Falsch-negatives SkelettSzintigramm bei einer biparietalen Schädelfraktur beim »Battered Child«-Syndrom

Es wird über ein kleines Mädchen berichtet, das nach einem Schädeltrauma radiologisch zwei Frakturen der Schädelkalotte aufwies, bei dem aber eine acht Tage später durchgeführte Skelett-Szintigraphie mit 99mTc-DPD unauffällig war. Die möglichen Gründe für diese Diskordanz werden diskutiert.

Association of apnea and nonacid gastroesophageal reflux in infants: Investigations with the intraluminal impedance technique

An association of apnea and gastroesophageal reflux (GER) was proposed previously. However, pH metry as the standard diagnostic tool for GER only measures acid reflux (pH < 4). It is difficult to interpret studies in infants with a presumed association between apnea and GER based on pH metry because the buffering effect of feeding may result in predominantly nonacid GER. The aim of this study was to investigate the temporal association of apnea and GER with the pH-independent intraluminal impedance technique (IMP). Infants with recurrent regurgitation or respiratory symptoms suggestive of apnea were investigated simultaneously with IMP, pH monitoring, and polygraphy. IMP patterns, pH, oronasal flow, and chest wall movement were recorded and analyzed. In 22 infants, 364 GER episodes were recorded by IMP. One hundred and sixty five apneas were documented by visual validation of polygraph records. Forty-nine apneas (29.7%) were associated with GER; 11 (22.4%) of these showed acid reflux (pH < 4). A significant correlation between the time spent apneic and GER was found (P < 0.001). There is marked association between apnea and gastroesophageal reflux in infants. Patients potentially at risk cannot be reliably identified by pH metry. Its exclusive use is therefore not suitable for the detection of all GER-associated apneas in infants. The pH-independent intraluminal impedance technique has proven to be a sensitive diagnostic tool for this approach.

Intraluminal impedance: an ideal technique for evaluation of pediatric gastroesophageal reflux disease

Gastroesophageal reflux (GER) in infants becomes gastroesophageal reflux disease (GERD) through association with distinct clinical symptoms. Monitoring of pH is considered the standard diagnostic tool through which episodes of acidity can be detected. Apparently, however, the major amount of GER occurs in the physiologic esophageal pH range, which is concealed to pHmetry. Intraluminal impedance is a new method for pH-independent detection of esophageal bolus movement. Long-term measurements and combination with other diagnostic methods, e.g., pHmetry or polygraphic recordings, are possible. Intraluminal impedance has proved especially useful in diagnosing GER and GERD in infants. It may develop into the ideal technique for this group of patients.

Effect of cisapride on acid gastro-oesophageal reflux during treatment with caffeine

About 50% of preterm infants and neonates receiving methylxanthines for respiratory stimulation will develop a pathological gastro-oesophageal reflux (GOR) pattern. In the face of potential GOR-related complications the effect of a concomitant treatment with a prokinetic agent, such as cisapride, should be evaluated. In this study 32 formerly preterm infants were studied simultaneously by 24-hour oesophageal pH monitoring and cardio-respirogram before the presumed end of caffeine treatment. In 14 of these infants a reflux index (RI; percentage of recording time) of more than 4% could be detected (pH <4). Ten of them were treated orally with cisapride (0. 2 mg/kg t.i.d.). Data of pH monitoring, cardio-respirogram and caffeine serum concentrations were obtained before and 5 days after introducing cisapride. The RI and the frequency of GOR decreased significantly with cisapride. The steady-state serum concentrations of caffeine were not influenced by cisapride and the extent of periodic breathing remained unchanged. In conclusion, cisapride has a positive influence on GOR parameters during caffeine treatment without impairing the oral bioavailability or therapeutic effect of caffeine.

Efficacy and safety of acarbose in patients with cystic fibrosis and impaired glucose tolerance

Impaired glucose tolerance (IGT) is an increasingly frequent complication of cystic fibrosis (CF). In CF patients, a fast postprandial rise in plasma glucose is typically followed by a delayed but prolonged insulin response. Patients may develop symptoms of both hyper- and hypoglycaemia. The alpha-glucosidase inhibitor, acarbose, delays the hydrolysis and subsequent absorption of ingested carbohydrates. The aim of this study was to investigate the efficacy of acarbose in CF patients with IGT. During a 2-week inpatient period for treatment of Pseudomonas infection, 12 CF patients with IGT were studied in a double-blinded, randomized crossover trial. Each patient received acarbose (50 mg t.i.d.) for 5 days and placebo for 5 days (days 3-8 and days 10-14, respectively). Glucose, insulin and C-peptide responses to a standardized nutritional load were measured at baseline and at the end of each study period (Days 2, 8 and 14). Treatment with acarbose was associated with significant reductions in the mean value, mean peak values and the area under the curve of plasma glucose, insulin and C-peptide, compared to respective baseline values and placebo. Gastro-intestinal disturbances were recorded in 67% of patients during therapy with acarbose.

