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Offical Publication of:Hong Kong College of PaediatriciansHong Kong Paediatric Society

HK J Paediatr (New Series) Vol 23. No. 2 April 2018

ISSN 2309-5393 (onl ine)ISSN 2309-5393 (onl ine)ISSN 2309-5393 (onl ine)ISSN 2309-5393 (onl ine)ISSN 2309-5393 (onl ine)ISSN 1013-9923 (pr in t)ISSN 1013-9923 (pr in t)ISSN 1013-9923 (pr in t)ISSN 1013-9923 (pr in t)ISSN 1013-9923 (pr in t)

Indexed in EMBASE/Excerpta Medica,Indexed in EMBASE/Excerpta Medica,Indexed in EMBASE/Excerpta Medica,Indexed in EMBASE/Excerpta Medica,Indexed in EMBASE/Excerpta Medica,Science Citation Index Expanded (SCIE) and ScopusScience Citation Index Expanded (SCIE) and ScopusScience Citation Index Expanded (SCIE) and ScopusScience Citation Index Expanded (SCIE) and ScopusScience Citation Index Expanded (SCIE) and ScopusFull text online at www.hkjpaed.orgFull text online at www.hkjpaed.orgFull text online at www.hkjpaed.orgFull text online at www.hkjpaed.orgFull text online at www.hkjpaed.org

EditorialPaediatric Diagnosis: When Human Mind Meets 155Artificial IntelligenceCheung

Original ArticlesDiagnosing Enteroviral Meningitis Using 157Real-time RT-PCR with Cerebrospinal Fluidand Stool SpecimensJeon, Song, Kim

Clinical Characteristics of Childhood Hydatid 162Disease: A Single Tertiary Centre Experiencefrom TurkeyTural-Kara, Özdemir, Karbuz, Kocaba , Yah i,Erat, Bingöl-Kolo lu, Fitöz, Tutar, Çiftçi, nce

Overweight and Obesity in Children Under 169Phenylalanine Restricted DietOzturk, Gençpinar, Erdur, Tokgöz, I ik, Akin

The Clinical and Molecular Spectrum of 17315q Duplication Syndrome in ChineseLuk, Lo

Case ReportsRare Clinical Presentation of Intestinal 179Malrotation After Neonatal Period:Protein-losing Enteropathy SymptomsDue to Chronic Midgut MalrotationFang, Shang, Chen

An Extramural Duodenal Ectopic Pancreas 182Mimicking an Exophytic Pancreatic Tumourin an AdolescentWu, Chen, Chang

Reye's Syndrome Arising from the Treatment 185of Kawasaki DiseaseSu, Hsieh, Hsu, Chen

Denys Drash Syndrome, What Paediatrician 188Should Know About?Kwok, Wong, Leung, Chan

CommentaryIntegrative, Integrated Medicine But No 192Integration: Tarnishing Steroid and ChineseMedicine is VanityHon, Leung

Letter to the EditorEthical Issue in Use of Expensive Drugs 195for Treatment of Rare Metabolic Diseasesin Hong KongYuen

Clinical QuizWhat is the Diagnosis? 196Fung, Wong, Chung

Abstracts of Articles in Chinese 197

MCQs 200

Announcements 203

HONG KONG JOURNAL OF PAEDIATRICS

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HK J Paediatr (new series) 2018;23:155-156

Hong Kong Journal of Paediatrics

(New Series)An Official Publication ofHong Kong College of Paediatricians &Hong Kong Paediatric Societyc/o Hong Kong College of Paediatricians, Room 801,Hong Kong Academy of Medicine Jockey Club Building,99 Wong Chuk Hang Road, Aberdeen,Hong Kong.

Editorial Board

Chief EditorCHEUNG Yiu Fai Associate EditorsCHUNG Hon Yin LAM Hung San LEUNG Ting Fan Honorary SecretaryCHAN Ching Ching MembersCHAN Chi Fung *CHAO Sih Yin CHEUK Ka Leung FUNG Po Gee HON Kam Lun HUI Wun Fung IP Patrick KWAN Yin Wah KWONG Ling LEE Pui Wah LI Albert Martin LIU Kam Wing SIU Luen YeeTSAO Yen Chow TSE Kei Chiu WONG Hiu Lei YEUNG Chap Yung YEUNG Wai Lan

Honorary Advisors to the EditorialBoardAndrew BUSH, United KingdomDon M. ROBERTON, AustraliaDavid K. STEVENSON, USAGUI Yong-Hao, China

Business ManagerTSOI Nai Shun **

*Representing HK College of Paediatricians**Representing HK Paediatric Society

PublisherHong Kong Journal of Paediatrics is publishedby Medcom Ltd, Flat E8, 10/F, Ka Ming Court,688-690 Castle Peak Road, Kowloon, HongKong SAR. Tel: (852) 2578 3833, Fax: (852)2578 3929, Email: [email protected] in EMBASE/Excerpta Medica, ScienceCitation Index Expanded (SCIE) and ScopusWebsite: www.hkjpaed.org

ISSN 1013-9923

Editorial

It is hard to disagree, even in this technology-driven world in the twenty-firstcentury, that the most revered components of the practice of clinical medicineremains to be a well-taken history followed by a carefully conducted physicalexamination. In children with heart conditions and prolonged fever, one is obligedto look for 'ephemeral spots of a painful nodular erythema, chiefly in the skin ofthe hands and feet',1 although young residents let alone medical students mayknow little of the 'Father of Modern Medicine' who lent his name to this cutaneousmanifestation referred to as Osler's nodes. 'Just listen to your patient, he is tellingyou the diagnosis', unsurprisingly remarked by Dr Osler who placed his firmbelief on the centrality of history taking and physical examination in each of theclinical encounters. By contrast, the fictional Dr McCoy, the iconic physician inStar Trek, begins his diagnosis almost without exception using the tricorder, thenon-invasive medical scanner, among the numerous other medical gadgets onboard Star Trek. To the people of the past, this fictional character and his gadgetsbelong to an unimaginable future. To us, perhaps, we are a step closer to seeingthe realisation of Dr McCoy's tricorder. To us, we are facing a non-fictional newbreed of digital physicians who is creeping into the consultation clinics and hospitalwards and finding its way to potentially transform the future of medicine.

