Infants With Dorsal Hand Compartment Syndrome Due to Intravenous Infiltration of Glucose Acetate Ringer's Solution

Compartment syndrome caused by glucose acetate Ringer's solution in children has not been sufficiently reported. We report the cases of two children who developed compartment syndrome of the dorsum of the hand and forearm after receiving only glucose acetate Ringer's solution during hospitalization, with one case requiring a releasing incision. In recent years, glucose acetate Ringer's solution has been frequently used for maintenance infusion. However, it is not always safe and should be used with caution due to the risk of serious side effects caused by infiltration.

Suppressed pediatric asthma hospitalizations during the COVID-19 pandemic in Japan, from a national survey

BACKGROUND

Acute asthma exacerbation in children is often caused by respiratory infections. In this study, a coordinated national surveillance system for acute asthma hospitalizations and causative respiratory infections was established. We herein report recent trends in pediatric acute asthma hospitalizations since the COVID-19 pandemic in Japan.

METHODS

Thirty-three sentinel hospitals in Japan registered all of their hospitalized pediatric asthma patients and their causal pathogens. The changes in acute asthma hospitalization in children before and after the onset of the COVID-19 pandemic and whether or not COVID-19 caused acute asthma exacerbation were investigated.

RESULTS

From fiscal years 2010-2019, the median number of acute asthma hospitalizations per year was 3524 (2462-4570), but in fiscal years 2020, 2021, and 2022, the numbers were 820, 1,001, and 1,026, respectively (the fiscal year in Japan is April to March). This decrease was observed in all age groups with the exception of the 3- to 6-year group. SARS-CoV-2 was evaluated in 2094 patients from fiscal years 2020-2022, but the first positive case was not detected until February 2022. Since then, only 36 of them have been identified with SARS-CoV-2, none of which required mechanical ventilation. Influenza, RS virus, and human metapneumovirus infections also decreased in FY 2020. In contrast, 24% of patients had not been receiving long-term control medications before admission despite the severity of bronchial asthma.

CONCLUSION

SARS-CoV-2 was hardly detected in children with acute asthma hospitalization during the COVID-19 pandemic. This result indicated that SARS-CoV-2 did not induce acute asthma exacerbation in children. Rather, infection control measures implemented against the pandemic may have consequently reduced other respiratory virus infections and thus acute asthma hospitalizations during this period. However, the fact that many hospitalized patients have not been receiving appropriate long-term control medications is a major problem that should be addressed.

Evaluation of Chemotherapy-induced Dysgeusia in Patients With Gastrointestinal Cancer: A Pilot Study

BACKGROUND/AIM

Dysgeusia, one of the adverse effects of cancer chemotherapy, and anorexia due to taste disorder can significantly impair the quality of life of patients. However, an evaluation method for dysgeusia has not yet been established. The present prospective study aimed to utilize a combination of subjective and objective assessment methods to evaluate dysgeusia in patients with gastrointestinal cancer initiating chemotherapy, to determine chemotherapeutic drugs and regimens causing dysgeusia, and to assess whether dysgeusia was associated with zinc deficiency.

PATIENTS AND METHODS

A total of 21 patients with newly diagnosed gastrointestinal cancer were registered between August 2020 to March 2021. The following regimens were also included in the evaluation if the patients did not develop dysgeusia. A total 30 regimens were administered to the patients during the study period. A salt-impregnated test paper (Salsave^®) was used as a subjective assessment, and the chemotherapy-induced taste alteration scale was used as an objective assessment.

RESULTS

Based on physician interviews, dysgeusia was diagnosed in 8 of 21 patients (38%) treated with 8 of 30 regimens (27%). All regimens that resulted in dysgeusia contained platinum-based drugs. The patients who developed dysgeusia had higher controlling nutritional status scores at the start of chemotherapy compared to those who did not develop dysgeusia. In both subjective and objective assessments, the patients with dysgeusia performed significantly worse than those without dysgeusia. Six of the eight patients who developed dysgeusia were administered Novelzine, which did not improve the taste disorder despite the improvement of serum zinc levels.

CONCLUSION

The combined approach using subjective and objective taste assessment methods was useful in assessing chemotherapy-induced dysgeusia. Mechanisms other than hypozincemia should be considered as contributors to taste disorders caused by platinum-based drugs.

Acute and Postacute Clinical Characteristics of Coronavirus Disease 2019 in Children in Japan

BACKGROUND

The clinical features of coronavirus disease 2019 (COVID-19) in children have been changing because of the emergence and rapid spread of variants of concern (VOC). The increase in cases infected with VOC has brought concern with persistent symptoms after COVID-19 in children. This survey aimed to analyze the clinical manifestations and persistent symptoms of pediatric COVID-19 cases in Japan.

METHODS

We analyzed the clinical manifestations of pediatric COVID-19 cases reported between February 2020 and April 2022 in Japan, using a dedicated database updated voluntarily by the members of the Japan Pediatric Society. Using the same database, we also analyzed persistent symptoms after COVID-19 in children who were diagnosed between February 2020 and November 2021.

RESULTS

A total of 5411 and 1697 pediatric COVID-19 cases were included for analyzing clinical manifestations and persistent symptoms, respectively. During the Omicron variant predominant period, the percentage of patients with seizures increased to 13.4% and 7.4% in patient groups 1-4 and 5-11 years of age, respectively, compared with the pre-Delta (1.3%, 0.4%) or Delta period (3.1%, 0.0%). Persistent and present symptoms after 28 days of COVID-19 onset were reported in 55 (3.2%).

CONCLUSIONS

Our survey showed that the rate of symptomatic pediatric COVID-19 cases increased gradually, especially during the Omicron variant predominant period, and a certain percentage of pediatric cases had persistent symptoms. Certain percentages of pediatric COVID-19 patients had severe complications or prolonged symptoms. Further studies are needed to follow such patients.

A case of Fukuyama-type congenital muscular dystrophy with acute carnitine deficiency triggered by fever, vomiting, and gastrointestinal bleeding

BACKGROUND

Carnitine is essential for transporting long-chain fatty acids into mitochondria and promotes energy metabolism via β-oxidation of long-chain fatty acids. Although carnitine is also present in the peripheral blood, 98% of total carnitine is stored in muscle tissue. Neuromuscular diseases accompanied by muscle atrophy are likely to lead to secondary carnitine deficiency, owing to the reduced amount of total carnitine stored in the body.

