Multisystem inflammatory syndrome in children associated with COVID-19 presenting as cervical inflammation

AIM

The major clinical manifestations multisystem inflammatory syndrome in children (MIS-C) are fever, gastrointestinal and cardiac. The aim of this study was to describe MIS-C in a series of patients who presented primarily with cervical manifestations.

METHODS

We retrospectively reviewed medical records of all patients who met the Centers for Disease Control and Prevention and World Health Organization MIS-C diagnostic criteria treated at Hadassah-Hebrew University Medical Center between April 2020 and September 2021.

RESULTS

Of 37 children diagnosed with MIS-C (median age: 10.2 years, range 1.5-18 years, 20 male) five, 13.5% (median age: 14.4 years, range 9.2-17.5 years) presented with cervical symptoms mimicking neck infections. One was hospitalised with a working diagnosis of retropharyngeal abscess, and four with acute cervical lymphadenitis that did not respond to early antibiotic treatment. All developed full MIS-C phenotype.

CONCLUSION

MIS-C may present as cervical inflammation. An ill-appearing child with symptoms and/or signs of cervical inflammation should be evaluated for clinical and laboratory features of MIS-C, thereby facilitating prompt treatment of this potentially fatal disorder.

Manual external chest compression reverses respiratory failure in children with severe air trapping

We report manual external chest compression (MECC) as an effective treatment for acute respiratory failure due to severe air trapping. In this retrospective study, we describe our experience with MECC administered to five children suffering from severe air trapping as a consequence of severe asthma or bronchiolitis. These children were admitted to the Pediatric Intensive Care Unit (PICU) with clinical and blood gases parameters compatible with acute respiratory failure. Before intubation MECC was performed. The results of blood gasses before, during, and after MECC showed gradual changes in PCO₂ over time indicating the improvement in tidal volume and ventilation. Respiratory failure resolved in all five children within 4 h with no complications. The need for intubation and mechanical ventilation was avoided, and all children were discharged from the PICU within 48 h.

The relationship between postprandial bile acid concentration, GLP-1, PYY and ghrelin

BACKGROUND

Gut hormones peptide YY (PYY) and glucagon-like peptide-1 (GLP-1) play an integral role in appetite control and energy homeostasis. Entero-endocrine L-cells can be stimulated by nutrients and or bile acids to co-secrete PYY and GLP-1. The aim of this study was to determine the response of bile acids, PYY, GLP-1 and ghrelin after a test meal.

DESIGN

Twelve subjects with a BMI of 22·8 (0·52) kg/m² [mean (SEM)] received a 400 kcal test meal after which blood samples were taken every 30 min from 0 to 180 min. PYY, GLP-1 and ghrelin were measured by radioimmunoassays. Fractionated bile acids were measured by HPLC-MSMS.

RESULTS

PYY positively correlated with glycochenodeoxycholic acid (GCDCA) (rs = 0·23, P = 0·03) and taurochenodeoxycholic acid (TCDCA) (rs = 0·26, P = 0·02). GLP-1 positively correlated with GCDCA (rs = 0·22, P = 0·047) and glycodeoxycholic acid (GDCA) (rs = 0·3, P = 0·005). Ghrelin negatively correlated with GDCA (rs = -0·45, P≤ 0·0001), TCDCA (rs = -0·23, P = 0·034) and taurodeoxycholic acid (TDCA) (rs = -0·44, P≤ 0·0001).

CONCLUSION

PYY and GLP-1 responses correlated with chenodeoxycholic acid (CDCA) counterparts, whereas ghrelin negatively correlated with deoxycholic acid (DCA) counterparts. Specific bile acids may thus differentially affect entero-endocrine cells.

Postprandial plasma bile acid responses in normal weight and obese subjects

Background

Bile acids can act as signalling molecules via various receptors including the nuclear farnesoid X receptor (FXR) and pregnane X receptor (PXR), and the cell surface G-protein-coupled receptor TGR5. The signalling has been implicated in the release of peptide YY (PYY) and glucagon-like peptide 1 (GLP-1), which improves glycaemic control and energy expenditure. We investigated whether morbidly obese subjects have altered postprandial bile acid responses in comparison to normal weight subjects.

Method

Blood samples were taken every 30 min from 0 to 180 min following a 400 kcal test meal. Samples were taken from 12 normal weight subjects with a body mass index (BMI) of 23.2 (2.8) kg/m2 (median [interquartile range (IQR)]) and seven obese patients with a BMI of 47.2 (7.2) kg/m2. Fractionated bile acids were measured on these samples using high-performance liquid chromatography tandem mass spectrometry.

Results

The obese subjects showed a lower postprandial response in total bile acids compared with the normal weight subjects. An increase of 6.4 (5.0) and 2.6 (3.3) μmol/L (median [IQR]) in normal weight and obese subjects was observed, respectively ( P = 0.02). The difference was predominantly due to the glycine-conjugated fraction ( P = 0.03). There was no difference in the increase of the unconjugated or taurine-conjugated fractions.

Conclusions

The decreased postprandial bile acid response in obese subjects compared with normal weight subjects may partly explain the suboptimal GLP-1 and PYY responses and could affect appetite, glycaemic control and energy expenditure.

Synergistic activity of trimethoprim and amikacin against gram-negative bacilli

The in vitro effect of trimethoprim on the inhibitory and bactericidal activity of amikacin against 20 strains each of Klebsiella pneumoniae and Serratia marcescens, 15 strains of Escherichia coli, and 10 strains of Pseudomonas aeruginosa was examined by the checkerboard technique in microtiter plates. Trimethoprim had a synergistic effect on the inhibitory and bactericidal activity of amikacin against the majority of non-pseudomonas strains tested. The mean +/- standard deviation fractional inhibitory concentration indexes were 0.59 +/- 0.19 for the Klebsiella strains, 0.48 +/- 0.18 for the Serratia strains, and 0.60 +/- 0.22 for the E. coli strains tested. Respective mean +/- standard deviation fractional bactericidal concentration indexes for these organisms were 0.55 +/- 0.17, 0.54 +/- 0.29, and 0.61 +/- 0.22. A total of 40% of the Klebsiella strains, 80% of the Serratia strains, and 46% of the E. coli strains had a fractional inhibitory concentration equal to or less than 0.25 for both of these antimicrobial agents and were considered to be synergistically inhibited by the combination. By applying this criterion to bactericidal activity, synergy was demonstrated against 50, 65, and 46% of these strains, respectively. All of the Enterobacteriaceae tested were inhibited by clinically achievable concentrations of trimethoprim and amikacin. Antagonism was not demonstrated with any of the organisms tested. Trimethoprim had no antibacterial effect on the Pseudomonas strains and did not alter amikacin's activity against these bacteria.