As vividly described by Obermeyer and Lee,2 'In the good old days, cliniciansthought in groups; "rounding", whether on the wards or in the radiology readingroom, was a chance for colleagues to work together on problems too difficult forany single mind to solve.' This time-honoured approach remains central to ourdaily clinical practice and is illustrated in the diagnosis of the various paediatricconditions highlighted in the current issue of the Journal: enteroviral meningitis,3childhood hydatid disease,4 syndromal disorders including 15q duplicationssyndrome,5 Reye's syndrome,6 and Denys Drash syndrome,7 and rare clinicalpresentations of paediatric surgical conditions including intestinal malrotationafter neonatal period8 and an extramural duodenal ectopic pancreas.9

Clinical diagnosis involves the connection of dots: dots of pieces of informationin the history provided by patients, parents and caretakers, dots of physical signsobtained through physical examination, dots of past experience whether good orbad being imprinted over the years of practice, dots of intuition, and dots of theyet unknown to be unveiled through exchanges with colleagues and, in the presentera, the use of search engines. It is inarguable, however, that medical knowledgeand clinical data are expanding rapidly, expanding at a pace beyond the ability ofthe human brain to assimilate, to analyze and to apply in a timely manner. On the otherhand, artificial intelligence, the mimicking of human cognition by computers, isbecoming a reality in medicine.10 For some, the combination of big data and artificial

Paediatric Diagnosis: When HumanMind Meets Artificial Intelligence

156 Paediatric Diagnosis

intelligence represents the next industrial revolution.11

The beating of the grandmaster of Go, an ancient Chineseabstract strategy board game, by AlphaGo Zero of GoogleDeepMind has made its way to the news headline. Its abilityto master the game without human knowledge is discussed ina recent article in Nature.12 By their very nature, the twoplayers of Go are competing against each other, one destinedto become the winner, while the other would inevitably becalled the loser. The AlphaGo Zero story that, to some, mayimplicate direct confrontation between artificial intelligenceand the human mind is probably not the best example toillustrate the potentials of translating artificial intelligence toclinical care. Multidisciplinary input from different membersof the healthcare profession is an important component inclinical diagnosis, decision making and management. The wayto incorporate the protean of artificial intelligencetechnologies, including data mining, machine learning, case-based reasoning, Bayesian modeling, and artificial neuralnetwork into the clinical diagnostic and management pathwaysis becoming the crux of the question for the present and futuregenerations of healthcare professionals.

In paediatrics, reports on the potential applications ofartificial intelligence are emerging. Kruszka et al from theNational Human Genome Research Institute, US, and theirinternational collaborators recently reported on thesuccessful use of facial recognition software to diagnose22q11.2 deletion syndrome in diverse populations.13

Machine learning algorithm based on the face scanningpatterns may be able to identify children with autisticspectrum disorders.14 The paediatric intensive care setting,with the wealth of data, may be the ideal interface betweenpaediatric intensivist and artificial intelligence technologies.15

Big datasets coupled with machine learning has also beenexplored to determine brain maturation in preterm infants16 andto predict the relapse of acute lymphoblastic leukaemia inchildren.17

Would the rise of artificial intelligence herald thediminution of human touch in clinical medicine? Inpaediatrics, the touch is the touch of sympathy, empathy, andaffection. Human touch is integral to the art of medicine. Thelate Stephen Hawking said, 'In short, the rise of powerfulartificial intelligence will be either the best, or the worst thing,ever to happen to humanity.' When the mind of humanphysician meets artificial intelligence, who is to decide theoutcome?

YF CheungChief Editor

References

1. Osler W. Chronic infectious endocarditis. Quart J Med 1909;2:219-30.

2. Obermeyer Z, Lee TH. Lost in thought - the limits of the humanmind and the future of medicine. N Engl J Med 2017;377:1209-11.

3. Jeon JS, Song HS, Kim JK. Diagnosing enteroviral meningitisusing real-time RT-PCR with cerebrospinal fluid and stoolspecimens. HK J Paediar (new series) 2018;23:157-61.

4. Tural-Kara T, Özdemir H, Karbuz A, et al. Clinical characteristicsof childhood hydatid disease: a single tertiary centre experiencefrom Turkey. HK J Paediar (new series) 2018;23:162-8.

5. Luk HM, Lo IFM. The clinical and molecular spectrum of 15qduplication syndrome in Chinese. HK J Paediar (new series) 2018;23:173-8.

6. Su EJ, Hsieh JH, Hsu CC, Chen KT. Reye's syndrome arisingfrom the treatment of Kawasaki disease. HK J Paediar (new series)2018;23:185-7.

7. Kwok AKH, Wong SMY, Leung MT, Chan WKY. Denys DrashSyndrome, what paediatrician should know about? HK J Paediar(new series) 2018;23:188-91.

8. Fang YH, Shang SQ, Chen J. Rare clinical presentation ofintestinal malrotation after neonatal period: protein-losingenteropathy symptoms due to chronic midgut malrotation. HK JPaediar (new series) 2018;23:179-81.

9. Wu YH, Chen CW, Chang YT. An extramural duodenal ectopicpancreas mimicking an exophytic pancreatic tumor in anadolescent. HK J Paediar (new series) 2018;23:182-4.

10. Jha S, Topol EJ. Adapting to artificial intelligence: Radiologistsand pathologists as information specialists. JAMA 2016;316:2353-4.

