Cyanosis revealing hepatopulmonary syndrome in a child with dyskeratosis congenita

We report the case of a 5-year-old child with dyskeratosis congenita who presented cyanosis and dyspnea at exertion. He had severe hypoxemia with elevated alveolar-arterial oxygen gradient in the setting of liver disease. Technetium-99m-labeled macroaggregated albumin scan showed abnormally high uptake in the brain, confirming hepatopulmonary syndrome.

Non-classic cystic fibrosis associated with D1152H CFTR mutation

BACKGROUND

Limited knowledge exists on phenotypes associated with the D1152H cystic fibrosis transmembrane conductance regulator (CFTR) mutation.

METHODS

Subjects with a D1152H allele in trans with another CFTR mutation were identified using the French Cystic Fibrosis Registry. Phenotypic characteristics were compared with those of pancreatic insufficient (PI) and pancreatic sufficient (PS) cystic fibrosis (CF) subjects in the Registry (CF cohort).

RESULTS

Forty-two subjects with D1152H alleles were identified. Features leading to diagnosis included chronic sinopulmonary disease (n = 25), congenital absence of the vas deferens (n = 11), systematic neonatal screening (n = 4), and genetic counseling (n = 2). Median age at diagnosis was 33 [interquartile range (IQR, 24-41)] years in D1152H subjects. Median sweat chloride concentrations were 43.5 (39-63) mmol/l in D1152H subjects and were markedly lower than in PI and PS CF subjects (p < 0.05). Bronchiectasis was present in 67% of D1152H subjects, but Pseudomonas aeruginosa colonization and pancreatic insufficiency were present in <30% of subjects. Estimated rates of decline in forced expiratory volume in 1 s (FEV(1)) were lower in D1152H subjects vs PI CF subjects (p < 0.05). None of the D1152H subjects identified since 1999 had died or required lung transplantation.

CONCLUSIONS

When present in trans with a CF-causing mutation, D1152H causes significant pulmonary disease, but all subjects had prolonged survival.

La fibroscopie bronchique chez l’enfant

INTRODUCTION

Fibreoptic bronchoscopy (FB) is an important diagnostic examination in paediatric pulmonology. In 2002 the Paediatric Pulmonology and Allergy Club undertook a retrospective study to establish the current status of fibreoptic bronchoscopy among its members.

METHODS

In 2001 sixty five paediatric pulmonologists carried out an average of 116 examinations (+/- 111) in 35 paediatric centres. FB was performed either in an operating theatre (15 centres), a dedicated bronchoscopy suite (6 centres) or an endoscopy suite shared with gastro-enterologists (7 centres). Other examinations were performed in areas dedicated to, or associated with intensive care. General anaesthesia was routinely used in 18 centres. The others used sedation including an equimolar mixture of oxygen and nitrous oxide in 14 centres. Ten centres performed less than 50 examinations, 12 between 51 and 100, 4 between 101 and 200 and 8 centres more than 200 in the year. Seventy two per cent of the children were less than 6 years old. The washing and disinfection procedures were manual in 20 centres and automatic in 15.

RESULTS

Three principal indications were reported: persistent wheezing, suspicion of a foreign body and ventilatory difficulties. Cough, desaturation and fever were the most frequently reported side effects.

CONCLUSIONS

This is the first survey in paediatric pulmonology in France. It shows a wide variation in the practice of fibreoptic bronchoscopy in children.

Ideal timing of thoracoscopic decortication and drainage for empyema in children

BACKGROUND

Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing.

METHODS

Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h).

RESULTS

In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures.

CONCLUSIONS

Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.

[Association of severe bronchial disease (bronchial casts, bronchiectasis) and partial abnormal pulmonary venous drainage in 2 children with Turner's syndrome]

The prevalence of cardiovascular malformation is high in Turner's syndrome. We report two cases of partial anomalous pulmonary venous drainage associated with a severe bronchial disease.

