Interacción madre-hijo en un grupo de lactantes con Enfermedad por Reflujo Gastroesofágico: estudio transversal

NTRODUCCIÓN: La Enfermedad por Reflujo Gastroesofágico (ERGE) suele presentarse con síntomas inespecíficos como irritabilidad, llanto y rechazo a la alimentación, que pudieran afectar las interacciones tempranas del lactante con su madre. Se ha reportado mayor frecuencia de alteraciones psicopatológicas en madres de niños con ERGE.OBJETIVO: Analizar la interacción madre-hijo en diadas de lactantes diagnosticados con ERGE en los primeros meses de vida.MATERIALES Y MÉTODOS: Estudio transversal recolectando los datos en forma prospectiva en el Centro de Investigación en Neurodesarrollo (CIND) del Instituto Nacional de Pediatría (INP) de julio de 2010 a septiembre de 2012. Participantes: 20 lactantes con bajo riesgo perinatal sanos excepto por ERGE y sus madres. Se evaluó la interacción madre-hijo durante una sesión de alimentación mediante la escala de interacción cuidador-hijo Nursing Child Assessment Feeding Scale (NCAFS). Los puntajes obtenidos fueron comparados con los referenciales para hispanos. Se analizó la asociación entre algunas características de las diadas y las interacciones.RESULTADOS: Los puntajes de las diadas estudiadas fueron menores que los de referencia (p>0.05) en todas las subescalas, excepto en la promoción del crecimiento cognitivo. Las mayores diferencias se registraron en las subescalas del infante. Las diadas con madres con menor escolarización obtuvieron menores puntajes tanto en la subescala materna como en la del lactante.CONCLUSIONES: Las interacciones cuidador-hijo en lactantes con ERGE mostraron restricciones con potencial impacto en el neurodesarrollo. La interacción madre-hijo debe ser evaluada tempranamente en estos pacientes para la detección y atención oportuna de posibles alteraciones. 

Infections With Enterohepatic Non-H. pylori Helicobacter Species in X-Linked Agammaglobulinemia: Clinical Cases and Review of the Literature

The genus Helicobacter is classified into two main groups according to its habitat: gastric and enterohepatic. Patients with X-linked agammaglobulinemia (XLA) appear to be associated with invasive infection with enterohepatic non-Helicobacter pylori species (NHPH), mainly H. cinaedi and H. bilis. Such infections are difficult to control and have a high potential for recurrence. The spectrum of illnesses caused by these species includes recurrent fever, bacteremia, arthritis, osteomyelitis, cellulitis, abdominal abscesses, and pyoderma gangrenosum-like ulcer. The presence of these Helicobacters is particularly difficult to diagnose and eradicate, as they are very fastidious bacteria and present resistance to several types of antibiotics. We report two clinical cases of XLA patients infected with H. bilis. These infections were chronic in these patients and could not be eradicated in one of them. We also review the cases of enterohepatic non-Helicobacter pylori species (NHPH) in patients with this inborn error of immunity.

[Logistic precautions in preparation and administration of allergen immunotherapy during the COVID-19 pandemic in Mexico]

La pandemia actual de COVID-19 ha representado un reto mayúsculo para la sociedad y la comunidad médica, no solo por su alta contagiosidad sino por la variabilidad de las manifestaciones clínicas y su comportamiento impredecible bajo diferentes contextos sanitarios. Ante ello, las medidas preventivas específicas son relevantes para evitar o disminuir contagios entre pacientes y personal de las unidades de salud, considerando que el periodo presintomático durante el cual el individuo contagiado ya puede transmitir el virus varía entre cinco y seis o hasta 14 días, según datos de la Organización Mundial de la Salud. Además, un paciente infectado puede estar asintomático, incluso, algunas personas después de haber padecido COVID-19 pueden continuar expulsando virus por algunos días más después de recuperarse.

Proteomics: a tool to develop novel diagnostic methods and unravel molecular mechanisms of pediatric diseases