11. http://www.economist.com/news/special-report/21700761-after-many-false-starts-artificial-intelligence-has-taken-will-it-cause-mass.

12. Silver D, Huang A, Maddison CJ, et al. Mastering the game ofGo with deep neural networks and tree search. Nature 2016;529:484-9.

13. Kruszka P, Addissie YA, McGinn DE, et al. 22q11.2 deletionsyndrome in diverse populations. Am J Med Genet A 2017;173:879-88.

14. Liu W, Li M, Yi L. Identifying children with autism spectrumdisorder based on their face processing abnormality: a machinelearning framework. Autism Res 2016;9:888-98.

15. Chang AC, Hunt J. Toward unreasonable effectiveness of cardiacICU data: artificial intelligence in pediatric cardiac intensive care.Pediatr Crit Care Med 2014;15:565-7.

16. Stevenson NJ, Oberdorfer L, Koolen N, et al. Functionalmaturation in preterm infants measured by serial recording ofcortical activity. Sci Rep 2017;7:12969.

17. Pan L, Liu G, Lin F, et al. Machine learning applications forprediction of relapse in childhood acute lymphoblastic leukemia.Sci Rep 2017;7:7402.


Diagnosing Enteroviral Meningitis Using Real-time RT-PCRwith Cerebrospinal Fluid and Stool Specimens

JS JEON, HS SONG, JK KIM

Abstract Enteroviral infections are common among children and are a main cause of meningitis. Cerebrospinalfluid (CSF) analysis is important for diagnosing meningitis, although CSF sampling is difficult and time-consuming. In contrast, stool testing provides simpler sampling and a higher positive rate. We performedpolymerase chain reaction testing for paediatric patients (≤18 years old) who were admitted to CheonanDankook University Hospital during 2011-2015 for suspected meningitis (942 patients, 1,884 specimens).The stool specimens exhibited the highest positive rate, and 114 patients exhibited positive CSF and stoolspecimens. Fourteen patients had positive CSF specimens and negative stool specimens, while 101 patientshad positive stool specimens and negative CSF specimens. CSF analysis combined with stool testing mayprovide a more efficient and accurate diagnosis of enteroviral meningitis, compared to only CSF or stooltesting.

Key words Enterovirus; Meningitis; Polymerase chain reaction

Department of Laboratory Medicine, Dankook UniversityCollege of Health Sciences, 119, Dandae-Ro, Dongnan-Gu,Cheonan-Si, Chungnam 330-714, South Korea

JS JEON MD

Department of Nursing, Dankook University College ofHealth Sciences, 119, Dandae-Ro, Dongnan-Gu, Cheonan-Si,Chungnam 330-714, South Korea

HS SONG PhD in Nursing

Department of Biomedical Laboratory Science, DankookUniversity College of Health Sciences, 119, Dandae-Ro,Dongnan-Gu, Cheonan-Si, Chungnam 330-714, South Korea

JK KIM PhD

Correspondence to: Prof. JK KIM

Email: [email protected]

Received April 29, 2016

Original Article

Introduction

Enteroviruses (EV) belong to the Picornaviridae familyand exhibit >70 different serotypes, which includecoxsackieviruses.1 In Korea, EV infections typically occurbetween early spring and summer.2,3 Large-scale EV

infections have been reported worldwide,4 although EVinfections occur more frequently in children, compared toadults.5 Once infected, the patient may exhibit variousclinical symptoms that range from mild upper respiratorytract infection and Guillain-Barre syndrome to severesymptoms of paralysis that are associated with transversemyelitis.6,7 Furthermore, EV infections are a major sourceof central nervous system infections in children and infants.8Moreover, 85% of aseptic meningitis cases are caused byEV.7,9,10 However, it is difficult to differentiate betweenbacterial meningitis and viral meningitis that is caused bythe herpes simplex virus, and this difficulty can result inunnecessary hospitalisation, excess treatment costs, andantibiotic misuse.11 Thus, it is important to accuratelydiagnose the meningitis, in order to prevent unnecessarydiagnostic testing and treatment.12

The traditional method for confirming a diagnosis ofaseptic meningitis is cerebrospinal fluid (CSF) analysis andculture to detect the virus. However, this procedure isinvasive, can cause patients anxiety,13 requires a prolongeddetection period, and can prevent early diagnosis andtreatment based on the difficulty of obtaining CSF cultureresults. In addition, low virus titers are common in clinicalspecimens, which can create low sensitivities for many

PCR Diagnosis of Enteroviral Meningitis158

serotypes, including the group A coxsackieviruses.14-16

Thus, polymerase chain reaction (PCR) testing has beendeveloped as an accurate and rapid diagnostic test for asepticmeningitis.17 Both CSF and stool specimens are typicallyused for PCR testing, as a CSF specimen is essential fordiagnosis,18 although it has a lower positive rate than PCRstool testing2,18 and has been associated with diagnostic issuesthat are related to the sampling period.18 Thus, it is difficultto confirm a diagnosis using PCR with only a CSF specimen.Moreover, very few studies have directly compared theefficacy of single or repeated testing. Therefore, the presentstudy aimed to evaluate the usefulness of real-time reverse-transcription PCR (real-time RT-PCR) with CSF and stoolspecimens that were obtained from children at our centerduring the last 5 years. We believe that the results of thisanalysis may provide the basis for fast and accurate diagnosisof aseptic meningitis.

Methods

1. PatientsThis retrospective study analysed real-time RT-PCR

results from CSF and stool specimens that were being testedfor EV infection. The specimens were obtained fromchildren (≤18 years old) who were admitted to CheonanDankook University Hospital for suspected asepticmeningitis between January 2011 and October 2015. Thisstudy received ethical approval from the Dankook Universityinstitutional ethics review board (2015-11-011).

