[Pediatric Crohn's disease in Tunisia]

Crohn's disease occur mainly in adults. However, pediatric onset forms are not rare and have many characteristics.

AIM

to study clinical, diagnostic, therapeutic and evolutive characteristics of crohn's disease in tunisian children.

METHODS

Retrospective multicenter study conducted in 10 pediatric departments on a period of 10 years (2000-2008) RESULTS : 43 children were included. The sex-ratio was 1.68. The mean age at the onset of the symptoms was 11+/-2.3 years (5-16 years). The age of onset was inferior to 10 years in 25 % of the children. The delay before management was superior to 1 year in 25% of cases. The initial symptoms were dominated by diarrhea (95%). Perineal manifestations were present at diagnosis in 30% of children and extra-digestive manifestations in 53%. Ileocolonic localization was the most frequent (46%). The initial disease flare was moderate in 83% of cases. The treatment was medical in 77 % of cases, nutritional and medical in 18.5%. Maintenance therapy was instituted in 86% of cases and consisted essentially in azathioprin (62%). The mean follow-up was 3 years and 4 months. 60% of the children had at least one acute flare. During evolution, 7% of children had anoperineal surgery and 11% an intestinal resection.

CONCLUSION

Crohn's disease seems rare in Tunisia. The time of diagnosis is often delayed. The management is based on immunosuppressive therapy and nutritional support.

[Biochemical and molecular diagnosis of primary hyperoxaluria type 1: Tunisian study about 15 cases]

BACKGROUND

The primary type 1 hyperoxaluria (HP1) is the most frequent and severe form of the primary hyperoxaluriae. It is related to an enzymatic deficit in alanine glyoxylate aminotransferase (AGT). It is a recessive autosomic disease. Rare in Europe, it is responsible for 13% of the end stage renal failure in the Tunisian child.

AIM

The aim of this work is to evaluate the biological and molecular examinations contributing with the early diagnosis and the follow-up of the HP1 patients and to test their response to pyridoxin.

PATIENTS AND METHODS

A prospective study of 15 children who have oxaluria lower than 500 μmol/l and normal renal function is carried out. The cristalluria study, oxaluria and the glycolate-glycerate urinary ratio were carried out on all the patients. The so-called mutation maghrebean T853 (Ile244 Thr) was detected by direct sequencing of the exon 7 gene AGXT. The response to pyridoxin was tested among 13 patients.

RESULTS

The oxaluria concentration was greater or equal to 1000 μmol/l in nine cases (60%) and ranging between 600 and 1000 μmol/l in the remaining cases. The oxaluria flow was significantly high depending on the age. The glycolaturia was high among eight patients (57%). In 61,5% of the cases, the most frequent crystalline species was whewellite (C1). The "maghrebin" mutation was identified in nine patients at the heterozygous state, showing 25% allelic frequency. The response to pyridoxin was observed in the 13 tested cases.

CONCLUSION

The HP1 is frequent in our country from where the need for an early diagnosis. The use of simple biochemical tools such as the study of the cristalluria, the morphological analysis of stones and the oxaluria allow to direct the diagnosis towards a HP1, confirmed by the glycolaturia determination. The molecular biology is required in the atypical forms.

Urolithiasis in Tunisian children: a study of 120 cases based on stone composition

The composition of urinary stones in children depends on socioeconomic conditions and hygiene, geographical area, and dietary habits. We analyzed urinary stones from 120 consecutive Tunisian children (81 males, 39 females) aged 5 months to 15 years. The stone was located in the upper urinary tract in 91 cases (76%). Stone analysis included both a morphological examination and an infrared analysis of the nucleus and the inner and peripheral layers. The main components of bladder calculi were whewellite (69%) and struvite (22%), whereas the main component of upper urinary tract calculi was whewellite (67%). The nucleus of bladder stones was composed of ammonium urate (45%), struvite (28%), cystine (10%), and carbapatite (7%). The nucleus of kidney and ureteral calculi was mainly composed of ammonium urate (38%), whewellite (24%), carbapatite (13%), or struvite (11%). Based on stone composition, urinary tract infection was involved in the nucleation or growth of a third of calculi. Endemic urolithiasis involving simultaneous nutritional, metabolic, and infectious factors, and defined by its nucleus composed of ammonium urate without struvite, represented 40% of cases. Exclusive metabolic factors - including genetic diseases such as primary hyperoxaluria, cystinuria, and hypercalciuria - were responsible for less than 25% of cases.