CASE PRESENTATION

An 8-y-old Japanese boy with Fukuyama-type congenital muscular dystrophy accompanied by severe psychomotor retardation had been constantly bedridden, suffered from dysphagia, and had been fed through a gastrostomy tube since the age of 1 y. Regular oral carnitine supplementation (5 mg/kg/d of levocarnitine) was initiated at the age of 7 y, which increased serum carnitine value to within the normal range (serum total carnitine concentration, 58.5-60.9 μmol/L; acylcarnitine concentration, 45.8-55.0 μmol/L; free carnitine concentration, 5.9-12.7 μmol/L). He developed a fever, vomiting, and gastrointestinal bleeding at the age of 8 y. He fell into a coma and visited an emergency room 12 h later. Hypoglycemia and hypocarnitinemia (serum total carnitine concentration, 3.7 μmol/L; acylcarnitine concentration, 2.9 μmol/L; free carnitine concentration, 0.8 μmol/L; acyl-to-free carnitine ratio, 3.6) were observed, and he was found to be negative for urinary ketone bodies.

CONCLUSIONS

Neuromuscular diseases accompanied by muscle atrophy may lead to acute carnitine deficiency, even if the serum carnitine concentration is within the normal range before onset. During sick days, it may be necessary to modify a patient's treatment, such as increasing both oral supplementation and intravenous administration of carnitine.

Paraspinal muscle abscesses in children - A case report and review of the literature

Background

Few pediatric cases with myositis and abscesses of the paraspinal muscles have been previously reported.

Case Description

We herein report on a 3-year-old patient who developed an epidural abscess in a paraspinal muscle abscess, after a complication of infectious impetigo due to atopic dermatitis. The child improved through the administration of an antibacterial drug. The median age of seven patients with a history of paraspinal muscle inflammation and muscle abscess was 12 years old (3-15-years-old), few of which had underlying diseases, with methicillin-sensitive Staphylococcus aureus being the main causative agent. Although the prognosis was well in many cases following the administration of antibacterial agents, there were also cases in which extensive lesions were found and neurological sequelae remained.

Conclusion

The current case was the youngest case ever reported of a paraspinal muscle abscess. Although pediatric cases are rare, in the episode of a fever of unknown origin and difficulty walking, paraspinal muscle abscesses should be cited as a differential diagnosis and appropriate early diagnostic imaging and treatment should be performed.

Factors affecting guardians' decision-making regarding the SARS-CoV-2 vaccine

BACKGROUND

In Japan, the vaccination rate against the SARS-CoV-2 vaccine for children was low. Therefore, in this study we investigated the factors influencing guardians' decision-making regarding vaccination of their children.

METHODS

From November 1, 2022 to March 31, 2023, pediatric clinics, departments, and midwifery clinics in Saitama Prefecture requested guardians of children under the age of 15 to complete an online questionnaire.

RESULTS

Responses were obtained from 894 guardians of children aged 6 months to 15 years; 142 had had one of their children vaccinated at least once and 629 had not had any of their children vaccinated. Among guardians who had not had any of their children vaccinated, "the Age of children" was significantly younger (p < 0.001) and "Prevalence" (p < 0.001), "Free vaccination" (p < 0.001), and "Intentions of national and local governments" (p = 0.005) were selected as reasons significantly less frequently in comparison to guardians who had vaccinated their children. "Japanese adverse reactions" (p < 0.001), "Japanese effectiveness" (p < 0.001), "Adverse reactions" (p < 0.001), "History of adverse reactions" (p < 0.001), and "Reputation of friends" (p = 0.006) were selected significantly more frequently by guardians who had not had any of their children vaccinated.

CONCLUSIONS

Guardians who had had one of their children vaccinated at least once emphasized the importance of prevalence and free vaccination. On the other hand, guardians who had not had any of their children vaccinated placed particular importance on adverse reactions and the Japanese data on effectiveness. To guide the decision-making of guardians, it is necessary to quickly collect and publish data on adverse reactions and effectiveness, particularly in Japanese individuals, so that citizens can decide whether to vaccinate themselves and their children.

First Pediatric Case of Clinically-Diagnosed Penicillin G-Induced Hemorrhagic Cystitis

Hemorrhagic cystitis is a diffuse inflammatory disease of the urinary bladder associated with macrohematuria. Several cases of hemorrhagic cystitis caused by penicillin G have been reported in adults but not children. Here we describe the first pediatric case of clinically-diagnosed penicillin G-induced hemorrhagic cystitis. The patient was a 9-year-old boy with a ventricular septal defect, chromosomal abnormalities, and infective endocarditis caused by Abiotrophia defectiva. After approximately four weeks of penicillin G administration, he had a culture-negative major hemorrhage with a clot. The hematuria resolved one week after penicillin G discontinuation, and a drug lymphocyte stimulation test for penicillin G was positive. In conclusion, penicillin G can also induce hemorrhagic cystitis in children. When large doses of penicillin G are used for long periods in adults or children, the patient should be monitored for hemorrhagic cystitis.

The clinical characteristics of pediatric coronavirus disease 2019 in 2020 in Japan

BACKGROUND

The COVID-19 pandemic has affected the lives of people of all ages. Most reports on pediatric cases suggest that children experience fewer and milder symptoms than do adults. This is the first nationwide study in Japan focusing on pediatric cases reported by pediatricians, including cases with no or mild symptoms.

METHODS

We analyzed the epidemiological and clinical characteristics and transmission patterns of 840 pediatric (<16 years old) COVID-19 cases reported between February and December 2020 in Japan, using a dedicated database which was maintained voluntarily by members of the Japan Pediatric Society.

RESULTS

Almost half of the patients (47.7%) were asymptomatic, while most of the others presented mild symptoms. At the time of admission or first outpatient clinic visit, 84.0% of the cases were afebrile (<37.5°C). In total, 609 cases (72.5%) were exposed to COVID-19-positive household members. We analyzed the influence of nationwide school closures that were introduced in March 2020 on COVID-19 transmission routes among children in Japan. Transmission within households occurred most frequently, with no significant difference between the periods before and after declaring nationwide school closures (70.9% and 74.5%, respectively).

CONCLUSIONS

COVID-19 symptoms in children are less severe than those in adults. School closure appeared to have a limited effect on transmission. Controlling household transmission from adult family members is the most important measure for prevention of COVID-19 among children.

Anaphylaxis and onsite treatment in schools, kindergartens, and nurseries

BACKGROUND

There have been no reports on both anaphylaxis incidence rate in schools, kindergarten, and nurseries, or how teachers have treated these children. This study was a fact-finding survey aimed at determining if appropriate responses to anaphylaxis onset were implemented in Oita Prefecture, Japan.