2. Experimental MethodsSpecimens were collected from patients with symptoms

of meningitis during a single hospital admission. CSFspecimens were collected via lumbar puncture, and stoolspecimens were also collected at approximately the sametime. The specimens were subjected to same-day nucleicacid extraction, or were stored at 4°C for next-day nucleicacid extraction. The CSF and stool nucleic acid extractionswere performed using an automated QIAcube system withthe QIAamp DNA Mini Kit (Qiagen, Hilden, Germany),according to the manufacturer's protocol. The real-time RT-PCR was performed using 40 µL of the eluent from theQIAamp Spin column. The extracted RNA was dissolved in50 µL of nuclease-free water and stored at -80°C untiltesting.

The real-time RT-PCR assay was performed accordingto the manufacturer's instructions using an AccuPower®

Enterovirus real-time RT-PCR Kit (Bioneer, Daejeon,

Korea), which contains primers and probes for the highly-conserved 5'-nontranslated region of the human EV genome.Positive specimens were subjected to semi-nested RT-PCRin the VP1 coding region for molecular typing, as previouslydescribed,19 and the VP1 amplicons were sequenced usinginternal primer sets.

All data were expressed as median and range. The chi-square test was used to analyse categorical data. A p-valueof <0.05 was considered statistically significant.

Results

A total of 942 patients were included in this study, andboth CSF and stool specimens were obtained from eachpatient (total: 1,884 specimens). Among the 942 patients,229 patients (24.3%) tested positive for EV, 128 CSFspecimens tested positive, and 215 stool specimens testedpositive (Table 1). Male patients were most likely to exhibitpositive CSF and stool results (Figure 1), although thedifference was not statistically significant (p=0.23). Theaverage age was 1.87 years, and children who were <1 yearold accounted for 49.2% of the CSF specimens and 54.4%of the stool specimens; similar results were observed forpatients who were <1 year old and ≥1 year old (Figure 2).During the 5-year study period, the lowest number ofpositive specimens was detected during 2012, and thehighest numbers were detected during 2011 and 2015(Figure 3). Monthly comparisons revealed that the positiverates were highest during June-August, and a gradual declinewas observed during late fall.

A comparison of the CSF and stool specimen resultsrevealed that 713 patients had negative results for bothspecimens, and 114 patients had positive results for bothspecimens. Fourteen patients had a positive CSF specimenand a negative stool specimen, and 101 patients had a

Table 1 Analysis of the PCR results

Positive

CSF Stool

Patients specimens specimens

(%) (%) (%)

All patients 942 229 (24.3) 128 (13.6) 215 (22.8)

Male patients 549 138 (25.1) 72 (13.1) 131 (23.9)

Female patients 393 91 (23.2) 56 (14.3) 84 (21.4)PCR: polymerase chain reaction; CSF: cerebrospinal fluid

Jeon et al 159

Figure 4 Monthly numbers of positive specimens.

Table 2 Comparing the CSF and stool results

Stool

Positive Negative

CSF Positive 114 14

Negative 101 713CSF: cerebrospinal fluid

Figure 2 Positive specimen rates according to age group.

Figure 1 Sex ratios for positive cerebrospinal fluid (CSF) andstool specimens.

Figure 3 Annual positive rates for cerebrospinal fluid (CSF)and stool specimens.

negative CSF specimen and a positive stool specimen (Table2). A higher positive rate was observed among stoolspecimens, compared to CSF specimens (Figure 4).

Discussion

In the present study, we analysed the use of CSF andstool specimens for real-time RT-PCR testing to diagnoseaseptic meningitis that was secondary to EV infection. Boththe CSF and stool results revealed that male patients had ahigher positive rate, compared to female patients, althoughthis difference was not statistically significant (p=0.23).Similarly, previous studies have reported higher positiverates among male patients (vs. female patients),18,20,21 andsome have even reported that the positive rate was two-foldhigher among male patients.21 This difference may be relatedto sex-based differences in immunity22 that arise fromdifferences in genetic and endocrine functions.23

When we compared the annual positive rates for EVduring the past 5 years, both the CSF and stool resultsexhibited similar increasing and decreasing trends. Forexample, the highest positive rates were observed in 2011and 2015. Moreover, examination of the entire 5-year periodrevealed that the EV infection rate appeared to exhibit asignificant quadrennial increase. This is similar to a previousstudy that found that a national EV pandemic occurredapproximately every 3 years.20

The monthly EV positive rates during the 5-year periodrevealed that positive CSF and stool specimens were mostfrequently detected during June-August, and that the numberof positive specimens gradually decreased during the fall.This result is similar to the findings of a study regardingEV infection in Chungnam during 2005-2006,24 and is also

PCR Diagnosis of Enteroviral Meningitis160

consistent with findings from other studies that reportedhigher frequencies of EV infection in the summer andfall.19,25,26 These findings are likely related to the hightemperature and humidity during the summer, as previousstudies have found that EV infection is common during thesummer and fall in temperate regions, but occurs year-roundin tropical regions.21 Moreover, this trend for EV infectionswas also observed during 2007-2009.8 Positive CSF andstool specimens were also most frequent among patientswho were <1 year old, and this finding is similar to those ofpast studies,18,24 which suggests that EV infection is morelikely among younger patients.