CONCLUSION

Acarbose has a positive therapeutic effect on glucose tolerance in cystic fibrosis patients, as shown by attenuation of postprandial plasma glucose increase and a significant decrease in insulin secretion response. However, acarbose treatment was associated with adverse gastro-intestinal effects that may prevent patients from accepting long-term therapy.

Gastroesophageal reflux and respiratory phenomena in infants: status of the intraluminal impedance technique

BACKGROUND

The coincidence of recurrent respiratory symptoms and gastroesophageal reflux (GER) is a well-known phenomenon in infants. Twenty-four-hour pH metry is the presumed gold standard of diagnostic tools for this symptom complex, but with this method, only acid (pH <4) and alkaline (pH >7) GER can be detected. Gastroesophageal reflux with an esophageal pH in the physiological range (pH 5-6.8) may represent many cases of clinically relevant GER unrecognized by pH metry. In this study the intraluminal multiple electrical impedance (IMP) procedure for complete registration of GER was compared with pH metry for its diagnostic value in the presence of respiratory symptoms.

METHODS

Twenty-two infants with recurrent regurgitation or pulmonary problems were investigated simultaneously with IMP, pH metry, and polygraphy during two feeding periods. Heart rate, oxygen saturation, sleep states, and oronasal flow were recorded, among other parameters.

RESULTS

Three hundred sixty-four occurrences of GER were detected by IMP; only 11.4% had a pH less than 4 and were therefore recognized by pH metry. Three hundred twelve (84.8%) occurrences were associated with breathing abnormalities, and 11.9% of these were detected by pH metry. Nineteen instances were accompanied by a decrease of oxygen saturation of more than 10% of the initial value. Only three (15.8%) of these had a pH less than 4. The remaining 16 reflux episodes were recognized by IMP only. After software-aided preselection, 165 instances of apnea were visually validated, 49 of which were accompanied by GER. Thirty-eight (77.6%) of these were exclusively recorded by IMP.

CONCLUSIONS

The use of pH metry alone cannot detect most GER incidents accompanied by respiratory symptoms and therefore does not appear to be suitable for this approach. The pH-independent IMP technique promises to be a reliable tool for presumably GER-associated respiratory symptoms.

Pharmacokinetics of oral fluconazole in premature infants

Systemic infections with Candida albicans in neonates are a frequent and well recognized problem. The therapeutic gold standard in this situation is the combined intravenous antimycotic treatment with amphotericin B and flucytosine. Potential adverse effects of this regimen have encouraged the search for desirable alternatives. We report on the use of oral fluconazole in neonates with Candida albicans septicaemia. Three premature infants were treated with four courses of therapy. Pharmacokinetic studies were performed during each course. At oral doses of 4.5-6 mg/kg once a day, serum levels of fluconazole were within the therapeutic range during the entire dosage interval. Follow up showed microbiological and clinical cure in all patients with no side-effects. In one patient a dosage of 4 mg/kg per day lead to a microbiological relapse with sub-therapeutic serum levels.

CONCLUSIONS

Oral fluconazole seems to be a safe and effective treatment for Candida albicans septicaemia even in premature infants.

Transient myeloproliferative disorder with 11q23 aberration in two neonates with Down syndrome

Infants with Down syndrome may develop a transient myeloproliferative disorder (TMD) with the features of acute leukemia but resolving in a spontaneous remission. Chromosomal aberrations in addition to trisomy 21 have only rarely been described. In many cases of infant acute leukemia band q23 of chromosome 11 is involved in nonrandom translocations, often resulting in a rearrangement of the ALL-1 (MLL, HRX, HTRX 1) gene. Generally, this translocation carries a bad prognosis. We describe two newborn girls with Down syndrome and TMD in whom the constitutional trisomy 21 was combined with an acquired abnormality of chromosome 11. During the TMD the morphological and immunologic features were consistent with those of megakaryoblastic leukemia. The chromosome 11 abnormalities were del(ll)(q23), but rearrangements of the ALL-1 gene were not found. Our patients had remissions that occurred spontaneously or after a mild chemotherapy. The important finding is that additional chromosomal changes may occur during TMD in Down syndrome. The fact that the abnormality was in region 11q23 raises the question of whether the risk for developing leukemia is increased under these conditions.