METHODS

The Oita Prefectural Allergy Control Committee administered a questionnaire using Google forms to all public and private schools, public and private kindergartens, certified child-care facilities, and day-care centers in the prefecture.

RESULTS

Responses to the questionnaire were obtained from 597 institutions, of which 125 890 children were affiliated with the responding institutions. Forty-eight children developed symptoms for which an adrenaline auto-injector was recommended in an Oita guideline. Among these children, three used the adrenaline auto-injector, three were prescribed the adrenaline auto-injector but were unable to use it, 27 were unable to use it as they were not prescribed an adrenaline auto-injector, and the final 15 responded that they handled their symptoms via another method because none of the above options apply.

CONCLUSIONS

Most children who developed symptoms which an adrenaline auto-injector was recommended had no prescription for an adrenaline auto-injector. There is thus a need for appropriate response training to anaphylaxis whether or not an adrenaline auto-injector was prescribed.

Psoriasis with short stature improved by adalimumab

Few cases of pediatric psoriasis with short stature, possibly resulting from chronic systemic inflammation, have been reported. We present the case of a child with short stature occurring after the onset of psoriasis wherein treatment with adalimumab resulted in the improvement of not only the psoriasis but also the child's short stature. Pediatric psoriasis associated with short stature may benefit from the early induction of biologic therapy.

Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy

BACKGROUND

Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure.

METHODS

This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy).

RESULTS

Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups.

CONCLUSIONS

Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.

Effect of a vaccine information statement (VIS) on immunization status and parental knowledge, attitudes, and beliefs regarding infant immunization in Japan

BACKGROUND

Because of the overabundance of vaccination information on the internet, in the media, and on social media, providing clear and correct information on immunization is critical for parental decision-making. In 2018, the Japan Pediatric Society created and distributed a Vaccine Information Statement (VIS) to provide appropriate immunization information to caregivers. The objectives of the present study were to evaluate the effect of the VIS on immunization rates, adherence to schedule, and parental understanding of immunization in Japan.

METHODS

This cross-sectional study was conducted at 18 centers in 2 prefectures in Japan. Caregivers were assigned to an intervention group, which received the VIS and a questionnaire when their child reached the age of 1 month, and a control group, which received only the questionnaire. Using the self-reported questionnaires, we evaluated vaccination rates and schedule adherence at age 2 months, and parental knowledge, attitudes, and beliefs regarding immunization. Three months later, the questionnaires were returned, and the findings were compared between the 2 groups.

RESULTS

We contacted 422 and 428 persons in the intervention and control groups, respectively, and 111/422 (26.3%) and 119/428 (27.8%) returned the surveys. Vaccination rates and adherence rates for the first dose of 4 recommended vaccines did not differ significantly (P > 0.25); however, there were some positive effects on items related to vaccine knowledge (P = 0.03), perceived benefits (P = 0.02), perceived barriers (P < 0.001), and perceived behavioral control (P = 0.01).

CONCLUSION

The VIS improved parent comprehension of infant immunization. Future studies should examine if the effects of such an intervention persist and affect vaccine uptake throughout childhood.

Three-Quarters Adrenalectomy for Infantile-Onset Cushing Syndrome due to Bilateral Adrenal Hyperplasia in McCune-Albright Syndrome

BACKGROUND

Bilateral adrenalectomy is performed in cases with infantile-onset Cushing syndrome due to bilateral adrenal hyperplasia in McCune-Albright syndrome (MAS) because severe Cushing syndrome with heart failure and liver dysfunction can have a lethal outcome. This procedure can completely ameliorate hypercortisolism, although lifetime steroid replacement therapy and steps to prevent adrenal crisis are necessary. Recently, the efficacy of unilateral adrenalectomy has been reported in adult cases of bilateral macronodular adrenal hyperplasia, but there is no consensus regarding the appropriate surgical treatment for bilateral adrenal hyperplasia in MAS.

OBJECTIVE

A 6-month-old girl presented with café-au-lait spots, short stature, central obesity, a moon face, and hypertension. Endocrinological tests and imaging studies led to the diagnosis of ACTH-independent Cushing syndrome due to bilateral adrenal hyperplasia induced by MAS. "Three-quarters adrenalectomy", namely right-sided total adrenalectomy and left-sided half adrenalectomy, was carried out. An activating mutation of the GNAS1 gene (p.Arg201Cys) was identified in the adrenal tissues. Since the operation, our patient has been in a state of clinical remission for more than 2 years.

CONCLUSION

Our original surgical intervention, three-quarters adrenalectomy, may be a new treatment option for Cushing syndrome associated with MAS.

Administration of the adrenaline auto-injector at the nursery/kindergarten/school in Western Japan

Background

In view of the increasing prevalence of food allergies, there has been an associated increase in frequency of situations requiring an emergency response for anaphylaxis at the home, childcare facilities and educational institutions.

Objective

To clarify the situation of adrenaline auto-injector administration in nursery/kindergarten/school, we carried out a questionnaire survey on pediatric physicians in Western Japan.

Methods

In 2015, self-reported questionnaires were mailed to 421 physicians who are members of the West Japan Research Society Pediatric Clinical Allergy and Shikoku Research Society Pediatric Clinical Allergy.

Results

The response rate was 44% (185 physicians) where 160 physicians had a prescription registration for the adrenaline auto-injector. In the past year, 1,330 patients were prescribed the adrenaline auto-injector where 83 patients (6% of the prescribed patients) actually administered the adrenaline auto-injector, of which 14 patients (17% of the administered patients) self-administered the adrenaline auto-injector. “Guardians” at the nursery/kindergarten and elementary school were found to have administered the adrenaline auto-injector the most. Among 117 adrenaline auto-injector prescription-registered physicians, 79% had experienced nonadministration of adrenaline auto-injector at nursery/kindergarten/school when anaphylaxis has occurred. The most frequent reason cited for not administering the adrenaline auto-injector was “hesitation about the timing of administration.”

Conclusion

If the adrenaline auto-injector was administered after the guardian arrived at the nursery/kindergarten/school, it may lead to delayed treatment of anaphylaxis in which symptoms develop in minutes. Education and cooperation among physicians and nursery/kindergarten/school staff will reduce the number of children suffering unfortunate outcomes due to anaphylaxis.

Medical certification reduces the number of children requiring allergen elimination diets for school lunches

Background

Following the increase in the number of children with food allergies, support systems are now required for school lunches, but a large-scale factual investigation has not been carried out.