Proteomics is the study of the expression of changes and post-translational modifications (PTM) of proteins along a metabolic condition either normal or pathological. In the field of health, proteomics allows obtaining valuable data for treatment, diagnosis or pathophysiological mechanisms of different illnesses. To illustrate the aforementioned, we describe two projects currently being performed at the Instituto Nacional de Pediatría: The immuno-proteomic study of cow milk allergy and the Proteomic study of childhood cataract. Cow's milk proteins (CMP) are the first antigens to which infants are exposed and generate allergy in some of them. In Mexico, the incidence of CMP allergy has been estimated at 5-7%. Clinical manifestations include both gastrointestinal and extra-gastrointestinal symptoms, making its diagnosis extremely difficult. An inappropriate diagnosis affects the development and growth of children. The goals of the study are to identify the main immune-reactive CMP in Mexican pediatric population and to design more accurate diagnostic tools for this disease. Childhood cataract is a major ocular disease representing one of the main causes of blindness in infants; in developing countries, this disease promotes up to 27% of cases related to visual loss. From this group, it has been estimated that close to 60% of children do not survive beyond two years after vision lost. PTM have been pointed out as the main cause of protein precipitation at the crystalline and, consequently, clouding of this tissue. The study of childhood cataract represents an outstanding opportunity to identify the PTM associated to the cataract-genesis process.

Respuesta a la carta al Editor

Le agradecemos por darnos la oportunidad de contestar a la carta “Magnitud del tamaño del efecto y su importancia en la investigación pediátrica”1 del Dr. Tomás Caycho. También quisiéramos agradecer por las observaciones y comentarios del Dr. Caycho, a través de los cuales se señala la importancia y necesidad de reportar tamaño de efecto en los resultados de análisis estadístico en las investigaciones y de nuestro trabajo: “Calidad de vida de los pacientes con inmunodeficiencias primarias de anticuerpos”2 publicado en esta revista.

Variations of B cell subpopulations in peripheral blood of healthy Mexican population according to age: Relevance for diagnosis of primary immunodeficiencies

BACKGROUND

Peripheral blood B cells include lymphocytes at various stages of differentiation, each with a specific function in the immune response. All these stages show variations in percentage and absolute number throughout human life. The numbers and proportions of B subpopulation are influenced by factors such as gender, age, ethnicity, and lifestyle. This study establishes reference values according to age of peripheral blood B cell subtypes in healthy Mexican population.

METHODS

Peripheral blood from healthy new-borns and adults were analysed for total B cell subpopulations, using surface markers such as CD19, IgM, IgD, CD21, CD24, CD27, and CD38, to identify naïve, memory with and without isotype switch, double-negative, transitional, and plasmablast cells.

RESULTS

We observed a significant variation in terms of frequency and absolute counts between all groups analysed. Values from each B cell subpopulation show variations according to age.

CONCLUSIONS

In order to attempt to elucidate reference values for B cell subpopulation, the present study evaluated a population sample of healthy blood donors from this region. Values reported here can also be used as a tool for diagnosis of diseases in which B cell maturation is affected.

A novel CD40LG deletion causes the hyper-IgM syndrome with normal CD40L expression in a 6-month-old child

The X-linked hyper-IgM syndrome (XHIGM) is the most common form of HIGM. Patients are clinically diagnosed on the basis of recurrent sinopulmonary infections, accompanied with low levels of IgG and IgA, normal to elevated levels of IgM, and the presence of peripheral B cells. Here, we have reported a novel deletion of four nucleotides in CD40LG exon 3, c.375_378delCAAA, which led to a frameshift mutation with a premature stop codon, p.Asn101*126. The deletion resulted in a truncated protein, in which majority of the extracellular domain was lost. However, detection of surface CD40L was still possible as the intracellular, transmembrane, and part of the extracellular domains were not affected. This indicated that this mutation did not affect protein stability and that immunodetection of CD40L expression is not enough for the diagnosis of XHIGM. Our study strongly suggests that genetic diagnosis for XHIGM should always be performed when clinical data support this diagnosis and CD40L protein is present.