Herpes virus (KSHV) associated Kaposi sarcoma in a 3-year-old child with non-HIV-induced immunodeficiency

A 3-year-old boy of German descent suffered from two episodes of Streptococcus pneumoniae meningitis within 2 months. One month previously, the first skin lesion of Kaposi sarcoma (KS) had been observed behind his right ear. During the following 2 years KS disseminated not only mucocutaneously but also to visceral organs. Immunological evaluation revealed severe lymphocytopenia with reduced helper/suppressor T-cell ratio and impaired humoral immune response to pneumococci. Extensive laboratory tests gave no evidence for known immunocompromising infections. However, recently described DNA sequences from a Kaposi sarcoma-associated herpesvirus (KSHV) could be identified within skin tissue. As chemotherapy failed to stop tumour progression the patient was referred for bone marrow transplantation. Eighteen months later the KS is in remission and the patient in a good general condition.

CONCLUSION

The case supports the hypothesis that KSHV is involved in the aetiology of KS. Bone marrow transplantation is possibly a therapeutic option for KS in patients with immunodeficiency not related to human immunodeficiency virus infection.

Gastroesophageal reflux in infants: evaluation of a new intraluminal impedance technique

In this study, pH metry was simultaneously applied with a new technique, the intraluminal multiple electrical impedance (IMP) procedure, for measuring gastrointestinal motility for gastroesophageal reflux (GER) detection. Seventeen infants with clinical symptoms of GER disease such as recurrent apnea, aspiration pneumonia, wheezing, and failure to thrive were investigated during two feeding periods. A single catheter combining a pH electrode with seven electrodes for impedance measurements over a distance of 8.5 cm was used for the investigation. In all patients, 185 acid episodes were detected by pH metry. In 106 of these 185 acid episodes, a unique pattern in the IMP readings was noted, indicated by a retrograde esophageal volume flow. These episodes were regarded as acid GER episodes. Seventy-one of the 185 acid episodes occurred during the clearance process of a preceding acid GER characterized by typical IMP readings of an anterograde bolus transport. Eight of 185 acid episodes were missed in the IMP readings for technical reasons. The IMP pattern described as characteristic for a GER was observed in 490 other episodes not detected by pH metry. More than 75% of all GER detected by IMP reached the pharyngeal space; 73% of all GER occurred during feeding and the first 2 postprandial hours and 27% occurred during the remaining time until the next feeding. Even during the latter period, 34% of GER were detected by IMP only; they were missed by pH metry. Volume clearance indicated by IMP was always completed earlier than acidity clearance. The results show that IMP technique facilitates the detection of all GER, whereas pH metry is confined to the measurement of acid GER. Therefore, this technique might improve the evaluation of GER disease and detection of GER in conditions with gastric hypoacidity.

[Antacids for postoperative prevention of stress ulcer in infants: a dose finding study]

In the prophylaxis of stress ulcers with antacids in young infants there are no recommendations of dosages that consider the physiologic maturation of gastric acid secretion. During the first six month of life the amount of gastric acid secretion in relation to body weight and body surface area increases exponentially. Therefore adult dosages of antacids cannot be transferred to infants.

METHODS

In a cross over study 12 infants aged between 4 and 174 days, who had been undergoing a cardiosurgical intervention with the heart lung machine, were treated during 48 hours with 2 different antacid regimens over a period of 24 hours each, monitoring the gastric pH continuously. The used antacid consisted of an aluminium-magnesium complex (Al(OH)3, 90 mg/ml and Mg(OH)2, 60 mg/ml): Regimen A: 6 x 0.5 ml per kg body weight. Regimen B: 0.25 ml per kg body weight at a gastric pH less than 3, with the pH read every 30 minutes.

RESULTS

Compared to 28 applications under regimen B, 72 single doses were given under regimen A, 58 of them at a gastric pH of higher than 3. Thus, the mean administered dose was significant lower under regimen B (2.2 ml) than under regimen A (12.0 ml). Consequently, the mean level of gastric pH was higher under regimen A (median: 5.96 +/- 1.31 versus 4.94 +/- 1.16). pH-values lower than 3 were more often measured under regimen B, whereas the phases at this pH-level were longer under regimen A.

CONCLUSION

The usual body weight related dosage of antacids seems to be to high for early infancy. In the face of the discrepancy of the administered antacid quantity comparing regimen A with regimen B, it seems to be reasonable for the studied age group to reduce the single antacid dose to 0.25 ml/kg body weight while adhering to a high application frequency of 6 times a day.