Objective

We evaluated the features of elimination diet due to food allergy and the support system in kindergartens and schools.

Methods

A prefecture-based questionnaire survey regarding measures for food allergies in school lunches of all kindergartens, public elementary schools, and public junior high schools (631 facilities) was conducted in Oita Prefecture, Japan.

Results

The recovery rate of the questionnaire was 99.5%, which included 106,008 students in total. A total of 1,562 children (1.5%) required elimination diets. The rate of children on elimination diets in kindergartens and elementary/junior high schools that required medical certification by a physician was 1.2% (324 among 27,761 children), which was significantly lower than the 1.8% of children (1,227 among 68,576 students) on elimination diets at the request of guardians without the need for medical certification (p < 0.0001). A total of 43.9% of the kindergartens and schools said that they would contact guardians if symptoms were observed after accidental ingestion, while a low 8.1% stated that they provided support to children themselves, including the administration of adrenaline auto-injectors.

Conclusion

Medical certification reduces the number of children requiring elimination diets, but it has not been adequately implemented. Furthermore, waiting to contact guardians after symptoms are observed may lead to the delayed treatment of anaphylaxis. Cooperation between physicians and teachers is desired to avoid the overdiagnosis and undertreatment of children with food allergies.

Pre-school development and behavior screening with a consecutive support programs for 5-year-olds reduces the rate of school refusal

OBJECTIVE

The efficacy of pre-school health consultation in improving developmental and behavioral problems at 5-years of age with follow-up consecutive educational support before and after entrance into regular elementary school for 8 years in a rural city, Taketa, Oita prefecture, was evaluated.

METHODS

This program involved a survey with a three-step method as follows. Step 1: interviews and checklists conducted by public health nurses and nursery/kindergarten teachers for all children. Step 2: medical screening for all children performed by a local/home-school doctor. Step 3: diagnosis in selected children carried out by child neurologists, special support education teachers and clinical/school psychologists. Subsequently, for 1-2 years until entrance into elementary school, these children and their parents were given speech, behavioral and mental support as well as group play therapy in nursery/kindergarten.

RESULTS

During the 8-years study period, 56 children (5.4%) were diagnosed with developmental disorders and six children were diagnosed with maltreatment by their parents among 1165 eligible children. Of these subjects, 40 children received support consecutively after entrance into school, 38 of whom entered regular elementary school and 32 attended regular classes for 1-6 years. A total of 39 of 40 children have attended school without refusal. Moreover, the total number of students refusing to attend school in elementary school decreased for 3 years from 8 of 3246 children (0.25%) in 2006-2008 and 13 of 2889 children (0.45%) in 2009-2011 to only 1 of 2646 children (0.04%) in 2012-2014.

CONCLUSIONS

Pre-school developmental-behavioral screening and consecutive support programs in a rural city reduced the number of students refusing to attend school.

A new cholesterol biosynthesis and absorption disorder associated with epilepsy, hypogonadism, and cerebro-cerebello-bulbar degeneration

BACKGROUND

Cholesterol is one of the main components of human cell membranes and constitutes an essential substance in the central nervous system, endocrine system, and its hormones, including sex hormones.

PATIENT

A 19-year-old male patient presented with failure to thrive, psychomotor deterioration, intractable epilepsy, hypogonadism, and cerebro-cerebello-bulbar degeneration. His serum level of cholesterol was low, ranging from 78.7 to 116.5 mg/dL.

RESULTS

The serum concentrations of intermediates in the cholesterol biosynthesis pathway, such as 7-dehydrocholesterol, 8-dehydrocholesterol, desmosterol, lathosterol, and dihydrolanosterol, were not increased. In addition, the levels of the urinary cholesterol biosynthesis marker mevalonic acid, the serum cholesterol absorption markers, campesterol and sitosterol, and the serum cholesterol catabolism marker, 7α-hydroxycholesterol, were all low.

CONCLUSIONS

A serum biomarker analysis indicated that the patient's basic abnormality differed from that of Smith-Lemli-Opitz syndrome and other known disorders of cholesterol metabolism. Therefore, this individual may have a new metabolic disorder with hypocholesterolemia because of decreased biosynthesis and absorption of cholesterol.

Progressive dysautonomia in two patients with xeroderma pigmentosum group A

BACKGROUND

Xeroderma pigmentosum group A (XPA) is a rare autosomal-recessive disorder caused by a defect in nucleotide excision repair. Progressive dysautonomia in patients with XPA is rarely described.

PATIENTS

Two juvenile male patients with XPA suffered from dysphagia, sleep interruption, and dysuria from the age of 10 to 19 years, successively. These autonomic symptoms might have been caused by progressive descending degeneration of cranial nerves IX and X and the sacral parasympathetic nerve, including Onuf's nucleus. One patient died from sudden cardiopulmonary arrest during postural change and tracheal suction.

RESULTS

Heart rate variability analyses of these patients revealed parasympathetic dysautonomia, based on decreased high-frequency values.

CONCLUSIONS

The insidiously progressive dysautonomia in these two patients with XPA suggested progressive descending degeneration extending from the medulla oblongata to the sacral spinal cord, which is an ominous sign of end-stage disease and a risk factor of sudden death attributable to XPA.

Central retinal vein occlusion in a pediatric patient with SLE and antiphospholipid antibodies without anti-cardiolipin or anti-β2 glycoprotein I antibodies

Background

Antiphospholipid antibody syndrome is characterized by venous and/or arterial thrombosis, and is found in patients with systemic lupus erythematosus. Its diagnosis requires the presence of both clinical and laboratory findings, such as positive anti-cardiolipin and anti-β2 glycoprotein I antibodies and lupus anticoagulant. However, cardiolipin is a minor component of the vascular endothelial cells in human, and phosphatidylcholine and phosphatidylethanolamine are major components.

Case presentation

A 15-year-old female suddenly developed massive left intraretinal hemorrhaging due to central retinal vein occlusion. She also had a butterfly rash, and her laboratory findings revealed positive serum anti-nuclear antibodies and decreased serum complement. During this episode, she was diagnosed with systemic lupus erythematosus. Although she was negative for serum anti-cardiolipin IgG and anti-β2 glycoprotein I antibodies as well as lupus anticoagulant, her serum anti-phosphatidylcholine, anti-phosphatidylethanolamine, anti-phosphatidylinositol and phosphatidylserine IgG antibodies levels were increased.

Conclusion

Pediatric cases of central retinal vein occlusion are rare. Even in patients without anti-cardiolipin or anti-β2 glycoprotein I antibodies and lupus anticoagulant, there is the potential for the development of antiphospholipid antibody-related thrombosis.