Stool specimens were more frequently positive for EV,compared to CSF specimens. Furthermore, there were agreater number of cases with negative CSF specimens andpositive stool specimens, compared to cases with positiveCSF specimens and negative stool specimens. These resultssuggest that stool testing was associated with a higherpositive rate, compared to CSF testing. However, there iscontroversy regarding whether CSF and/or stool specimensshould be used to diagnose aseptic meningitis, as varyingpositive rates are observed in clinical practice. For example,one study found a higher positive rate in stool specimens,compared to CSF specimens,18,27,28 and our findings validatethat difference. This difference may be explained by thenature of EV, which is stable in an acidic environment andeasily reaches the lower gastrointestinal tract.21 Thus, oncean infection has developed, it may take 4-8 weeks (or evenup to 11 weeks) for the virus to be cleared from the stool.28

Moreover, other studies have suggested that there is a highpossibility of past EV infections causing aseptic meningitis,based on the prolonged clearance time, although it is difficultto evaluate this theory.18

Kim et al have reported that there is a sharp decline inpositive rates that is based on the sampling time.18 Forexample, positive RT-PCR results were observed inapproximately 50% of their specimens that were obtainedwithin 2 days, compared to 4.2% in specimens that wereobtained after 2 days. In contrast, stool specimens providedan average positive rate of 90.5%, even after 7 days. Thismay be because EV meningitis is caused by viremia duringthe early EV infection period, and viral detection in CSFspecimens may only be possible during a short period afterthe infection. Moreover, EV replication persists in thegastrointestinal tract after infection, which led those authorsto conclude that sampling time was an important factor.18

This study has several limitations that warrantconsideration. First, we only analysed results from a singleinstitution in the Cheonan area during 2011-2015. Second,

we used a retrospective design, which is associated withseveral well-known risks of bias. Third, it is possible thatwe did not identify all cases of EV infection, based onpotential procedural variations that may have introducedRNA denaturation during the specimen freezing andthawing.29

In conclusion, our comparison of real-time RT-PCRresults from CSF and stool specimens during the past 5 yearsrevealed similar trends in the sex-specific, annual, andmonthly positive rates. Furthermore, we did not observeany significant source-specific differences, unlike thedifferences in the age-specific positive rates (highest amongpatients who were <1 year old). Thus, we propose that theco-analysis of CSF and stool specimens during the earlydisease stage may provide a faster and more accuratediagnosis. This is especially important because differencesin the source-specific positive rates and sampling times maycomplicate the diagnosis of EV infection. Therefore, ourresults may help to reduce the extended hospitalisation,medical costs, and antibiotic misuse that are related toincorrect diagnosis in cases of EV infection.

Sources of Funding

The authors acknowledge Dankook University, whichprovided funding for this research in 2015(R201500938).

Declaration of Interest

The authors have no conflicts of interest.

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Jeon et al 161

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12. Na YR, Joe HC, Lee YS, Bin JH, Cheigh HS, Min SK. Comparisonof the Real-Time Nucleic Acid Sequence-Based Amplification(NASBA) Assay, Reverse Transcription-realtime PCR (RT-realtime PCR) and Virus Isolation for the Detection of EnterovirusRNA. Journal of Life Science 2008;18:374-80.

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20. Kang BH. Laboratory-based surveillance of enterovirus associateddisease in Korea, 2010. Public report weekly report. KoreanCenters for Disease Control & Prevention 2011;4:935-9.

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26. Baek KA, Yeo SG, Lee BH, et al. Epidemics of enterovirusinfection in Chungnam Korea, 2008 and 2009. Virol J 2011;8:297.

27. Cho HK, Lee NY, Lee H, et al. Enterovirus 71-associated hand,foot and mouth diseases with neurologic symptoms, a universityhospital experience in Korea, 2009. Korean J Pediatr 2009;54:639-43.

28. Chung PW, Huang YC, Chang LY, Lin TY, Ning HC. Durationof enterovirus shedding in stool. J Microbiol Immunol Infect 2001;34:167-70.

29. Guneya C, Ozkayab E, Yapara M, Gumusa I, Kubara A, DoganciL. Laboratory diagnosis of enteroviral infections of the centralnervous system by using RT-polymerase chain reaction (PCR)assay. Diagn Microbiol Infect Dis 2003;47:557-62.


Clinical Characteristics of Childhood Hydatid Disease:A Single Tertiary Centre Experience from Turkey

T TURAL-KARA, H ÖZDEMIR, A KARBUZ, BA KOCABA , A YAH I,T ERAT, M BINGöL-KOLO LU, S FITöZ, E TUTAR, E ÇIFTçI, E iNCE

Abstract Purpose: Hydatid disease is a parasitic infection and it is a major health problem in some areas. Weaimed to evaluate the demographic and clinical findings of patients with hydatid disease in our hospital.Methods: Between January 2009 and December 2015, patients with hydatid disease were includedretrospectively in this study. Demographic characteristics, clinical findings, laboratory and imaging results,treatment modalities and complications were collected. Findings: Twenty-eight patients were involvedin our study. The median age of patients' was 134 (55-197) months. Most frequently affected organs wereliver (71.4%) and lungs (57.1%). In addition cysts were detected in atypical locations. Medical treatmentwas given in all patients. Conclusions: Hydatid disease is an important problem in Turkey. Multipleorgan involvement may occur at the same time. Therefore, advanced imaging methods should be used forthe detection of localised atypical cysts. Long term outcomes are satisfactory with adequate treatment.

Key words Children; Echinococcus granulosus; Hydatid disease; Treatment outcomes

Department of Pediatric Infectious Diseases, AnkaraUniversity Medical School, Ankara, Turkey

T TURAL-KARA MDH ÖZDEMIR MDA KARBUZ MDBA KOCABA MDA YAH I MDT ERAT MDE ÇIFTçI MD, ProfE iNCE MD, Prof

Department of Pediatric Surgery, Ankara University MedicalSchool, Ankara, Turkey

M BINGöL-KOLO LU MD, Prof

Department of Pediatric Radiology, Ankara UniversityMedical School, Ankara, Turkey

S FITöZ MD, Prof

Department of Pediatric Cardiology, Ankara UniversityMedical School, Ankara, Turkey