Calidad de vida de los pacientes con inmunodeficiencias primarias de anticuerpos

<p>Las inmunodeficiencias primarias son enfermedades genéticas caracterizadas, en la mayoría de los casos, por la predisposición del individuo afectado a infecciones recurrentes o graves con afectación de su calidad de vida. Las más frecuentes son las de defectos en la producción de anticuerpos. Cuando no se hace un diagnóstico y tratamiento oportunos puede ocurrir daño permanente a órganos blanco afectando aún más la calidad de vida.</p><p><br />Objetivo: evaluar la calidad de vida de los pacientes con inmunodeficiencias primarias por defectos en la producción de anticuerpos y compararla con la de controles sanos.</p><p>Material y métodos: estudio transversal analítico mediante la aplicación del instrumento “Pediatric Quality of Life Inventory” (Peds- QL) en su versión validada en español mexicano. La diferencia del puntaje de PedsQL entre niños con inmunodeficiencias primarias y controles sanos se determinó por la prueba de t de Student. El efecto del retraso en el diagnóstico fue evaluado por el modelo de<br />análisis de covarianza. Se incluyeron 28 pacientes. La mediana de edad fue 5 años y 5 meses.</p><p><br />Resultados: el promedio de edad al diagnóstico fue de 6 años con 3 meses. La mediana de retraso diagnóstico fue de 3 años 3 meses. El promedio de calidad de vida en los pacientes fue de 74.1 (DE ± 13.8) y de 83.3 (DE ± 10.1) para los controles (p = 0.005). La relación entre calidad de vida, retraso diagnóstico y presencia de complicaciones se analizó mediante un modelo lineal que fue marginalmente significativo (p = 0.056). Se encontró correlación negativa entre concentraciones de IgG en el último año y la calidad de vida. Se observó que, en los pacientes que presentaban bronquiectasias, conforme aumentan los años de retraso en el diagnóstico la calidad de vida disminuye de forma significativa (p = 0.007).</p><p>Conclusiones: consideramos necesario evaluar la calidad de vida para conocer el estado de salud de los pacientes con inmunodeficiencias primarias y para su seguimiento durante el tratamiento con el objeto de incidir no sólo en la reducción del número de infecciones, hospitalizaciones y complicaciones, sino también en la mejoría de su calidad de vida. Deberá diseñarse un instrumento específico para evaluar la calidad de vida de los pacientes con inmunodeficiencias primarias. </p><p> </p>

Enfermedad de Kawasaki: cuadro clínico, exámenes de laboratorio y lesiones coronarias

<p>La enfermedad de Kawasaki es una vasculitis aguda, sistémica, de etiología desconocida y que remite generalmente de manera espontánea; ocurre principalmente en pacientes menores de cinco años de edad (80%). La enfermedad de Kawasaki se caracteriza por fiebre, conjuntivitis no supurativa bilateral, eritema de los labios y de la mucosa oral, alteraciones en las extremidades, exantema y adenopatía cervical. Su diagnóstico oportuno es un reto para el médico ya que no existe una prueba específica y se siguen utilizando los criterios clínicos descritos en 1967. Los resultados de laboratorio en la fase aguda de la enfermedad no son específicos ni diagnósticos.</p><p>Objetivo: describir las características clínicas, exámenes de laboratorio, tratamiento empleado y presencia de lesiones coronarias en la etapa aguda de pacientes con enfermedad de Kawasaki atendidos en un hospital pediátrico de tercer nivel en la Ciudad de México. </p><p>Materiales y métodos: estudio retrospectivo, observacional, en pacientes con diagnóstico de enfermedad de Kawasaki tratados entre agosto de 1995 y diciembre de 2013. Se recabó información que incluyó datos demográficos de los pacientes, características clínicas, exámenes de laboratorio, tratamiento empleado y hallazgos ecocardiográficos en la etapa aguda de la enfermedad.</p><p><br />Resultados: se estudiaron 338 casos de enfermedad de Kawasaki en 322 pacientes. La edad media al diagnóstico fue de 38.94 ± 36.53 meses (rango de 2 a 200 meses). El predominio fue de pacientes masculinos (66.9%) con una relación masculino:femenino de 2:1. La gran mayoría de los pacientes (82.2%) tuvo presentación completa de la afección. Se administró inmunoglobulina endovenosa en 88.2% de los casos. En 287 casos la fiebre remitió 48 horas después de administrar inmunoglobulina endovenosa y solamente en 12 casos se administró una segunda dosis. De 1995 a 2003 se diagnosticaron 48 casos de enfermedad de Kawasaki con 22 pacientes que desarrollaron lesiones coronarias (45.8%); de 2004 a 2008 se diagnosticaron 108 de los cuales 61 (56.5%) desarrollaron lesiones coronarias y, finalmente, en el período de 2009 a 2013 se diagnosticaron 182 casos de enfermedad de Kawasaki, 52 con lesiones coronarias (28.6%). En toda la serie fallecieron 4 pacientes en la etapa aguda por complicaciones cardiacas.</p><p>Conclusiones: el diagnóstico de enfermedad de Kawasaki es cada vez más frecuente en nuestro medio; su diagnóstico temprano y un tratamiento oportuno pueden disminuir el riesgo de desarrollar lesiones coronarias.</p><p> </p>

Guidelines for the use of human immunoglobulin therapy in patients with primary immunodeficiencies in Latin America

Antibodies are an essential component of the adaptative immune response and hold long-term memory of the immunological experiences throughout life. Antibody defects represent approximately half of the well-known primary immunodeficiencies requiring immunoglobulin replacement therapy. In this article, the authors review the current indications and therapeutic protocols in the Latin American environment. Immunoglobulin replacement therapy has been a safe procedure that induces dramatic positive changes in the clinical outcome of patients who carry antibody defects.