Neonatal onset diffuse cutaneous mastocytosis: a case report and review of the literature

Diffuse cutaneous mastocytosis is a rare variant of mast cell disease with widespread erythroderma, which is normally clinically apparent in early infancy. We report the case of a neonate who presented with diffuse erythrodermic rash and bullous lesions. Biopsy specimens showed a dense dermal infiltrate of mast cells. Serum histamine and tryptase levels were elevated. No somatic mutation of the c-kit gene was found. Blistering ceased at 5 months of age, but atopic dermatitis appeared at 6 months and allergic workup revealed a high level of food-specific IgE. Herein, we describe the case and provide the first review of the literature on neonatal onset diffuse cutaneous mastocytosis to clarify the prognosis of this condition.

Sex- and age-related differences in morbidity rates of 2009 pandemic influenza A H1N1 virus of swine origin in Japan

BACKGROUND

The objective of the present study was to determine whether the morbidity rates of the 2009 pandemic influenza A H1N1 virus (pdmH1N1) varied by age and/or sex.

METHODS AND FINDINGS

Retrospective analysis of 2,024,367 cases of pdmH1N1 was performed using the national surveillance data from influenza sentinel points in Japan. The male-to-female morbidity ratios (M/F ratios) in nineteen age groups were estimated as the primary outcome. The M/F ratios for pdmH1N1 influenza were: >1 in age groups <20 years and ≥80 years (p<0.001); <1 in age groups 20-79 years (p<0.001). This data suggests that males <20 years of age may be more likely to suffer from pdmH1N1 influenza than females in the same age categories. When the infection pattern for pdmH1N1 was compared with that of seasonal influenza outbreaks between 2000 and 2008, the M/F ratio for pdmH1N1 influenza was higher in ages 3-29 years and lower in ages 40-79 years. Because the present study was based on the national surveillance, it was impossible to estimate the morbidity rate for the Japanese population. It is also likely that the data did not capture asymptomatic or mild infections.

CONCLUSIONS

Although exposure to the pdmH1N1 virus is assumed to be similar in both boys and girls, M/F ratios were >1 in those younger than 20 years. The subsequent reversal of the M/F ratio in the adult generation could be due to several possibilities, including: greater immunity among adult males, more asymptomatic infections among males, less reporting of illness by males, or differences in exposure to the virus and probability of visiting a clinic. These results suggest that the infection and virulence patterns of pdmH1N1 are more complex than previously considered.

The indication and effectiveness of low-dose erythromycin therapy in pediatric patients with bronchial asthma

To elucidate the mechanisms of intractable pediatric bronchial asthma and the indication of low-dose erythromycin (EM) therapy, the serum chemokine levels of and the angiogenic factor were evaluated in 55 pediatric patients with bronchial asthma; 7.4 +/- 3.5 yr old, who had been treated with inhaled steroid, leukotriene receptor antagonist, theophylline and others for more than a year. Both the levels of interleukin (IL) 8 (p = 0.036) and vascular endothelial growth factor (VEGF) (p = 0.005) were higher in patients with severe type than those of patients with the milder type, while other chemokine levels such as serum eotaxin and MCP1 did not show the correlation with the severity of bronchial asthma. Induction of therapy with low-dose EM induced improvement of the clinical symptoms in patients with severe type and decrease of their serum chemokine levels: IL8; from 736 +/- 88 to 75 +/- 85 pg/ml (p < 0.0005), and VEGF; from 352.0 +/- 160.5 to 132.2 +/- 59.9 pg/ml (p = 0.021) within the next 6 months. Moreover, low-dose EM resulted in a decreased daily peak-trough fluctuation rate of the serum theophylline concentration; (C(max )- C(min))/C(min), from 1.3 +/- 0.5 to 0.5 +/- 0.3, which led to the maintenance of effective serum levels. These results indicated that IL8 and VEGF affect the severity of standard therapies resistance intractable bronchial asthma. Through the suppression of these chemokines and maintenance of effective theophylline levels, low-dose EM therapy improves the symptoms of bronchial asthma.

[Alterations in immunological responses: conformational changes of allergens and application to hyposensitivity therapy]

To establish a novel strategy for allergen immunotherapy, human immunoresponses against conformational variants of a mite allergen were examined. Heat treatment of major house dust mite allergen, Der f2 caused molecular aggregation, while its ability to bind IgE remained unchanged. C8/119S, a mutant protein of Der f2 with the cysteine residues at positions 8 and 119 being replaced by serines, leads to degenerate secondary structure, molecular polymerization and Th1 cell differentiation. C8/119S also lost the ability to bind IgE. On the other hand, misfolded recombinant Der f2 also exhibits degenerate secondary structure, molecular polymerization and Th1 cell differentiation, however, its ability to bind IgE is retained. Loss of IgE binding ability and Th1 skewed immunogenicity of C8/119S are attributed to alterations in antigen-presenting cells and its cytokine profiles. These findings may lead to a novel allergen immunotherapy.

The subclassification of schizencephaly and its clinical characterization

We subclassified schizencephaly based on the association with optic nerve hypoplasia (ONH) and the absence of the septum pellucidum (ASP), and then characterized their clinical presentation and prognosis. The subjects of our study consisted of 10 cases with a mean age at the final evaluation of 10 years 3 months (range, 7 months to 25 years). The subclassification of schizencephaly consisted of the septo-optic dysplasia (SOD) group (n=3), with ONH and ASP; the optic hypoplasia (OHP) group (n=2), with ONH and without ASP, and; the classical group (n=5), without ONH. The subjects with an open-lip cleft in the SOD and the classical group showed hydrocephalus, but those in the OHP group did not. The SOD and the OHP group displayed severe psychomotor retardation regardless of the cleft morphology, but in the classical group, the subjects with an open-lip cleft or with diffuse cortical dysplasia were severely retarded. The SOD and the OHP group displayed intractable epilepsy. In contrast, all subjects in the classical group showed good control of epilepsy. The results of our investigation show that the subclassification of schizencephaly based on the association with ONH and ASP is useful. The SOD group means early fetal brain injury which results in extended cortical dysplasia while the OHP group means severe destructive brain injury which results in cerebro-cerebellar disruption.