E TUTAR MD, Prof

Correspondence to: Dr T TURAL-KARA


Received June 28, 2016

Original Article

Introduction

Hydatid disease (HD) is a zoonotic infection which iscaused by larval forms of Echinococcus species. The adultform is located in intestinal lumen of dogs. Infected eggsare dispersed into the environment with animal feces.Intermediate host (sheep, goats, etc.) eats contaminated foodand parasite eggs drop to the intestine of animals. It maycause cysts formation in organs by absorption into thebloodstream. Then carnivores eat the animals' organs whichcontain cysts, and the parasite becomes adult form byreaching the animal's intestine again. Humans may beinfected by ingestion of parasitic eggs, occasionally maybecome an intermediate host.1

Hydatid disease is a major problem in large sheep raisingareas like Mediterranean, South America, Asia, Europe andKenya.2 The incidence is reported <1 to 220 per 100000 inendemic areas.3 Although it is seen in all regions of Turkey,most patients are reported from Eastern Anatolia,Southeastern Anatolia and Central Anatolia. The incidenceis approximately 2-6/100000 in Turkey.4 Hydatid diseaseis more frequently reported in children compared to adults.Liver, lungs, spleen, kidney, heart, bones and central

Tural-Kara et al 163

nervous system may be affected.5

We aimed to examine epidemiologic characteristics,clinical and laboratory findings of patients with HD and tocompare our data with previous studies.

Methods

Patients admitted to our hospital between January 2009and December 2015 with diagnosis of HD, wereretrospectively included in this study. Patients who did notcome to routine examinations were excluded. Hydatiddisease was diagnosed with clinical, radiological andserological tests. Pathological examination was performedin all patients who underwent surgical procedures.Demographic characteristics like patients' age, gender,contact with an animal, symptoms, clinical and laboratoryfindings, echinococcal indirect hemagglutination test (IHA)results, radiological imaging, treatment modalities andcomplications were collected from data system by usingICD-10 codes. Chest X-ray, abdominal ultrasonography,echocardiography and brain magnetic resonance imaging(MRI) were performed in all patients. Thorax and abdomencomputed tomography (CT) was used in some cases thatrequired advanced imaging. Echinococcal IHA result≥1/32 was accepted as positive. All patients receivedalbendazole (15 mg/kg/day in two divided doses) treatmentafter diagnosis. Radiologic imaging was periodicallyperformed to non-operated patients. Disappearance of cysts,calcified cysts and collapse were accepted as a completehealing and treatment was discontinued. Puncture-aspiration-injection-reaspiration (PAIR) was performed insome patients with hepatic hydatid cysts. While albendazoletreatment was given to operated patients for one month afterthe surgery, non-operated patients received treatment atleast 6 months.

Results

Thirty-one patients were diagnosed as a HD betweenJanuary 2009 and December 2015. Three of them wereexcluded because they did not come to routine examination.Twenty (71.4%) patients were male. The median age ofpatients' was 134 (55-197) months. A history of animalcontact was found in 35% of boys (7/20) and in 25% ofgirls (2/8).

Most common complaints were cough, fever, abdominalpain, nausea and vomiting. In addition, 3 (10.7%) patients

Table 1 Clinical symptoms and physical examination findingsof patients

n (%)

Symptoms

Cough 11 (39.3)Fever 10 (35.7)Abdominal pain 8 (28.6)Nausea 7 (25.0)Vomiting 7 (25.0)Haemoptysis 4 (14.3)Chest pain 3 (10.7)Asymptomatic 3 (10.7)Shortness of breath 5 (17.9)Purulent sputum 3 (10.7)Weight loss 2 (7.1)Urticaria 2 (7.1)

Physical examination findingsDecreased breath sounds 11 (39.3)Pulmonary crackle 4 (14.3)Hepatomegaly 2 (7.1)Hepatosplenomegaly 1 (3.6)Convulsions 2 (7.1)Abdominal mass 1 (3.6)Normal 9 (32.1)

were asymptomatic and they were diagnosed incidentally.Two of these patients who were admitted to hospital becauseof chest pain, were diagnosed during transthoracicechocardiographic examination. Another patient wasdiagnosed with abdominal ultrasonography which wasperformed after trauma. Most common physical findingwas decreased breath sounds. Pulmonary crackle,hepatomegaly, hepatosplenomegaly, convulsions andabdominal mass were detected as other findings. Physicalexamination was found completely normal in 9 (32.1%)patients. But history and radiographic images of thesepatient support HD. Patients' clinical symptoms andphysical examination findings are summarised inTable 1.

According to localisation; HD was found in as follows:20 (71.4%) liver, 16 (57.1%) lungs, 2 (10.7%) spleen, 2(7.1%) heart, 2 (10.7%) brain, 1 (3.6%) pancreas, 1 (3.6%)kidney and 1 (3.6%) pelvis. While 5 (17.9%) patients hadonly lung involvement; in 10 (35.7%) patients cysts were

Childhood Hydatid Disease164

seen in only liver. Hydatid disease was detected in 37.5%(6/16) right lobe, 37.5% (6/16) left lobe and 25% (4/16)both lobes of lungs. In addition it was found in 45% (9/20)right lobe, 40% (8/20) left lobe and 15% (3/20) both lobesof liver (Table 2). Some radiographic imaging of patientswith hydatid cyst are presented in Figures 1-4.

Echinococcus IHA was not performed in 2 patients whowere previously diagnosed at another hospital. This testwas found positive in 69.2% (18/26) of the patients.

Treatment modalities were as follows: 60.7% (17/28)surgical treatment, 14.3% (4/28) interventional radiologicdrainage, 21.4% (6/28) only medical treatment and 3.6%

Table 2 Localisation of cyst hydatid lesions

Localisation n (%)

Liver 10 (35.7)

Lung 5 (17.9)

Liver+Lung 7 (25.0)

Liver+Lung+Spleen 1 (3.6)

Liver+Lung+Heart+Spleen 1 (3.6)

Lung+Renal 1 (3.6)

Liver+Lung+Pelvis 1 (3.6)

Heart+Brain+Pancreas 1 (3.6)

Brain 1 (3.6)

Figure 1 Contrast enhanced CT coronal refomatted imageshows hepatic and splenic hydatic cysts (arrows).