[Laparoscopic resection of bleeding Meckel's diverticulum]

The most malformations of the gastrointestinal tract are the Meckel's diverticula. In 25% of all complications of this disease you will find a bleeding of the diverticulum. We report a case of a 12 year old boy treated laparoscopically for a bleeding diverticulum and we describe the technical procedure. The first choice in diagnosis in the scintigraphy with 99mTc-pertechnate, at which the proof of ectop stomach mucous membrane is necessary. Laparoscopic resection of a bleeding Meckel's diverticulum performed by an experienced surgeon is a safe and considerate procedure in laparoscopic technique.

Midazolam and ketamine as premedication in colonoscopies: a pharmacodynamic study

As colonoscopy is often painful, a premedication appears to be indispensable. Commonly, benzodiazepines, i.e. midazolam, alone or in combination with analgesic drugs are used. Besides all advantages, midazolam especially is known to have the risk of oversedation and respiratory depression. Therefore it should be used at minimal dose. In a double-blind, randomized study, three premedication-schedules of midazolam (mid) plus ketamine (ket) were compared in 33 patients, aged between 8 and 60 years, with regard to safety and acceptance by patients and endoscopist. I: ket 1 mg/kg+mid 0.1 mg/kg, max. 5 mg II: ket 1 mg/kg+mid 0.05 mg/kg, max. 2.5 mg III: ket 0.75 mg/kg+mid 0.1 mg/kg, max. 5 mg Oxygen-saturation, heart rate and blood pressure were recorded as well as the evaluations of sedation, cooperation and complaint of pain. To assess the recovery-time of the patients, the reaction time and the attention were evaluated by "Wiener's determination apparatus" and "test d2", respectively, before and at 1, 2, 3 and 4 hours after premedication. Medication I resulted in heavy sedation, good cooperation and amnesia but had the strongest tendency towards hypoxemia. Under schedule III, reduced cooperation and acceptance were seen due to a strong experience of pain. The best conditions during the examination with regard to cooperation, experience of pain and acceptance were found after premedication II without relevant depression of vital parameters. It can be concluded that midazolam can be used at minimal recommended doses as premedication for colonoscopy if combined with ketamine in a sufficient analgesic dosage.

[Increased incidence of developmental hip dysplasia in hypertrophic newborn infants]

"Lack of space" in utero is considered to be a major factor in the aetiology of the congenital dislocation of the hip. This study tries to answer the question whether hypertrophy of a newborn has to be regarded as a risk factor on the basis of the principle mentioned above. The results of postnatal clinical and sonographical examination performed on 98 large-for-gestational-age (LGA-) newborn were compared to those performed on 310 newborn children during a non selective screening program. Among the LGA-newborn pathological hip joints were found more often mainly female LGA-newborn infants were affected. It seemed that the birth weight did not correlate to the extent of the retardation of the hip joint development. It was again confirmed that the restriction to only clinical diagnostic procedures in the neonatal period is not effective in the early diagnosis of the malformation. Hypertrophy of a newborn has to be considered as a risk factor behind the development of congenital dislocation of the hip. It is recommended to examine all LGA-newborn infants post partum by clinical and most importantly also by sonographical means to recognize a retardation of hip joint development.

[A false negative bone scintigram in a biparietal skull fracture in a case of a Battered Child Syndrome]

The case of a small girl is reported who after a head injury showed radiologically two fractures of the skull whereas the bone scintigram done eight days later with 99mTc-DPD was normal. The possible reasons for this discrepancy are discussed.

Hirschsprung disease: paternal transmission to a son

Hirschsprung disease (HD) is genetically heterogeneous with approximately 4% familial occurrence. The recurrence risk is higher in patients with severe involvement. We describe the transmission of histotopochemically proven HD from a father with long aganglionic segment disease to a son with ultrashort segment disease. This observation suggests that the length of involvement in HD is related to the variable expression of the gene defect. It also suggests autosomal dominant inheritance of HD.

Increased physiological dead space during exercise after bronchodilation in cystic fibrosis

Bicycle ergospirometry was performed on 14 patients with cystic fibrosis (CF), for evaluating the effects of salbutamol and theophylline on the ventilatory response to exercise. After 1 week without bronchodilator therapy the patients cycled at 1/3 and 2/3 of their individual maximal working capacity (Wmax). The test was repeated three times after treatment with salbutamol, theophylline, or both drugs, respectively. After the combined therapy, physiological deadspace, ventilation, ventilatory equivalent of oxygen, and end-expiratory oxygen pressure increased significantly during steady state exercise at 1/3 Wmax. Similar, although not statistically significant changes, were observed after monotherapy with salbutamol or theophylline and during exercise at 2/3 Wmax. These effects could not be predicted by any lung function tests at rest or by the Shwachman-Kulczycki score. The results indicate that in some patients with CF bronchodilators can impair lung function during exercise. In conclusion, the effects of medication on exercise performance of patients with CF have to be considered. Especially, the use of bronchodilators requires a careful evaluation of their real benefit in each individual patient.