[Urinary calculi in children: contribution of anamnesis, biological exploration and physical analysis of calculi to the etiological diagnosis]

BACKGROUND

It is always of importance to define the cause of urinary calculi disease in children to prevent recurrence and possible impairing of renal function. Nevertheless, etiology is not always easy to prove and must be deduced from both clinical and biological arguments.

PATIENTS AND METHODS

The aim of this prospective study including 39 Tunisian children with urinary stones was to identify etiology and stone risk factors and detail the part of clinical and biological data and results of physical analysis of stones in determining the cause of the stone.

RESULTS

In 31 cases among 39, clinical and biological data were not sufficient to identify clearly the stone etiology. When considering the structure and stone composition, the cause of the stone could be determined in 97.4% of the cases. An inherited disease was found responsible for the stone in 11 children, urinary tract infection in 13 cases, idiopathic hypercalciuria in nine cases and a nutritional deficiency disease in seven cases. In one case, polycystic kidney disease with metabolic risk factors could explain the stone process. No precise etiology was found in one case. Among infection stones, struvite stones could be related to urea-splitting bacteria while other calculi, containing whitlockite and protein matrix could be related to other micro-organisms. Earlier severe chronic diarrhoea episodes were noted in six among seven children presenting stones with a nucleus mainly composed of ammonium urate.

CONCLUSION

Clinical data, biological data from both urine and blood of the patients and also the structure and composition of the stones are needed to identify the cause of urinary calculi. Such a procedure could provide the stone etiology in most cases.

[Primary hyperoxaluria: Tunisian experience apropos of 24 pediatric cases]

We report on 24 children (10 girls) presenting with primary hyperoxaluria. The mean age at diagnosis was 6.3 years (range: 3 months-14.8 years). The mean interval between initial symptom and diagnosis was 1.3 year. The average follow-up period was 22 months (range: 1-60 months). At the time of diagnosis the renal function was normal in 6 children, moderately altered in 1 and severely in 17. During the follow-up the renal function remained stable in 6 patients, improved in 2, deteriorated in 4. The 12 patients with end-stage renal disease at diagnosis remained unchanged. Urolithiasis were present in all patients older than 2 years, and in 1 among the 5 infants. Medullary nephrocalcinosis was observed in 3 patients in whom the renal function was preserved. Diffuse nephrocalcinosis was present in all patients with end-stage renal failure. Improvement of renal function was secondary to stone removal in 2 patients. Extracorporeal shock wave lithotripsy performed in 7 patients was efficient only in 3. In 10 patients oxalate bone disease was correlated with both renal function and dialysis duration, whereas retinal involvement noted in 6 patients was not.

[Ocular signs of primary hyperoxaluria type I]

PURPOSE

To report the results of ophthalmological examination of 14 patients with primary oxalosis of type I, and to appreciate the diagnostic value of these signs.

MATERIAL AND METHODS

Fourteen patients, 7 girls and 7 boys with an average age of 8-35 years (3 months - 15 years). Ten patients had renal failure, 2 died without dialysis and eight were treated with dialysis; 5 out of 8 had hemodialysis and the duration of this treatment varied between 3 months and 3.5 years, 3 out of 8 had peritoneal dialysis.

RESULTS

Visual acuity was 10/10 in 11 cases and we noted a vision of 5/10 in one eye in one case. Ocular fundus examination was normal in 7 cases. In 5 cases, it showed numerous minute white round flecks at the posterior pole and near the retinal vessels which probably correspond to deposition of calcium oxalate crystals. In one case we found a diffuse retinal pigment atrophy and in another case a sectorial papillar atrophy without loss of vision.

CONCLUSION

This flecked retinopathy can occur before hemodialysis or after a few months or years of hemodialysis. There is no correlation between duration of dialysis and ocular lesions.

[Infantile forms of primary hyperoxaluria type I: apropos of 4 cases]

BACKGROUND

Approximately 10% of the cases with primary hyperoxaluria type I present before age 1 and are usually classified as neonatal primary oxaluria.

CASE REPORTS

Four unrelated infants, aged 3 to 9 months, were admitted for severe renal failure due to primary hyperoxaluria type I. Other affected members were known in two of these four families but the disease was not present at the same age in each family. Echogenicity of kidneys was increased in all the patients and calcium oxalate crystals were seen in the collecting system and within the renal parenchyma. Urolithiasis was not present. Treatment of renal failure, ie, peritoneal dialysis, was uneffective in one patient and was interrupted in two others because organ transplantation was impossible.

CONCLUSIONS

The infantile forms of primary hyperoxaluria type I may be rapidly complicated by severe renal failure in the absence of urolithiasis.