Attending to warning signs of primary immunodeficiency diseases across the range of clinical practice

Purpose

Patients with primary immunodeficiency diseases (PIDD) may present with recurrent infections affecting different organs, organ-specific inflammation/autoimmunity, and also increased cancer risk, particularly hematopoietic malignancies. The diversity of PIDD and the wide age range over which these clinical occurrences become apparent often make the identification of patients difficult for physicians other than immunologists. The aim of this report is to develop a tool for educative programs targeted to specialists and applied by clinical immunologists.

Methods

Considering the data from national surveys and clinical reports of experiences with specific PIDD patients, an evidence-based list of symptoms, signs, and corresponding laboratory tests were elaborated to help physicians other than immunologists look for PIDD.

Results

Tables including main clinical manifestations, restricted immunological evaluation, and possible related diagnosis were organized for general practitioners and 5 specialties. Tables include information on specific warning signs of PIDD for pulmonologists, gastroenterologists, dermatologists, hematologists, and infectious disease specialists.

Conclusions

This report provides clinical immunologists with an instrument they can use to introduce specialists in other areas of medicine to the warning signs of PIDD and increase early diagnosis. Educational programs should be developed attending the needs of each specialty.

Survival of Mexican patients with paediatric-onset systemic lupus erythematosus and abnormal electroencephalogram

BACKGROUND

Over the past three decades, there has been a remarkable improvement in the outcome of children diagnosed with systemic lupus erythematosus (SLE). In general, paediatric-onset SLE has been associated with higher mortality rates and more disease damage than adults with SLE. The objective was to determinate the impact of clinical, laboratory, and electroencephalographic findings on survival amongst patients with paediatric-onset SLE.

METHODS

Charts of Mexican patients with paediatric-onset SLE diagnosed between 1970 and 2001 were analysed retrospectively; univariate and multivariate analyses were used for analysing associations between clinical and laboratory features and death; Kaplan-Meier tests were used to estimate survival curves.

RESULTS

159 patients were included, 105 were female, with a median age of 12.7 years at diagnosis and a median duration of symptoms prior to diagnosis of 8.4 months. Univariate analysis showed that haematuria, leukocyturia, proteinuria, presence of urine cast, <60% glomerular filtration rate, haemolytic anaemia, and abnormal electroencephalogram, were all poor prognostic factors (p<0.05). Multivariate analysis showed that the presence of proteinuria and abnormal electroencephalograms (p<0.05) were independent factors associated with death. The overall survival rate was 82.9% at five years and 77.4% at ten years upon follow-up. Infection and high disease activity were the most common causes of death.

CONCLUSIONS

Survival of paediatric-onset SLE patients was lower compared to that reported for patients in wealthier countries. Amongst the patients who died, the presence of proteinuria and abnormal electroencephalograms were found to be determinant for survival. Infection and activity were the most common causes of death.

Advances in primary immunodeficiency diseases in Latin America: epidemiology, research, and perspectives

Primary immunodeficiencies (PIDs) are genetic disorders of the immune system comprising many different phenotypes. Although previously considered rare, recent advances in their clinical, epidemiological, and molecular definitions are revealing how much we still need to learn about them. For example, geographical and ethnic variations as well as the impact of certain practices influence their frequency and presentation, making it necessary to consider their study in terms of regions. The Latin American Society for Immunodeficiencies was established as an organization dedicated to provide scientific support for basic and clinical research and to develop tools and educational resources to promote awareness in the medical community. Initiatives such as these are positively influencing the way PIDs are tackled in these countries, as shown by recent reports and publications. This paper provides a historical compilation and a current view of the many issues faced by scientists studying these diseases in these countries, highlighting the diverse scientific contributions and offering a promising perspective for the further developments in this field in Latin America.

Primary immunodeficiency diseases in Latin America: proceedings of the Second Latin American Society for Immunodeficiencies (LASID) Advisory Board

Early diagnosis and appropriate therapy are essential for the best prognosis and quality of life in patients with primary immunodeficiency diseases (PIDDs). Experts from several Latin American countries have been meeting on a regular basis as part of an ongoing effort to improve the diagnosis and treatment of PIDD in this region. Three programmes are in development that will expand education and training and improve access to testing facilities throughout Latin America. These programmes are: an educational outreach programme (The L-Project); an immunology fellowship programme; and the establishment of a laboratory network to expand access to testing facilities. This report provides the status of these programmes based on the most recent discussions and describes the next steps toward full implementation of these programmes.