[Tongue ultrasound and pressure measurement in infantile sucking. Initial results]

The sucking procedure was examined in 10 healthy, term infants and in one newborn with disturbed sucking actions suffering from recurrent aspiration pneumonia. We applied ultrasonography of the tongue and simultaneous intraoral pressure measurements in the examinations. Observations were made with a bottle feeding system (NUK). Sonography and intraoral measurements both gave reliable informations. Parallel recordings of tongue dorsum movements by pseudo-3-dimensional imaging and simultaneously obtained pressure curves show, that increasing suction is maintained by withdrawing the tongue dorso-cranially. Computer-aided evaluation of ultrasound images and pressure data demonstrate the possibility to distinguish between coordinated and uncoordinated sucking movements. Simultaneous use of both examination techniques can be helpful in diagnosis and documentation of disturbed sucking actions.

[Glucose homeostasis in cystic fibrosis. Oral glucose tolerance test in comparison with formula administration]

BACKGROUND

Glucose tolerance is often impaired in Cystic Fibrosis. The impact of this condition on enteral nutritional support in case of malnourishment remains to be studied.

METHOD

In this study the glucose-, C-peptide- and insulin-responses to an OGTT and a standard enteral formula load were investigated in 19 non-diabetic CF-patients. Each test was performed with a carbohydrate load of 1.75 g/kg bodyweight.

RESULTS

11 patients had a normal OGTT (Group I) and 8 had an impaired glucose tolerance (Group II). After the formula load the glucose concentrations were significantly lower than after the OGTT at 30, 60, and 90 min in both groups and at 120 min in group II only. In group II the glucose values exceeded 6.7 mmol/l at 120 min after both OGTT and formula load and were significantly higher than in group I. The food glycaemic index, a parameter for comparison of glucose response to different diets was calculated. It ranged from 30 to 80% in both groups. An increased C-peptide- and insulin-secretion was found in patients with impaired glucose tolerance.

CONCLUSIONS

The condition of impaired glucose tolerance must be considered for enteral hyperalimentation of Cystic Fibrosis-patients. The selection of formulas for nutritional support should be based on the calculation of the Food Glycemic Index because of its high interindividual variability.

[Cardiopulmonary capacity in patients with mucoviscidosis. Comparison of ergospirometry findings with clinical and radiological scores]

AIM OF STUDY

Shwachman-Kulczycki- and Chrispin-Norman-Scores are widely used scoring systems for CF-patients. Maximum bicycle exercise testing was performed in 15 patients (medium age 13.4 years) to investigate whether clinical and radiographic scores or pulmonary function testing could predict cardiorespiratory fitness.

METHODS

A progressive exercise test was used to determine maximum working capacity (Wmax). Prior to exercise testing, lung function and blood gases were investigated. Chest radiographs were scored by an independent radiologist (G.B.) applying the Chrispin-Norman-Score. The Shwachman-Kulczycki-Score was determined by two observers (F.F., H.S.).

RESULTS

Chrispin-Norman-Score, Schwachman-Kulczycki-Score, results of lung function testing and blood gas values were significantly correlated to each other. However no significant correlation was found to the degree of exercise limitation.

CONCLUSION

Clinical, radiographic scores and lung function testing cannot predict exercise tolerance. Exercise testing is mandatory to evaluate cardio-respiratory fitness in CF-patients.

Exophiala dermatitidis pneumonia in cystic fibrosis

The chest X-ray film of a girl with cystic fibrosis (CF) showed slowly increasing mottled densities during the 6th and 7th year of her life. Pulmonary symptoms and distress proceeded fast in spite of intensive treatment with antibiotics, corticosteroids, and physiotherapy. Three different fungal organisms were repeatedly cultured from the sputum: Candida albicans, Aspergillus fumigatus, and Exophiala dermatitidis. Antibodies against C. albicans were in the normal range. Candida antigen in blood and antibodies against A. fumigatus were absent. Antibodies against E. dermatitidis were detected by a recently developed indirect immunofluorescence assay. It seems most probable that E. dermatitidis was the causal agent for fungal pneumonia in this case. Under therapy with amphotericin B and flucytosine the clinical course and radiological appearance improved but definitive eradication of E. dermatitidis was only achieved after treatment with itraconazole. The isolation of this fungus from the sputum of a CF patient is reported for the first time. The significance of fungal infections in CF is discussed.