Figure 2 A 9-year-old girl, coronal reformatted contrast-enhanced CT reveals a thick-walled right renal hydatic cyst(arrows).

Figure 3 Axial contrast-enhanced CT; liver hydatic cyst, wallcalcifications are noted.

(1/28) interventional radiology drainage and surgerytreatment together (Table 3). All patients receivedalbendazole treatment in various times and any drug sideeffects were not observed.

Post-operative complications were seen in 4 (14.3%)


patients. While bile leakage and cholangitis occurred in 2patients with hepatic hydatid cysts, pneumothorax and lungfistula were seen in 1 patient with pulmonary hydatid cysts.Post-operatively infected cyst was detected in 1 (3.6%)patient. Additionally during preoperative period, cyst wasinfected in 5 (17.9%) patients with lung hydatid cyst.

No mortality occurred, but recurrence was seen in 1(3.6%) patient with brain hydatid cyst. This patient wasoperated and received albendazole treatment for 6 months.After the surgery, the cyst had completely disappeared.However, one year after operation, cyst occurred in thebrain again. The patient was operated on a second timeand received albendazole treatment for 6 months. The cystdisappeared at the end of therapy.

Treatment failure was detected in 1 patient with kidneyhydatid cyst who received only medical treatment. Surgicalfeatures, postoperative complications and recurrence aresummarised in Table 4.

Discussion

Hydatid disease is a parasitic infection which is causedby larval form of the genus Echinococcus. Most responsiblespecies are Echinococcus granulosus and Echinococcusmultilocularis. It is a major health problem in some areaswhere farming is widespread.3 This disease may be acquiredin childhood, however diagnosis may be delayed due tolong incubation period. In literature many centers report

their experience of childhood HD.6-13 In this study, we aimedto evaluate our experience of childhood HD and to compareour results with previous studies.

Hydatid disease is more frequently reported in boys thangirls. This difference was considered due to more contactwith animals in boys.14 We reported a history of animalcontact was found in 35% of boys and 25% of girls. Ourstudy supports the hypothesis above.

Although HD may be seen in many organs; liver andlungs are commonly involved. Lungs are affected moreoften than liver in children.11,15 Hepatic involvement is mostfrequently seen in adults.3 In addition cysts may be detectedatypical in locations such as heart, brain, spleen, pancreas,kidney, eye and pelvis. Çaklr et al analysed 41 pediatricpatients with HD which was detected in 37% lungs, 35%liver, 17% both lungs and liver, 5% spleen, 2% both spleenand heart, 2% brain, 2% both brain and heart. Hydatid cystswere identified in 29% right lobe, 15% left lobe and 10%both lobes of lungs. In addition 34% right lobe, 12% leftlobe and 7% both lobes of liver involvement were seen inchildren.11 However there were some studies showingopposite results.6,9 In Tiryaki et al's study 101 children whowere operated because of hydatid cysts were examinedretrospectively. They found HD in 32% lungs, 48% liver,16% both lungs and liver, 2% spleen, 1% retrovesical and1% retroperitoneal region.9 Djuricic et al's study included149 children with 272 hydatid cysts. They reported HDwas detected in 60.7% liver, 30.1% lungs and 9.2% otherlocalisations (omentum, peritoneum, intestine, spleen,

Figure 4 CT of thorax axial images in soft tissue (A) and lung (B) window demonstrate ruptured lung hydatic cyst. Detached membrans(arrows) and fulid collections and right sided pneumothorax (asterisk) is visible.


kidney, abdomen, heart, pancreas and abdominal wall). Bothlungs and liver involvement were identified in 9 (6.0%)patients.6 We found liver was more frequently affected thanlungs and some cysts were detected in atypical localisation.

In our study cardiac involvement was found in 2 patients.In literature cardiac hydatid cysts are rare and it is reported0.2-3% of all cases. The most common affected areas arethe left (75%) and right ventricles (18%) and theinterventricular septum.16 In our patients, left ventricle andinterventricular septum involvement were detected. Bothpatients had also operated and they were completelyrecovered.

This disease may have different number of cyst. As singlecyst may be detected in single organ, multiple cysts mayoccur in multiple organs. Djuricic et al identified single cystin 59 patients, multiple organ involvement was seen in 18children. Additionally in 24 patients, multiple cysts weredetected in the same organ.9 In our study, 16 patients hadone organ involvement and single cyst was found in singleorgan in 10 patients. Our study supports single cysts aremore common in children.

Clinical manifestations of HD may be seen according to

Table 3 Treatment modalities in patients with hydatid cyst

n (%)

Liver

Surgery + medical 11 (68.8)Only medical 5 (31.3)

Liver

Surgery + medical 5 (25.0)PAIR+ medical 6 (30.0)Only medical 9 (45.0)

Pelvis

Only medical 1 (100.0)

Spleen


Heart


Renal

Surgery + medical 1 (100.0)

Brain

Surgery + medical 2 (100.0)PAIR: puncture-aspiration-injection-reaspiration

Table 4 Surgical features, postoperative complications andrecurrence

Surgery features PAIR Surgery Only medical

Postoperative complications

Bile leakage+cholangitis 1 1 0

Pneumothorax+fistula 0 1 0

Infection 1 0 0

Recurrence 0 1 0PAIR: puncture-aspiration-injection-reaspiration

localisation, size, number and condition of cyst. Whileabdominal pain, vomiting, hepatomegaly, obstructivejaundice may occur in hepatic hydatid cysts; cough, fever,dyspnea, haemoptysis and chest pain may be seen inpulmonary hydatid cysts. Symptoms may appear early inlungs and brain tissue because of weak tissue support.17

Oral et al found abdominal pain, tenderness, abdominal massand fever were common symptoms in hepatic hydatidcysts.7 Tiryaki et al detected abdominal pain and cough werethe most prevalent clinical findings.9 In our study, patientswere frequently admitted to hospital with abdominal pain,cough, and fever. Although liver was more often affectedthan lungs, patients were frequently admitted to hospital withpulmonary symptoms. It supports that clinical symptomsoccur earlier in lungs. Brain hydatid cysts may causeheadache, seizures, nausea, vomiting, increased intracranialpressure syndrome and cranial nerve palsy. Our patients withbrain HD had headache and seizures.

