Anal signs in haemolytic uraemic syndrome

Extrarenal manifestations of the hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC HUS)

Hemolytic uremic syndrome is commonly caused by Shiga toxin-producing Escherichia coli (STEC). Up to 15% of individuals with STEC-associated hemorrhagic diarrhea develop hemolytic uremic syndrome (STEC HUS). Hemolytic uremic syndrome (HUS) is a disorder comprising of thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. The kidney is the most commonly affected organ and approximately half of the affected patients require dialysis. Other organ systems can also be affected including the central nervous system and the gastrointestinal, cardiac, and musculoskeletal systems. Neurological complications include altered mental status, seizures, stroke, and coma. Gastrointestinal manifestations may present as hemorrhagic colitis, bowel ischemia/necrosis, and perforation. Pancreatitis and pancreatic beta cell dysfunction resulting in both acute and chronic insulin dependant diabetes mellitus can occur. Thrombotic microangiopathy (TMA) in cardiac microvasculature and troponin elevation has been reported, and musculoskeletal involvement manifesting as rhabdomyolysis has also been described. Extrarenal complications occur not only in the acute setting but may also be seen well after recovery from the acute phase of HUS. This review will focus on the extrarenal complications of STEC HUS. To date, management remains mainly supportive, and while there is no specific therapy for STEC HUS, supportive therapy has significantly reduced the mortality rate.

Anal signs of child sexual abuse: a case-control study

Background

There is uncertainty about the nature and specificity of physical signs following anal child sexual abuse. The study investigates the extent to which physical findings discriminate between children with and without a history of anal abuse.

Methods

Retrospective case note review in a paediatric forensic unit.

Cases: all eligible cases from1990 to 2007 alleging anal abuse.

Controls: all children examined anally from 1998 to 2007 with possible physical abuse or neglect with no identified concern regarding sexual abuse. Fisher’s exact test (two-tailed) was performed to ascertain the significance of differences for individual signs between cases and controls. To explore the potential role of confounding, logistic regression was used to produce odds ratios adjusted for age and gender.

Results

A total of 184 cases (105 boys, 79 girls), average age 98.5 months (range 26 to 179) were compared with 179 controls (94 boys, 85 girls) average age 83.7 months (range 35–193). Of the cases 136 (74%) had one or more signs described in anal abuse, compared to 29 (16%) controls. 79 (43%) cases and 2 (1.1%) controls had >1 sign. Reflex anal dilatation (RAD) and venous congestion were seen in 22% and 36% of cases but <1% of controls (likelihood ratios (LR) 40, 60 respectively), anal fissure in 14% cases and 1.1% controls (LR 13), anal laxity in 27% cases and 3% controls (LR 10).

Novel signs seen significantly more commonly in cases were anal fold changes, swelling and twitching. Erythema, swelling and fold changes were seen most commonly within 7 days of last reported contact; RAD, laxity, venous congestion, fissure and twitching were observed up to 6 months after the alleged assault.

Conclusions

Anal findings are more common in children alleging anal abuse than in those presenting with physical abuse or neglect with no concern about sexual abuse. Multiple signs are rare in controls and support disclosed anal abuse.

Pitfalls in the diagnosis of child sexual abuse

Case 1: nurses in charge of a 6-year-old girl in a holiday camp noticed some blood spots on the girl's underwear. The possibility of sexual abuse was considered and the girl alleged that her father was responsible. The father was arrested. A surgeon was asked to examine the girl and planned to do it under general anesthaesia. Meanwhile, the girl was brought to the Forensic Medicine Unit. We found a normal hymen and no detectable anal lesions. The girl complained of dysuria and pollakiuria. Urinalysis revealed the presence of blood, leukocytes, and nitrite. Antibiotic treatment for lower urinary tract infection was initiated and all symptoms improved rapidly. The father was released. Case 2: a 7-year-old boy complained of having been sexually assaulted 24 h before. The boy did not report any pain or bleeding during or after the assault. Examination of the perianal region and of the anal sphineter were normal. Proctoscopy did not show any evidence of trauma to the anal canal. Tests to detect spermatozoa in the rectum were positive. The assailant was arrested. The present cases illustrate that: (i) psychological and social consequences of the biased interpretation of common symptoms may be dramatic in the case of child sexual abuse; (ii) both questioning and examining a child may be difficult for non-specialized practitioners; and (iii) tests to detect spermatozoa should be systematically performed in the case of a suspected or alleged recent assault, even in the absence of any clinical lesions.

Diffuse pneumocephalus due to Clostridium septicum cerebritis in haemolytic uraemic syndrome: CT demonstration

The computed tomography finding of diffuse pneumocephalus due to infection by gas-forming organisms is very unusual. We report such a case due to secondary infection by Clostridium septicum in a child with diarrhoea-associated haemolytic uraemic syndrome.

Oesophageal and severe gut involvement in the haemolytic uraemic syndrome

Between 1982 and 1989, 78 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) were referred to this hospital. Most presented with abdominal pain, bloody diarrhoea and vomiting. Seven had severe gastrointestinal involvement, four of whom required resection for bowel perforation or necrosis. One also developed an oesophageal stricture, a previously unreported complication of HUS. These seven children had a high incidence of other complications including hypertension, and cerebral and pancreatic involvement. One died from severe cerebral involvement, one has a residual neurological deficit and one has residual renal impairment. Severe gastrointestinal involvement did not significantly affect the long-term outcome. Simple haematological indices helped predict severe gut involvement. Four of the 78 children had undergone appendicectomy before the diagnosis of HUS was made. The operative findings were in no case typical of primary acute appendicitis, although histological examination did confirm inflammation of the appendix in two patients. Diagnosis is difficult in early disease, but increased awareness may help prevent unnecessary appendicectomy.