Neonatal theophylline intoxication: pharmacokinetics and clinical evaluation

The pharmacokinetics of theophylline and its metabolites, caffeine, 1,3-dimethyluric acid, 1-methyluric acid and 3-methylxanthine were studied in a 5-day old 1.3 kg premature neonate who accidentally received 180 mg theophylline in 26 h during treatment for bradycardia. Tachycardia, hyperventilation, increased diuresis, central nervous system excitation, an increase in blood glucose concentrations followed by a prolonged decrease and hypercalcaemia were the predominant clinical and laboratory manifestations. The patient responded to supportive care and survived without sequelae. The concentration time course of theophylline and its metabolites in plasma and the pattern of urinary and gastric elimination were determined over 95 h. Theophylline showed, in contrast to its metabolites, a log linear decline in plasma. Elimination of theophylline and caffeine, calculated from their urinary excretion rates, were both exponential during the entire observation period. Urine flow dependence of renal clearance was obvious for theophylline and caffeine. Implications of theophylline disposition in neonates are discussed with special regard to theophylline poisoning.

Pharmacokinetics and antibacterial activity of daily gentamicin

Twenty full term neonates with suspected bacterial infection were randomly assigned to a once daily or a twice daily dosage regimen with gentamicin (4 mg/kg/day). Concomitantly all patients were treated with ampicillin (200 mg/kg/day). The gentamicin concentration time curves were analysed by an open two compartment model under steady state conditions on day 4 of treatment. The mean theoretical maximum serum concentration in the group taking gentamicin once daily (10.9 micrograms/ml) was significantly higher than in the group taking it twice daily (7.4 micrograms/ml). Potentially toxic serum concentrations were never reached. Mean trough concentrations were comparable in both groups (once daily 0.8 micrograms/ml; twice daily 1.0 micrograms/ml). Urinary alanine aminopeptidase excretion increased during and even two days after end of treatment in both groups without any significant differences. The results of the dynamic in vitro model revealed that both dosage schedules showed comparable bactericidal effects on pathogens inhibited by low concentrations of gentamicin like Escherichia coli and Staphylococcus aureus. However the once daily regimen was significantly superior in isolates with high minimal inhibitory concentrations.

[Tuberculosis and cystic fibrosis]

Mycobacterial infections are rarely reported in Cystic Fibrosis patients although they quite often develop predisposing risk factors such as underweight, secondary diabetes mellitus and chronic inflammatory pulmonary disease. Furthermore glucocorticoid therapy is mandatory in some patients. CF heterozygotes are said to have a selective advantage due to an increased host resistance against Mycobacterium tuberculosis. In this survey 1926 CF patients were investigated for the incidence of tuberculin conversion and manifest infection with mycobacterium tuberculosis in the Federal Republic of Germany (FRG). The results do not support the hypothesis of increased host resistance nor do they show any evidence of a higher risk for tuberculosis in CF. Implications for prophylactic, diagnostic and therapeutic measures are discussed in accordance to the recent epidemiologic data of tuberculosis in the FRG.

Long-term fungal cultures from sputum of patients with cystic fibrosis

Mycological examination of sputum from 121 patients with cystic fibrosis by means of long-term cultures (4 weeks) revealed the occurrence of Candida albicans in low quantities in 70%, Aspergillus fumigatus in 30%, and Exophiala/Wangiella dermatitidis in 9% of the examined patients. A. fumigatus frequently causes the development of allergic bronchopulmonary aspergillosis in patients with cystic fibrosis. The predisposing factors for colonization with the otherwise seldom found fungus E. dermatitidis in these patients and the consequences of these findings are discussed. In conclusion, long-term fungal cultures are advocated for specimens from CF patients.

[Gastrointestinal symptoms in disseminated Langerhans cell histiocytosis. Case report and review of the literature]

Symptoms of gastrointestinal disease are variable in Langerhans' cell histiocytosis (LCH). The incidence of gastrointestinal involvement is estimated to be approximately 5% in disseminated LCH. This report focuses on a 10.5 months old female infant who suffered from relapsing diarrhea and intermittent anal blood loss since the second week of life and from weight loss later in the course of disease. Definite diagnosis of LCH was not established before the patient developed additional characteristic symptoms. Analysis of large series of patients and a retrospective histopathological study reveals that an involvement of the gastrointestinal tract must be anticipated in about 50% of all cases with disseminated LCH.