Critical issues and needs in management of primary immunodeficiency diseases in Latin America

Experts from six Latin American countries met to discuss critical issues and needs in the diagnosis and management of primary immunodeficiency diseases (PIDD). The diagnosis of PIDD is generally made following referral to an immunology centre located in a major city, but many paediatricians and general practitioners are not sufficiently trained to suspect PIDD in the first place. Access to laboratory testing is generally limited, and only some screening tests are typically covered by government health programmes. Specialised diagnostic tests are generally not reimbursed. Access to treatment varies by country reflecting differences in healthcare systems and reimbursement policies. An online PIDD Registry Programme for Latin America has been available since 2009, which will provide information about PIDD epidemiology in the region. Additional collaboration across countries appears feasible in at least two areas: a laboratory network to facilitate the diagnosis of PIDD, and educational programmes to improve PIDD awareness. In total, these collaborations should make it possible to advance the diagnosis and management of PIDD in Latin America.

Revisiting human IL-12Rβ1 deficiency: a survey of 141 patients from 30 countries

Interleukin-12 receptor β1 (IL-12Rβ1) deficiency is the most common form of Mendelian susceptibility to mycobacterial disease (MSMD). We undertook an international survey of 141 patients from 102 kindreds in 30 countries. Among 102 probands, the first infection occurred at a mean age of 2.4 years. In 78 patients, this infection was caused by Bacille Calmette-Guérin (BCG; n = 65), environmental mycobacteria (EM; also known as atypical or nontuberculous mycobacteria) (n = 9) or Mycobacterium tuberculosis (n = 4). Twenty-two of the remaining 24 probands initially presented with nontyphoidal, extraintestinal salmonellosis. Twenty of the 29 genetically affected sibs displayed clinical signs (69%); however 8 remained asymptomatic (27%). Nine nongenotyped sibs with symptoms died. Recurrent BCG infection was diagnosed in 15 cases, recurrent EM in 3 cases, recurrent salmonellosis in 22 patients. Ninety of the 132 symptomatic patients had infections with a single microorganism. Multiple infections were diagnosed in 40 cases, with combined mycobacteriosis and salmonellosis in 36 individuals. BCG disease strongly protected against subsequent EM disease (p = 0.00008). Various other infectious diseases occurred, albeit each rarely, yet candidiasis was reported in 33 of the patients (23%). Ninety-nine patients (70%) survived, with a mean age at last follow-up visit of 12.7 years ± 9.8 years (range, 0.5-46.4 yr). IL-12Rβ1 deficiency is characterized by childhood-onset mycobacteriosis and salmonellosis, rare recurrences of mycobacterial disease, and more frequent recurrence of salmonellosis. The condition has higher clinical penetrance, broader susceptibility to infections, and less favorable outcome than previously thought.

Primary immunodeficiency diseases in Latin America: the second report of the LAGID registry

This is the second report on the continuing efforts of LAGID to increase the recognition and registration of patients with primary immunodeficiency diseases in 12 Latin American countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Honduras, Mexico, Panama, Paraguay, Peru, Uruguay, and Venezuela. This report reveals that from a total of 3321 patients registered, the most common form of primary immunodeficiency disease was predominantly antibody deficiency (53.2%) with IgA deficiency reported as the most frequent phenotype. This category was followed by 22.6% other well-defined ID syndromes, 9.5% combined T- and B-cell inmunodeficiency, 8.6% phagocytic disorders, 3.3% diseases of immune dysregulation, and 2.8% complement deficiencies. All countries that participated in the first publication in 1998 reported an increase in registered primary immunodeficiency cases, ranging between 10 and 80%. A comparison of the estimated minimal incidence of X-linked agammaglobulinemia, chronic granulomatous disease, and severe combined immunodeficiency between the first report and the present one shows an increase in the reporting of these diseases in all countries. In this report, the estimated minimal incidence of chronic granulomatous disease was between 0.72 and 1.26 cases per 100,000 births in Argentina, Chile, Costa Rica, and Uruguay and the incidence of severe combined immunodeficiency was 1.28 and 3.79 per 100,000 births in Chile and Costa Rica, respectively. However, these diseases are underreported in other participating countries. In addition to a better diagnosis of primary immunodeficiency diseases, more work on improving the registration of patients by each participating country and by countries that have not yet joined LAGID is still needed.