Novel mutation of early, perinatal-onset, myopathic-type very-long-chain acyl-CoA dehydrogenase deficiency

A male neonate demonstrated fetal distress, neonatal asphyxia, and transient hyper-creatine kinase-emia (8400IU/L), followed by repeated episodes of rhabdomyolysis 1-2 times/year during infancy and early childhood. At age 6 years, decreased levels of total and free carnitine in serum, and mild fiber size variation and increased fatty droplets in muscle, were confirmed. Both blood and serum fatty-acid analysis demonstrated elevated 5-tetradecenoate levels, and the acyl-CoA dehydrogenase activity of the palmitoyl-CoA/octanoyl-CoA ratio decreased in skin fibroblasts. The sequenced clone analysis of a complimentary DNA fragment revealed a compound heterozygote mutation of exon 9 (A790G) and exon 10 (997 ins T), which is a novel mutation of a myopathic-type very-long-chain acyl-CoA dehydrogenase deficiency. The patient has reached age 13 years. By treatment with an avoidance of fasting, feeding with a high-carbohydrate and low-fat diet, and intravenous drip infusion soon after every onset of rhabdomyolysis, his physical and mental development has stayed within the normal range. Patients with a perinatal onset of myopathic-type very-long-chain acyl-CoA dehydrogenase deficiency have not yet been reported. His novel mutation might be related to his clinical characterization.

Clinical presentation of patients with neurofibromatosis type 1 in infancy and childhood: genetic traits and gender effects

The clinical presentations of 32 patients with neurofibromatosis type 1 were examined based on genetic traits, clinical findings, electroencephalogram, and neuroimaging findings. Twenty-eight sequential magnetic resonance images showed multifocal hyperintense T2-weighted images in 14 patients. Seven (5 boys and 2 girls) of the 8 patients (88%) who inherited neurofibromatosis type 1 from affected mothers, and 7 (2 boys and 5 girls) of the 16 de novo patients (44%) had multifocal hyperintense T2-weighted images. In contrast, the patients who inherited this disease from affected fathers did not have any multifocal hyperintense T2-weighted images. Multiple plexiform neurofibromas were observed in 4 patients, of whom 3 boys inherited through at least 3 generations of women. They all presented severe psychomotor delay and epilepsy. These findings suggest that genetic traits, especially through the passage of several generations of women, may affect the clinical presentation in patients with neurofibromatosis type 1.

Efficacy of fluticasone metered-dose inhaler and dry powder inhaler for pediatric asthma

BACKGROUND

For the treatment of bronchial asthma, two types of fluticasone inhaler devices are available, namely, metered-dose inhaler with spacer (MDI-S) and the dry powder inhaler (DPI). The former is recommended for young children with a low peak inspiratory flow (PIF) and the latter for adolescents and adults. But the difference in the therapeutic efficacy between them has been studied only rarely in adolescent patients.

METHODS

In the present study, 21 post-elementary school-age patients with moderate persistent bronchial asthma (age 8-15 years, 10.3 +/- 2.1 years), who all had a sufficient PIF of 114 +/- 29 L/min, were examined in order to compare the two types of fluticasone inhalers. Eleven of 21 patients inhaled 200 microg/day Flutide using the MDI-S twice daily for 1 month in the first month, and the same dose using the DPI for the next month. The other 10 patients inhaled the opposite regimens. At the end of the each treatment, spirometry was examined.

RESULTS

Measurements done before therapy and then at the end of MDI-S and DPI therapy, respectively, were as follows: forced expiratory volume in 1 s (FEV(1.0)), 72.4 +/- 18.2%, 91.5 +/- 18.2% and 84.1 +/- 16.3% (MDI-S vs DPI, P > 0.040); maximal mid-expiratory flow (MMEF), 62.0 +/- 23.6%, 88.7 +/- 26.5%, 79.3 +/- 33.4% (P > 0.044) and the peak expiratory flow (PEF) was 73.9 +/- 25.0%, 95.6 +/- 32.8%, and 90.5 +/- 29.5%, respectively (n.s.). MDI-S was thus found to be more effective in terms of %FEV(1.0) and in %MMEF.

CONCLUSIONS

High therapeutic efficacy was obtained with the use of the MDI-S in fluticasone inhalation for post-elementary school-age patients with sufficient inspiration ability.

Theophylline-associated seizures and their clinical characterizations

BACKGROUND

To elucidate the basic mechanism of theophylline-associated seizures (TAS), the clinical symptoms, electroencephalogram (EEG) and neuroradiological imaging of eight pediatric patients were all retrospectively evaluated.

METHODS

Patients whose seizures represented their first episode were selected, while patients with cerebrospinal fluid abnormalities including pleocytosis and protein elevation, present illness of head trauma, epilepsy, febrile convulsion or any psychomotor retardation were excluded although they were given theophylline.

RESULTS

Eight patients, 3.5 +/- 1.7 years of age, thus fulfilled the definition of TAS in the past 5 years. Based on their seizure patterns, EEG findings, brain single-photon emission computed tomography and head magnetic resonance imaging, a total of seven of eight patients had either localized or unilateral dominant lesions. They all had fever, > or =38 degrees C, and six of eight patients had a family history of febrile convulsions and/or idiopathic epilepsy. Thereafter none of them had convulsions after the cessation of theophylline administration. Through the TAS event, a 6-year-old female patient was found to have a right deep lateral cerebral venous angioma.

CONCLUSION

In infants with idiopathic low seizure threshold and fever, theophylline administration might possibly trigger a seizure. Moreover, based on these patients' clinical findings, some kind of cerebral vascular involvements is speculated to be related with TAS.

Hemophagocytic lymphohistiocytosis in a human immunodeficiency virus-positive homosexual high school student

The spread of human immunodeficiency virus (HIV) infection has exploded over the past two decades and such infections in young people are no longer uncommon. However, the major infection route of pediatric patients remains vertical transmission, and sexual, especially homosexual transmission, is highly unusual. We herein describe the case of a 17-year-old boy who developed hemophagocytic lymphohistiocytosis (HLH). Although HLH was remitted soon with dexamethasone therapy, an HIV infection caused by homosexual transmission was detected.

Human gammadelta T cells modulate the mite allergen-specific T-helper type 2-skewed immunity

BACKGROUND

Gammadelta T cells have been described as one of immune regulators in patients with infection, malignancy, and allergy.

OBJECTIVE

To elucidate the ability of gammadelta T cells as an allergen immunotherapy candidate, the effectiveness of human gammadelta T cells in allergen-specific T-helper type 2 (Th2)-type T cells was evaluated in vitro.