End-stage renal disease of the Tunisian child: epidemiology, etiologies, and outcome

From December 1989 to December 1993, 90 children under 15 years were admitted to our department for end-stage renal disease; 9 children were less than 5 years and 28 were aged between 5 and 10 years. The sex ratio (M/F) of the children was 2.1. The estimated incidence of pediatric end-stage renal disease in Tunisia is 7 new cases per year and per million child population under 15 years. The chief etiologies of end-stage renal disease are glomerulonephritis (19%), hereditary nephropathies (29%), and malformative uropathies (13%); 26% of the end-stage renal diseases are of unknown etiologies. Our findings, compared with the European data, show a particularly high frequency of primary hyperoxaluria (13.5%) and an unusual proportion of male subjects.

[Etiologic factors of urinary lithiasis in Tunisian children]

Fifty-five Tunisian children with urinary stones, between the ages of 8 months and 15 years, underwent morphological and infrared spectrophotometric analysis of their stones. This study provides an approach to the aetiological profile of urinary stones in Tunisian children. The nucleus of the stones was composed of acidic ammonium urate in 48% of cases with a morphology suggestive of phosphorus deficiency associated with a history of diarrhoea. In 24% of cases, the nucleus contained struvite indicating the presence of urinary tract infection by urease-positive bacteria. The main growth factors of urinary stones were hyperoxaluria and urinary tract infection. In 5 cases, the stones were due to a hereditary lithogenic metabolic disease : cystinuria in 1 case and primary hyperoxaluria in 4 cases.

[Value of extracorporeal shockwave lithotripsy in primary hyperoxaluria type I]

BACKGROUND

Application of extracoporal shock wave lithotripsy (ESWL) has revolutionized the management of many types of urolithiasis, including that observed in primary hyperoxaluria where surgical attempts to remove calculi sometimes result in worsening of renal function.

CASE REPORTS

Three unrelated patients aged 8, 10 and 11 years, respectively, with type I primary hyperoxaluria, suffered from recurrent bouts of abdominal pain (two patients) or anemia (one patient). Two patients had chronic renal failure. Plain abdominal films and ultrasonography showed several large bilateral stones. ESWL was applied to the three patients permitting complete removal of stones following three sessions in one patient and partial removal following four sessions in the second patient who developed infection after the first session with transitory increase in creatinemia. Several sessions of ESWL failed to fragment stones in the third patient.

CONCLUSION

ESWL may represent a safe procedure for attempting stone removal in patients with primary hyperoxaluria.

A unique mutation underlying carbonic anhydrase II deficiency syndrome in patients of Arab descent

We have investigated, in the genomic DNA of ten Tunisian patients, the presence of a splice junction mutation at the 5' end of intron 2 in the carbonic anhydrase II gene (CAII) previously described in six CAII-deficient patients presumed to be of Arab origin. All our patients were homozygous for this mutation and were mentally retarded, a characteristic feature of the phenotype of patients with an Arabic background. This mutation is found exclusively in patients with an Arabic background and thus may be confined to this ethnic group.

[Successful treatment of chronic active hepatitis with high-dose intravenous immunoglobulins in agammaglobulinemia]

BACKGROUND

Rapid progression of chronic active hepatitis can occur in patients with hypogammaglobulinemia. This report describes the successful use of i.v. immunoglobulins to treat chronic hepatitis in a child with agammaglobulinemia.

CASE REPORT

A 17 month-old boy was admitted because he had suffered from recurrent infections since the age of 6 months. His family history was normal. Clinical and laboratory investigations showed hepatomegaly, agammaglobulinemia with absence of IgG, IgA, IgM and IgE, absence of beta cells, normal T cells, normal T cell proliferation and normal levels of complement, elevated ALAT (70 and 200 IU/ml) and ASAT (60 and 188 IU/ml). Liver biopsy showed typical features of chronic active hepatitis. The cause of this hepatitis (B and C virus, EBV, autoimmune markers) was not found. The patient was first given gammaglobulins (80 mg/kg) every week, subcutaneously, for 9 weeks, which did not change his transaminasemia. A second course of gamma-globulins, 400 mg/kg every 3 weeks, intravenously, for 6 months, resulted in a transient normalization of transaminases for 3 months. Definitive normalization was only obtained when the patient was given i.v. gammaglobulins (400 mg/kg/week) which gave a residual level of blood IgG of 10 g/l. This apparent cessation of hepatitis activity was confirmed by a second liver biopsy. The patient is now given i.v. gammaglobulins, twice a month, producing a residual blood IgG concentration of 5 g/l.