CASE REPORTS

Case 1: a 5-year-old girl with monosomy X presented with acute respiratory failure. The chest X-ray showed an atelectasis of the left lower lobe. The patient improved following bronchoscopic removal of a bronchial cast. During hospitalization, an anomalous pulmonary venous drainage of the right lung was discovered. In spite of complete surgical repair of the cardiac malformation, several episodes of respiratory failure occurred several years after the operation. Case 2: a 9-year-old girl with monosomy X and coarctation of the aorta underwent pre-operative cardiac catheterization. She had a history of bronchiectasis, leading to a lobectomy. Her respiratory condition improved following surgery. A partial anomalous pulmonary venous return was discovered during the cardiac angiography. The coarctation was repaired surgically. The correction of the left-to-right shunt was not necessary.

CONCLUSION

The partial anomalous pulmonary venous return is frequently reported in Turner's syndrome. The possible respiratory disease associated with this cardiac malformation is usually described as a consequence of the increase in pulmonary blood flow. Our two cases did not match this hypothesis.

[Cardiac adaptation to muscular exercise in children after complete repair of tetralogy of Fallot]

The aim of this study was to assess cardiac adaptation to muscular exercise in children operated for tetralogy of Fallot. Eight children with a history of tetralogy of Fallot were studied and compared with ten control children. The basal evaluation consisted of an electrocardiogram, spirometry in all cases. Chest X-ray and echocardiography in all operated children. A muscular exercise stress test with incremental load on a bicycle ergometer was carried out with measurement of the cardiac output by CO2 rebreathing (experimental method). Under resting conditions, the two groups were comparable with respect to anthropometrical parameters and respiratory function. The cardiovascular data confirmed the good postoperative results of the children with a history of tetralogy of Fallot; cardiothoracic index of 0.49 to 0.55; sinus rhythm on the electrocardiogram; right ventricular pressures within normal limits; residual instantaneous right ventricular-pulmonary artery pressure gradient less than 25 mmH. On exercise, there was no significant difference with respect to VO2max, maximal heart rate, maximal cardiac output and maximal ventilation. The relationship between cardiac output and oxygen consumption was linear in two groups: y = 8.17x + 1.95 in the control group, y = 8.57x + 2.82 in the operated children. The change in cardiac output on exercise was comparable in the two groups. These observations seemed to be related to the good postoperative haemodynamic result: absence of pulmonary sequellae and right ventricular dysfunction. Despite the normality of the results obtained in this series, exercise stress testing with analysis of cardiac and respiratory adaptation would seem to be necessary in the follow-up of children operated for tetralogy of Fallot to exclude a ventilatory or circulatory limitation.

[Materno-fetal infections caused by unusual germs. Apropos of 9 cases]

A retrospective study carried out from January 1981 through August 1988 identified nine cases of materno-fetal infections (Staphylococcus aureus, 1 case; Klebsiella pneumoniae, 3 cases; enterococcus, 3 cases; Hemophilus influenzae, 1 case; and Pneumococcus, 1 case) in six girls and three boys; four premature infants developed respiratory distress requiring mechanical ventilation. In four cases, maternal history found risk factors for infection. All patients developed circulatory failure and one had purulent meningitis. Diagnosis was confirmed upon recovery of the microorganism from a central sample in six cases; in three cases, only the peripheral cultures were positive but diagnosis was supported by the positive maternal history and by clinical findings. Bacterial species were not associated with specific clinical or biological features, but infections due to Hemophilus influenzae, Klebsiella pneumoniae and pneumococcus were particularly severe (two deaths and two infants with neurologic sequelae). In some studies, unusual microorganisms account for 46% of septicemias and 36% of purulent meningitis. Group D streptococci are the most common bacteria in this category and may account for 10% to 15% of early neonatal septicemias. Organism-specific features are analyzed on the basis of data from the literature. Concerning therapy, this epidemiologic aspect of materno-fetal infections complicates the choice of the initial antimicrobial agents; because third-generation cephalosporins are not effective on listeria and group D streptococci, we advocate more widespread use of the ureidopenicillins instead of ampicillin.