METHODS

House dust mite-specific Th2-type T cell clones, Bacillus Calmette-Guerin (BCG)-specific Th1-type T cell clones, and gammadelta T cell lines were established from the peripheral blood mononuclear cells of two patients with allergic rhinitis. The effectiveness of gammadelta T cells and BCG-specific Th1-type T cell clones in the modulation of allergen-specific Th2 cells in terms of their cytokine productions was evaluated.

RESULTS

In response to cognate antigens, the gammadelta T cell lines demonstrated a proliferation and production of IFN-gamma that exceeded that of BCG-specific Th1-type T cell clones (mean stimulation index: 14.5 vs. 2.8, mean IFN-gamma: 130.5 vs. 10.0 pg/mL). When the gammadelta T cell lines and mite-allergen-specific Th2 clones were co-cultured with each other, only the levels of IL-4 (mean, -87%) decreased, but not the levels of IL-5 and IL-13, with an increasing concentration of gammadelta T cell antigen and IFN-gamma production (mean, +730%).

CONCLUSION

These results demonstrated that gammadelta T cells derived from allergic patients might thus have a partial ability to modulate allergen-specific Th2-skewed immunity.

The characterization of cerebrospinal fluid and serum cytokines in patients with Kawasaki disease

BACKGROUND

The central nervous system (CNS) inflammation of Kawasaki disease (KD) has not been sufficiently evaluated in spite of the complications of irritability and CSF pleocytosis.

PATIENTS AND METHODS

Cerebrospinal fluid (CSF) and serum inflammatory cytokine values were simultaneously examined in 10 patients (2.6 +/- 2.1 year of age) during the acute phase. They were all irritable and demonstrated mild consciousness disturbance.

RESULTS

The CSF IL6 was elevated (>3.0 pg/mL) in 6 patients, and 4 of them showed higher CSF than serum values. The CSF sTNFR1 was elevated (>0.5 microg/mL) in 6 patients, and 1 showed higher CSF than serum values. These CSF cytokine (IL6; 81.4 +/- 192.8 pg/mL, sTNFR1; 1.1 +/- 0.8 microg/mL) and CSF/serum ratio (IL6; 2.8 +/- 5.2, sTNFR1 0.4 +/- 0.4) in patients with KD were the same as those of patients with acute encephalitis/acute encephalopathy.

CONCLUSIONS

The differences in the inflammatory cytokine value between CSF and serum suggest that the degree of systemic vasculitis is different between CSF and the circulating blood, and some patients with KD showed a higher degree of CSF inflammation.

Congenital neuromuscular disease with uniform type-1 fibers, presenting early stage dystrophic muscle pathology

We report two male siblings presenting with severe hypotonia, generalized muscle atrophy, multiple joint contractures and respiratory failure. The serum creatine kinase levels were within normal limits, 75 IU/l in the younger boy and 123 IU/l in the older one. Muscle biopsies at the age of 28 days in the younger boy and 48 days in the older one revealed dystrophic pathology with increased interstitial fibrous tissue, scattered basophilic fibers and an increased number of undeveloped type-2C fibers. Although the elder brother died from respiratory failure at 4 months of age, the younger child has been sustained with mechanical ventilation, and has been exhibiting non-progressive muscle symptoms. Upon re-biopsy of the younger sibling at the age of 3 years, neither basophilic regenerating fibers nor degenerating fibers were found. All muscle fibers were found to be extremely atrophic and behaved mostly like type-1 fibers, displaying the features of congenital neuromuscular disease with uniform type-1 fibers. Since early biopsies in congenital myopathies reveal numerous undifferentiated immature muscle fibers, it is difficult to make a definite diagnosis, unless we recognize disease-specific cytoplastic abnormalities of nemaline body formation and abnormalities of core structure.

Crystal structure and some properties of a major house dust mite allergen, Derf 2

Pyroglyphid house dust mites are a major source of allergens in house dust. Mite allergens sensitize and induce asthma, rhinitis, and eczema in a large portion of patients with allergic diseases. Here, the crystal structure of a major mite allergen, Derf 2, derived from Dermatophagoides farinae was solved by single isomorphous replacement method with anomalous scattering (SIRAS) at 2.1A resolution. The present study also demonstrated that the conformation of the allergen was critical in the determination of Th1/Th2 shift based on physicochemical and immunological analyses. This indicates that rigidly folded and singly dispersed structure is essentially required for the generation of Th2 type cells by the allergen, while conformational variant protein leads to Th1 skewing, irrespective of the same amino acid sequence. This structure/function relationship may allow us to develop a novel strategy for hyposensitization therapy in patients with allergic diseases triggered by house dust mite allergens.

[Cedar pollinosis in Japanese schoolchildren: results from a large questionnaire-based survey]

PURPOSE

To evaluate the prevalence and clinical characteristics of Japanese cedar (Cryptomeria japonica) pollinosis (CP) in Japanese schoolchildren.

METHODS

Questionnaire made by the Study Group of Epidemiology of Allergic Diseases founded by the Japanese Ministry of Public Health and Welfare was distributed to 56,108 schoolchildren living in the suburban areas of Kyoto, Japan. The data recovered from 50,086 children (recovery rate 89.3%) was analyzed.

RESULTS AND DISCUSSION

Overall prevalence of CP was 5.2%. The prevalence was higher in older children, and in those born in autumn and winter. Prevalence of CP in southern urban area was significantly higher (p < 0.001) than that in northern rural area, suggesting that urban environment including air pollution might increase the prevalence of CP. Among children with AD, there was statistically significant correlation between the severity of AD and the presence of CP (p = 0.016), i.e. those with CP tended to have more severe AD symptoms. On the other hand, the severity of BA was not affected by the presence of CP (p = 0.323). These data suggest a contribution of cedar pollen to AD, but not to BA, symptoms. Overall, our present data shown that CP has become one of the important allergic diseases in childhood, and that further evaluation of CP among children would be necessary.

Distinct aggregation of beta- and gamma-chains of the high-affinity IgE receptor on cross-linking

The high-affinity IgE receptor (FcepsilonRI) on mast cells and basophils consists of a ligand-binding alpha-chain and two kinds of signaling chains, a beta-chain and disulfide-linked homodimeric gamma-chains. Crosslinking by multivalent antigen results in the aggregation of the bound IgE/alpha-chain complexes at the cell surface, triggering cell activation, and subsequent internalization through coated pits. However, the precise topographical alterations of the signaling beta- and gamma-chains during stimulation remain unclarified despite their importance in ligand binding/signaling coupling. Here we describe the dynamics of FcepsilonRI subunit distribution in rat basophilic leukemia cells during stimulation as revealed by immunofluorescence and immunogold electron microscopy. Immunolocalization of beta- and gamma-chains was homogeneously distributed on the cell surfaces before stimulation, while crosslinking with multivalent antigen, which elicited optimal degranulation, caused a distinct aggregation of these signaling chains on the cell membrane. Moreover, only gamma- but not beta-chains were aggregated during the stimulation that evoked suboptimal secretion. These findings suggest that high-affinity IgE receptor beta- and gamma-chains do not co-aggregate but for the most part form homogenous aggregates of beta-chains or gamma-chains after crosslinking.