CONCLUSIONS

The activity of this chronic hepatitis is closely correlated with the residual blood IgG concentration. Gammaglobulins could help neutralize virus extra-cellularly, although the viral origin of this hepatitis has not been-demonstrated.

[Non-typhoid Salmonella in pediatric patients in Tunis (Hospital Charles-Nicolle) from 1980 to 1991]

252 nontyphoidic salmonellae strains isolated from pediatrics were identified by using standard laboratory procedures and were serotyped with commercial antisera. Antibiotic susceptibility tests were performed by the agar diffusion method. Mostly isolates obtained from feces (182) and blood (67) and 89% of them from newborns and nursings. S. sér. Wien represented 75% of the isolates. The other serovars were essentially S. sér Typhimurium, S. sér Infantis and S. sér Enteritidis. All the isolates of S. sér Wien and S. sér Typhimurium were resistant to amoxicillin, carbenicillin, cephalothin, streptomycin, chloramphenicol and tetracycline from 1980. From 1987 S. sér Wien isolates developed resistance to cefotaxime and amikacin. Distribution nontyphoidic salmonellae strains according to the year was variable. Maximal isolates were in September and October. Two major epidemics were observed in this study, in 1982 and 1989. 94% of the strains determined nosocomial infections. The source of infection was established during the epidemic of 1989. The application of hygiene measures led to decline the number of isolates in 1990 and their disappearance in 1991, any strains of S. sér Wien was isolated.

Failure of immunosuppressive therapy and high-dose intravenous immunoglobulins in four transfusion-dependent, steroid-unresponsive Blackfan-Diamond anemia patients

Blackfan-Diamond anemia (BDA) is a rare hypoproliferative anemia occurring in infancy or in early childhood. Patients who fail on usual doses of steroids did not achieve remission with other pharmacological agents. Claims that other molecules such as cyclosporin A (CSA) or antithymocyte globulin (ATG) are effective require substantiation. We treated four transfusion-dependent, steroid-unresponsive BDA patients with ATG and methylprednisolone (MP). Only a transient response was obtained in one case. None of these patients responded to high-dose intravenous immunoglobulins (HDIg) or CSA.

[Lupus in children in Tunisia]

In this study, we have analyzed the clinical and serological features related to 16 Tunisian children in whom diagnosis of systemic lupus erythematosus was made before or at the age of 15. Renal involvement was found in 75% of cases and renal biopsies have mostly revealed severe histologic patterns. All of the patients who have been followed received corticosteroids and in some cases required additional cytotoxic drugs in order to control disease activity. Five children died in a context of a renal failure. This study of childhood lupus in Tunisia confirms that the clinical course of this disease in children is often aggressive.

[Recessive osteopetrosis. Identification of a form of medium severity]

BACKGROUND

Several distinct forms of osteopetrosis have been identified. Some of the autosomally recessive inherited forms are benign, much like the autosomal dominant form. Others are more malignant.

PATIENTS

The clinical data, skeletal radiographs, histological features and histories of 32 children with osteopetrosis were analyzed retrospectively.

RESULTS

The 32 patients, belonging to 20 sibships were divided into two groups. The first group included 24 patients, aged 1 day-11 months (mean 4.5 months), suffering from hepatosplenomegaly, anemia, thrombocytopenia and optic atrophy in early infancy. They also had a generalized increase in bone density, abnormal bone remodeling, rachitic lesions and a "bone-within-bone" appearance. Biopsies showed severe bone resorption and myelofibrosis. 19 of the 20 patients whose outcomes were known died during the first year of life. The second group included 8 patients, aged 40 days-3 years (mean: 11 months). Hepatosplenomegaly appeared later, anemia was less severe and thrombocytopenia occurred in only 1 patient. However, all 8 patients suffered from optic atrophy and 3 were deaf. Radiographs showed bone growth without rachitic lesions. Biopsies from 2 patients showed bone resorption, but no myelofibrosis. The outcome was less severe: 6 patients, now aged 8 months to 8 years, have survived, 3 of them for over 5 years. Genetic investigation showed patterns compatible with autosomal recessive inheritance in both groups, with similar sets of features within each sibship.

CONCLUSION

This study reveals a new type of recessively inherited osteopetrosis. It can be classified as an intermediate form, distinct from both the malignant and the benign forms, and also distinct from osteopetrosis with carbonic anhydrase II deficiency.