Analysis of pancreatic serum markers in patients with cystic fibrosis

The occurrence of increased serum concentrations of pancreatic tumor markers CA 19-9, CA 50 and elastase 1 in cystic fibrosis (CF) prompted us to investigate the pancreatic markers DU-PAN-2 and TATI. DU-PAN-2 was measured in serum samples of 48 CF patients, 42 pediatric control patients, and 51 parents of CF children by a competition radioimmunoassay (RIA). A commercially available RIA test kit was used to measure TATI serum levels of 38 CF patients and 40 control patients. Nineteen percent of CF patients, 0% of the control group, and 6% of the parents exceeded the DU-PAN-2 threshold value of 300 U/ml. TATI concentrations were increased (greater than 20 micrograms/L) in 24% of CF patients and in 17% of control patients. The sensitivity-specificity curve of DU-PAN-2 was similar to those of CA 50 and elastase 1 but less discriminating than that of CA 19-9. However, the sensitivity-specificity profile of CA 19-9 can only be marginally enhanced in a range of low specificity by simultaneously determining elastase 1 and/or DU-PAN-2 antigens. TATI does not provide any diagnostic use in CF.

[Taurine supplementation in cystic fibrosis (CF): effect on vitamin E absorption kinetics]

Oral vitamin E (Vit.E) bioavailability is reduced in CF patients especially in case of malnourishment. Both exocrine pancreatic insufficiency and an altered bile acid composition showing an elevated glycine taurine ratio of conjugated bile acids which is due to excessive loss of bile acids in the stools may contribute to this observation. Because taurine supplementation reduces the glycine/taurine ratio of bile acids in duodenal juice of CF-patients it was the objective of this study to evaluate the effect of taurine supplementation on Vit.E absorption kinetics. Oral Vit.E tolerance tests (50 mg/kg) were performed before and after 3 months of taurine supplementation (30 mg/kg/day) in 11 CF patients (ages 7 to 22 years) under fasting conditions. Bodyweight and or weight for height of all patients were below the 25th percentile. Doses of all medications except antibiotics were kept unchanged during the study. Any additional Vit.E supplementation was stopped 14 days prior to each test. Serum Vit.E levels were measured over a 24 hour period. Determination of serum Vit.E concentrations was performed with a HPLC fluorescence technique. The glycine/taurine ratio in serum served as compliance parameter and dropped in all but one patients. Baseline Vit.E concentrations and serum Vit.E/total lipids ratios in serum considered as parameters of the Vit.E status increased significantly. Both the maximal Vit.E concentrations in serum and the areas under the oral absorption curves showed a significant increase with taurine supplementation. This study shows that the Vit.E status of malnourished CF patients can be improved with taurine supplementation due to improved Vit.E absorption kinetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Infantile hypertrophic pyloric stenosis: myopathic type

Smooth muscle cell biopsies obtained at pyloromyotomy from 37 children with infantile hypertrophic pyloric stenosis (IHPS) were studied by light and electron microscopy and compared with 6 autopsy control cases without any clinical evidence of this disorder. In cases with IHPS an apparently irregular increase in the number of smooth muscle cells by mitosis was accompanied by an increase of the endoplasmic reticulum, proliferation of mitochondria and regressive changes, such as shrinkage, swelling, necrosis and apoptosis of smooth muscle cells. Other alterations, seen in some but not all cases consisted of large numbers of unusual dense granules some of which were clearly associated with actin filaments and, therefore, regarded as derivatives of the normally occurring dense bodies. Furthermore, intermyofibrillar and subsarcolemmal glycogen accumulations, various nuclear abnormalities and pleomorphic membranous cytoplasmic or nuclear bodies occurred. While smooth muscle cell abnormalities predominated in some cases of IHPS, in others there were more severe axonal changes in the myenteric plexus. It is suggested, therefore, that a primarily myogenic type of IHPS can be distinguished from a predominantly neurogenic type.

[Effect of methylxanthines on periodic respiration and acid gastroesophageal reflux in newborn infants]

The treatment of neonatal apnea and bradycardia with methylated xanthines--theophylline and caffeine--is generally accepted. Besides the desired effects of these drugs they induce a wide range of side effects including relaxation of smooth muscles and increased gastric secretion. The aims of this study were, at first to investigate the coincidence of periodic breathing (PA) and acid gastro-esophageal reflux (GER) in neonates (n = 15) without therapy; at second to examine the influence of the consecutive medication with theophylline and caffeine on these parameters in patients (n = 10) with recurrent episodes of bradycardia and apnea. A 24 h esophageal pH-monitoring and 24 h cardiorespirography were performed simultaneously under standarized conditions. In the 15 neonates studied a weak correlation was found between the time spent breathing periodically and the duration of GER; the overlap of PB and GER was minimal. Theophylline and caffeine medication resulted in a marked reduction of PB which was more pronounced than it could be expected from maturation. The total time of a 24 h esophageal pH-monitoring was subdivided in an early postprandial time (FPP: first two hours after the beginning of a meal) and a late postprandial time (SPP: remaining time until the following meal). An increased duration of acid GER was observed during the SPP under therapy with theophylline and even more distinct with caffeine treatment.