C8/119S mutation of major mite allergen Derf-2 leads to degenerate secondary structure and molecular polymerization and induces potent and exclusive Th1 cell differentiation

Hyposensitization therapy for atopic diseases has been conducted for decades but suffered from many problems including anaphylactic reactions. We previously developed a mutant protein of the major mite allergen Derf-2, C8/119S, which showed reduced binding to IgE. The C8/119S mutant was shown to exhibit more efficient hyposensitizing effect than Derf-2 in the animal model of allergic bronchial asthma. In the present study, we indicate that C8/119S exhibits markedly augmented immunogenicity for the proliferation of Derf-2-specific human T cells and T cell clones irrespective of the epitope specificity as compared with Derf-2. Furthermore, C8/119S has induced potent and almost exclusive differentiation of Th1 cells from the peripheral blood of atopic patients in vitro. Neither Ag dosage effect nor absence of B cell-mediated Ag presentation could fully account for these effects. C8/119S has been indicated to lose the characteristic beta-barrel structure as judged by circular dichroism spectroscopic analysis and to polymerize solubly in physiological condition. Heating of Derf-2 also caused less stable molecular aggregation, but it hardly affected the secondary structure and failed to induce such a polarity toward the Th1 cell differentiation. These results have indicated that the degenerate secondary structure of C8/119S leading to stable molecular polymerization is primarily responsible for the marked increase in T cell-immunogenicity and the induction of exclusive Th1 cell differentiation in atopic patients. It has been suggested strongly that the recombinant C8/119S protein can provide an effective Ag with the least risk of anaphylaxis for allergen immunotherapy against house dust mite in human.

Comparison of skin prick test with serially diluted wild-type and genetically engineered recombinant Der f2

BACKGROUND

C8/119S, a genetically engineered less allergenic mutant of group II allergen (Der f2) of house dust mite, Dermatophagoidesfarinae, was constructed in order to reduce the risk of anaphylactic reactions of allergen specific immunotherapy.

OBJECTIVE

To further evaluate, with a larger number of mite-allergic patients, the safety of C8/119S for the treatments of humans.

METHOD

We tested the dose-dependent responses of 20 mite-allergic volunteers to a skin prick test with C8/119S and wild-type recombinant Der f2 and compared the biologic potentials of these allergens to induce type I allergic reactions. In a separate experiment, we compared IgE binding capacities to C8/119S and to wild-type recombinant Der f2 in individual sera from 34 mite-allergic donors.

RESULTS

The concentration of C8/119S needed to induce positive skin prick test (SPT) reaction was at least 100 times more than that of recombinant Der f2 in 95% of the volunteers tested. Consistent with this result, IgE binding data showed that 85% of the mite-allergic donors had little or no detectable IgE bound to C8/119S. Our data also shows that a minority of mite-allergic patients responded in a similar manner to both C8/119S and wild-type recombinant Der f2.

CONCLUSION

Our data confirms that C8/119S is much less allergenic and thus can be used safely for immunotherapy of most of mite-allergic patients. Care should still be taken because, in a minority of patients, C8/119S may cause similar type I allergic reactions as does wild-type recombinant Der f2.

[Recent pollen sensitization and its possible involvement in allergic diseases among children in a pediatric allergy clinic]

We studied the rate of sensitization to several pollen allergens as well as to house dust mites in 226 children visiting our pediatric allergy clinic during the past 3 years (from April 1996 to March 1999). The allergens studied were Sugi (Japanese cedar pollen, Cryptomeria japonica), Kamogaya (Dactylis gromerata), Butakusa (ragweed, Ambrosia artemisiifolia), and Der f (house dust mite, Dermatophagoides farinae). The presence of nasal symptoms (either seasonal and perenial) was checked in 97 children visiting the clinic in March 1999. Overall average sensitization rates were 82.3% for Der f, 53.1% for Sugi, 38.5% for Kamogaya, and 17.1% for Butakusa. Among children aged 12 or more, sensitization rates for Sugi and Kamogaya were much higher (68.8%, 56.3%, respectively). Those who had seasonal nasal symptoms showed significantly higher rates of sensitization to the pollens. However, more than half of patients without nasal symptoms, 62.8% of whom had only atopic dermatitis (AD), also showed sensitization to the pollens. Several possible factors accounting for pollen sensitization in children with only AD and no sasal symptoms, such as existence of occult allergic rhinitis, future onset of allergic rhinitis, or pollen as directly aggravating factor of AD, need to be evaluated by careful follow-up of these cases.

Month of birth and prevalence of atopic dermatitis in schoolchildren: dry skin in early infancy as a possible etiologic factor

BACKGROUND

Month of birth has been shown to affect later development of allergic diseases.

OBJECTIVE

We sought to evaluate the relationship between month of birth and the prevalence of atopic dermatitis (AD) in a large-scale general population of schoolchildren and to elucidate the possible mechanism for this relationship.

METHODS

Questionnaire data on the prevalence of allergic diseases were obtained for 33,725 schoolchildren aged 7 to 15 years. In a separate study the water-holding capacity of "uninvolved" skin was compared for children with and without AD.

RESULTS

We found striking differences in the prevalence of AD according to the month of birth (chi2 = 34.9, P <.0001). Overall, those born in autumn showed the highest (7.5%), and those born in spring showed the lowest (5.5%), prevalence of AD. There was little or no such tendency for the prevalence of bronchial asthma (chi2 = 17.2, P =.103) and allergic rhinitis (chi2 = 24, P =.01). We found no statistical variation across birth month in the ratio of AD with no other allergic disease/total AD, indicating that this deviation was observed whatever the allergic predisposition of the subjects. In a separate study a significantly lower water-holding capacity of uninvolved skin was observed in children with AD even from early infancy.

CONCLUSION

These findings lead us to speculate that the climate in early infancy affects the skin condition and that those born in autumn have dry skin in early infancy, which may ultimately result in a higher prevalence of AD among young schoolchildren. This might be at least one of the "nonallergic" etiologic factors of this complex disease.