[Lymphoid hyperplasia of the intestine in children. 15 cases]

Fifteen cases of nodular lymphoid hyperplasia (NLH) of the bowel in patients aged 17 months to 15 years are reported. Fourteen patients had NLH confined to the small bowel and one had involvement of both the small bowel and colon. Mean age at diagnosis was 10 years. The most common presenting symptoms were intestinal manifestations (86%). Diagnosis was suspected upon roentgenographic studies in one case and digestive endoscopy in ten cases. Histologic confirmation was obtained in all fifteen patients. Immunohistochemical studies, done in 8 patients, demonstrated a paucity of IgA plasmocytes in one patient with an immune deficiency and a polyclonal plasmocyte population with mainly IgA plasmocytes in the seven other patients. Five patients had a deficiency in humoral immunity, with variable expression hypogammaglobulinemia in three patients and IgA deficiency in two; intestinal giardiasis was found in eight patients. Histologic outcome was documented in five cases; evidence of NLH disappeared in only one patient. Metronidazole improved clinical symptoms in most instances.

[Case report of skin manifestations in infantile Mediterranean kala-azar]

The case of a 19-month-old girl with visceral leishmaniasis and unusual skin manifestations is reported. Emphasis is put on the fact that such manifestations are unusual in Mediterranean infantile leishmaniasis. The clinical features, parasitology, histology, and course of these skin lesions are discussed.

[Syndrome associating: osteopetrosis, tubular acidosis, mental retardation and cerebral calcifications due to carbonic anhydrase II deficiency. Apropos of 3 cases in the siblings]

Three new cases of a syndrome including osteopetrosis, tubular acidosis, mental retardation and cerebral calcifications are reported in the same sibship. This rare syndrome has an autosomal recessive inheritance and is due to carbonic anhydrase II deficiency. Fractures and mild sensorial manifestations were noticed in 2 cases. Mental deficiency and otitis were present in the 3 cases. Blood count and phosphocalcic metabolites were normal. A proximal tubular acidosis was present in each case. The radiological features were specific: cerebral calcifications were present in all cases since the age of 2 1/2 years; osteocondensation and bone modeling were predominant in long bones metaphyses. Alcalinization improved the height growth.

[Duplication of mouth and mandible. Apropos of a case]

We report a case of duplication of the mouth, tongue, mandible, and cervical spine in a female neonate. Findings in this patient were somewhat different from those in previously reported cases. Clinical, radiological and therapeutic features in this localized duplication are reviewed. Embryologic hypotheses include defective midline development, such as in the split notochord syndrome, and development of totipotent cells from the first branchial arch.

[Hydatid cysts in children. Diagnostic and therapeutic aspects. Apropos of 1195 cases]

Hydatid cysts represent a true social problem in Tunisia where 2.1% of rural inhabitants are affected. Hydatid disease is responsible for 10% of the country's surgical activity and costs approximately 800 $ per patient. From April 1967 through January 1987, 1,195 cases of hydatid cyst in children aged 2 to 15 years were treated at the Children's Hospital in Tunis. The involved organ was the lung in 643 cases, the liver in 486 cases, the spleen in 27 cases, and the kidney in 18 cases. With the exception of seven patients with malignant forms, surgery was always performed, with a 1.4% mortality rate and a 2% morbidity rate. We analyze the diagnostic and therapeutic particularities of the various locations of hydatid cyst. Diagnosis rests mainly on ultrasound findings and treatment on conservative procedures as hydatid disease in children carries a good prognosis.

[Continuous perfusion of insulin in the treatment of acidoketotic coma in children]

Ketoacidosis is still a frequent complication as far as our diabetic patients are concerned. The insulin regimen during this acute diabetic ketoacidosis was, until October 1981, administered at the start, half intravenously and half intramuscularly, then discontinuously every four hours, subcutaneously, according to the rate of glucose and acetoacetate. Since then, a new method has been used for the treatment of diabetic ketoacidosis providing a continuous perfusion without pumps, of insulin, glucose and electrolytes. The authors describe their experience, using this technique on ten children admitted to hospital because of severe diabetic ketoacidosis. A certain number of parameters and the evolution were studied. The glycemia graph shows a more harmonious and regular normalisation, urinary ketosis disappears within 8 and 24 hours (with an average of 16,22 h). The next step that consists in administering mixed insulin is taken between the 16th and 48th hours (with an average of 25,42 h). Two hypoglycemia have been reported contrary to the statements of other authors. Furthermore, these parameters were compared to those of 10 children submitted to the classical regimen. The authors conclude that a continuous perfusion presents a better method with approximately similar results, and its use is much simpler both for the patient and for the staff.