Macrophage Activation Syndrome in Paediatric Rheumatic Diseases

Macrophage activation syndrome (MAS) is a potentially fatal complication of rheumatic disorders, which commonly occurs in systemic juvenile idiopathic arthritis (sJIA).This study was carried out with the aims of describing the clinical features, laboratory findings and outcomes of MAS associated with paediatric rheumatic diseases in the Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU) and compare these results with previous studies on MAS. This retrospective study was conducted in the paediatric rheumatology wing of the Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Clinical and laboratory profile of all the diagnosed cases of MAS were analyzed from the medical records from January 2010 to July 2015. Among 10 MAS patients, 6 were female and 4 were male. Seven patients of systemic JIA, two patients of SLE and one patient with Kawasaki Disease developed MAS in their course of primary disease. Mean duration of primary disease prior to development of MAS was 2.9 years and mean age of onset was 9.1 years. High continued fever and new onset hepatosplenomegaly were the hallmark of the clinical presentation. White blood cell count and platelet count came down from the mean of 16.2 to 10.2×10⁹/L and 254 to 90×10⁹/L. Mean erythrocyte sedimentation rate was dropped from 56 to 29 mm/hr. Six patients had abnormal liver enzyme level (ALT) and 5 had evidence of coagulopathy (prolonged prothrombin time and APTT) at the onset of disease. Hyperferritinnemia were found in all the patients. Bone marrow study was done in 5 patients but features of hamophagocytosis were found only in 2 patients. All patients received intravenous steroid and 3 patients who did not respond to steroid received additional cyclosporine. Mortality rate was 30% in this series. Macrophage activation syndrome is a fatal complication of paediatric rheumatic diseases among which s-JIA was predominant. Early diagnosis and aggressive therapy is essential to reduce the morbidity and mortality of this illness.

Rectovestibular fistula with vaginal malformations

Anorectal malformations are associated with other anomalies among which vaginal malformations are occasionally encountered and may go unnoticed by the primary physician. Between January 1998 and December 2003, 563 cases of anorectal malformations were managed in Pediatric Surgery Department, Chittagong Medical College & Hospital, Chittagong, Bangladesh. Among these, five cases of rectovestibular fistula were associated with vaginal malformations. In this retrospective study age, physical findings, operative findings and procedures, outcome of operation and postoperative follow-up were evaluated. Mean age at presentation was 8.67 years (range 2 months to 17 years). All cases referred as rectovaginal fistula and vaginal anomalies (atresia to agenesis) were detected after thorough examination. Initial pelvic colostomy was done in all patients. Cases 1, 3 and 4 had distal vaginal agenesis and underwent posterior sagittal anorectovaginoplasty. In case 5, atretic vaginal duplication was found with didelphic hypoplastic uterus and absent left kidney. Case 2 (vaginal atresia) operated elsewhere is waiting for definitive surgery. Colostomy closure was done in four cases. The third patient had already married and conceived. Bowel habits are regular in all except the second patient. In females, a thorough understanding of anorectal malformations is necessary to identify the association with vaginal anomalies and awareness of this association will lead to earlier diagnosis and appropriate operative measures.