnostics was expanded to genetic tests for Mowat–Wilson syndrome, which revealed an 857_858delAG pathogenic mutation in one of the ZEB2 gene alleles (exon 7) – one of the rarer causes of Mowat–Wilson syndrome. At present, the girl is 13 months old. Her development is delayed. Currently, the girl is under multidisciplinary care and she is undergoing intensive rehabilitation. The knowledge of the syndrome’s clinical features allows a faster diagnosis to be made and multispecialty care to be provided to the child.

Keywords: Mowat–Wilson syndrome, Hirschsprung’s disease, mental retardation, congenital defects
Atypical cystic fibrosis diagnosed in a 14-year-old boy
Pediatr Med Rodz 2016, 12 (2), p. 209–213
DOI: 10.15557/PiMR.2016.0021

The diagnosis of cystic fibrosis is based on the occurrence of clinical symptoms and evidence of two mutations in cystic fibrosis transmembrane conductance regulator. However, in cases of atypical cystic fibrosis, not all symptoms may be manifested and not all diagnostic tests may be positive. The World Health Organization has recognised the need for a category that covers patients with atypical (often single organ disease), who may or may not supply evidence for cystic fibrosis transmembrane conductance regulator dysfunction (sweat test) or two cystic fibrosis transmembrane conductance regulator mutations. The aim of this case report is to highlight the difficulties in cystic fibrosis diagnosis in some groups of patients who do not fit in the “gold standard” of the diagnostic scheme. Individuals with atypical cystic fibrosis might only have dysfunction in one organ system and of a much milder degree than those with typical cystic fibrosis. This may be the main reason for a diagnosis and treatment delay.

Keywords: cystic fibrosis, atypical cystic fibrosis, diagnostics, CFTR, genetics
Late diagnosis of agammaglobulinemia in an 8-year-old boy
Pediatr Med Rodz 2016, 12 (2), p. 214–219
DOI: 10.15557/PiMR.2016.0022

Chromosome X-linked Bruton agammaglobulinemia is classified as a primary immunodeficiency disorder. It is a genetic condition associated with a mutation in the BTK gene encoding tyrosine kinase. It is characterised by the lack or only trace amounts of B cells and immunoglobulins, which results in humoral immunodeficiency. Clinical signs of Bruton agammaglobulinemia include recurring bacterial respiratory tract infections, sinusitis and otitis media. Physical examination reveals hypoplastic palatine tonsils and peripheral lymph nodes. Patients are predisposed to severe, chronic and life-threatening infections, usually caused by polysaccharide encapsulated bacteria, such as: Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis and Moraxella catarrhalis. The diagnostic process of agammaglobulinemia is based on B cell and immunoglobulin counts. Its treatment consists in regular immunoglobulin supplementation. The paper presents a case of a patient admitted to hospital due to pneumonia. The interview revealed recurring infections, including severe pneumonia.

Keywords: primary immunodeficiency disorder, agammaglobulinemia, tyrosine kinase, immunoglobulins, bacterial infections