[Effect of nutritional status on absorption kinetics of vitamin E in mucoviscidosis]

Exocrine pancreatic insufficiency with varying severity must be anticipated in 85-95% of CF patients. It leads to fat maldigestion and malabsorption of the liposoluble vitamins - A, D, E, K - and fecal loss of fat. In general, supplementation with fat-soluble vitamins is recommended in CF patients. In this study an oral vitamin E tolerance test (100 mg/kg bodyweight) was performed in 5 healthy adult volunteers to elaborate a vitamin E absorption kinetics and additionally in CF patients on medication with pancreatic enzymes to evaluate the absorption of vitamin E. 19 CF patients (ages 4 to 19 years) were studied after cessation of any additional vitamin E supplementation for 7 days. Vitamin E serum concentrations were sampled over a 72 hour period. Serum vitamin E determinations were performed with a HPLC-fluorescence technique. The kinetics of Vitamin E in healthy volunteers can be described with an open 2 compartment model. CF patients revealed consistently an altered kinetics of absorption of vitamin E, which was not compatible with this model. Baseline (c*) and maximal serum concentrations (cmax) of vitamin E as well as the area outer the oral absorption curve (AUC) correlated with the nutritional status expressed by bodyweight percentiles in CF patients. The results of this study show that in normal weight CF patients on pancreatic enzymes medication vitamin E depletion is unlikely.(ABSTRACT TRUNCATED AT 250 WORDS)

[Glucose homeostasis in mucoviscidosis]

In patients with cystic fibrosis (CF) of the pancreas an endocrine imbalance especially of insulin secretion due to progressive structural abnormalities of the pancreas must be expected. 30-75 percent of CF-patient exhibit impaired oral glucose tolerance tests (oGTT). Deterioration of the glucose homeostasis leads to a secondary diabetes mellitus that mimics a type II diabetes in the early stage, in the later course of disease it resembles a type I diabetes with absolute insulinopenia. In this study glucose homeostasis was investigated after an oral glucose load with 1.75 g glucose/kg bodyweight. Glucose, C-peptide and insulin were measured during 180 minutes. 32 nondiabetic CF-patients were studied. 16 patients revealed an impaired oral glucose tolerance according to the criteria of the National Diabetes Data Group. 6 patients showed a normal glucose tolerance and 10 patients with normal fasting and 120 minute glucose concentrations were hyperglycemic at midtest determinations. Impaired oGTTs were observed in malnourished CF-patients in a higher rate than in normal weight patients. A delayed and exceeded C-peptide and insulin response to the oral glucose load was determined with deteriorating glucose tolerance. Glucose values did not drop to fasting values at the 180 minute determination in cases of impaired oral glucose tolerance.

CA 19-9, CA 50 and elastase 1 as additional markers of cystic fibrosis

Since reliable diagnosis of cystic fibrosis (CF) is still difficult, the occurrence of serum markers CA 19-9, CA 50 and elastase 1 was analysed. Serum levels of CA 19-9, CA 50, CA 125 and elastase 1 were estimated in 54 CF patients as well as in a control group of 66 children of similar age suffering from various other diseases and in 57 parents of CF patients. In 67% of CF patients CA 19-9 was higher than 37 U/ml, whereas 8% of the control group and only 2% of the parents showed an increased concentration. In the case of CA 50, 65% of the CF group, 21% of the control and none of the parents exhibited concentrations higher than 17 U/ml. In CF 22% showed decreased, 8% increased elastase 1 values. In the control group 2% had less than 80 ng/dl and 3% had higher elastase 1 levels than 400 ng/dl. In parents there were only increased levels in 4%. Accordingly CA 19-9 has been proven as a suitable marker and its sensitivity can be improved from 67% to 86% by additional testing of CA 50 and elastase 1. With regard to CA 125 in 11% of CF patients, 5% of control persons and 5% of parents CA 125 levels ranged above 35 U/ml. The determination of saliva CA 19-9 and CA 125 does not yield further information. Taking all previous findings into account elastase 1 is a better marker for acute pancreatitis than for pancreatic cancer and CF.(ABSTRACT TRUNCATED AT 250 WORDS)