Chest X-ray may show pulmonary hydatid cysts and givesinformation whether the cyst is intact, ruptured and rupturingof cysts indicates specific radiologic findings like "meniscussign and snake sign". Ultrasonography is useful test fordiagnosis and follow up. According to the WHOclassification; cysts are seen in 5 stages. Type I cysts areunilocular and simple which may contain uniform anechoiccontent. Type II cysts are multivesicular and multiseptated.Daughter cysts may fill the unilocular mother cyst. TypeIII cysts are uniocular and they may contain daughter cystsand echoic areas. Type IV cysts show heterogeneous echopattern; and type V cysts have a calcified wall.18 Otherimaging techniques such as computed tomography (CT),echocardiography and MRI are used to identify detailedanatomical location and appearance of cysts (daughter cysts,ruptured or calcified cysts).19 In this study, tests above weresufficient for diagnosis.

There is no consensus about ideal serological test forHD. Echinococcus IHA, specific immunoglobulin (Ig)E,


IgM, and IgG enzyme-linked immunosorbent assay, latexagglutination or immunoelectrophoresis tests are used forsupporting the diagnosis. Serologic titers may be increaseddue to antigen release within 3 months after surgery.Immunoelectrophoresis, specific IgE and IgM antibodytitres reduce and become negative within the postoperativesecond year. If recurrence occurs, their levels rise again.Serum IgG titer remains positive for a long time aftersuccessful operation.20,21 Because of all these reasons, useof serological tests for diagnosis and evaluation the responseof treatment may lead to false results. In this study,Echinococcus IHA was 78% positive. Specific IgE, IgMand IgG tests were not used routinely for diagnosis andfollow-up.

Medical, surgical treatment and PAIR are used fortherapy. Surgery is the first choice treatment for cysts whichhave following criteria: large cysts with multiple daughtercysts, superficial location amenable to rupture, cystcompressing the neighboring organs and cysts in atypicallocations such as brain, bones, spleen, kidneys, heart.22-24

In this study, surgery was the most preferred treatmentmodality. Antimicrobial treatment (albendazole ormebendazole) is given to prevent the spread of protoscolexinto the abdominal cavity during surgery and it is startedone week before the surgery and continued until at leastpostoperative four weeks.25

While postoperative complications are reported in lessthan 1% of cases; recurrence is seen 2-25% in literature.26,27

In Ran et al's study 26 children who underwent radicalsurgery were compared with 86 pediatric patients withconservative surgery. They found that biliary complicationsand recurrence were more commonly seen in conservativesurgery group than in radical surgery group. However, therewas no significant difference between these groups.28 Inour study post-operative complications after treatment weredetected in 14.3% of the patients.

Recurrence was seen in 1 (3.6%) patient with brain HD.The patient was admitted with seizures and vomiting toour hospital. Brain CT showed cyst in the right parietalregion of the brain and she was successfully operated.However five months after the operation, she was admittedagain with seizures and headache. Radiologic imagingshowed hydatid cyst in right occipital region of brain. Thepatient was operated again and on follow up hydatid cystdid not occur again. Although recurrence is seen very rarelyin the literature, some cases with recurrent HD were reportedat the postoperative period.29,30

In one patient with kidney hydatid cyst who had receivedonly medical treatment, the size of the cyst was increased

and it was considered treatment failure. The patient wasoperated and there were no complications during follow-up. Mortality has also been reported rarely. Jordanova etal's study included 2005 children and 7366 adult patientswith HD. They detected 3 patients died due to anaphylaxiswhich occurred after spontaneous rupture of cysts.31 In ourstudy, there was no mortality.

In conclusion, HD should be considered in patientswith suspicious clinical and radiological findings inendemic areas. According to affected organs, clinicalsigns may vary. Multi organ involvement should beconsidered. Advanced imaging methods such asabdominal ultrasonography, echocardiography and brainMRI should be performed in all patients for the detectionof atypically located cyst. Serological tests may be usedfor supporting the diagnosis. Clinical results aresatisfactory with adequate treatment.

References

1. Tuazon AO, Pasterkamp H. Hydatid disease of the lung(pulmonary hydatidosis). In: Chernick V, Boat TF, Kendig EL,editors. Kendig's disorders of the respiratory tract in children.Philadelphia (PA): WB Saunders 1998:1050-7.

2. Ammann RW, Eckert J. Cestodes. Echinococcus. GastroenterolClin North Am 1996;25:655-89.

3. Anadol D, Özçelik U, Kiper N, Göçmen A. Treatment of hydatiddisease. Paediatr Drugs 2001;3:123-5.

4. Uysal A, Gürüz Y, Köktürk O, et al. Türk Toraks Derne i ParaziterAkci er Hastallklarl Tanl ve Tedavi Uzla l Raporu. TurkishThoracic Journal 2009,10;Suppl B (in Turkish).

5. Khuroo MS, Wani NA, Javid G, et al. Percutaneous drainagecompared with surgery for hepatic hydatid cysts. N Engl J Med1997;337:881-7.

6. Djuricic SM, Grebeldinger S, Kafka DI, Djan I, Vukadin M,Vasiljevic ZV. Cystic echinococcosis in children - the seventeen-year experience of two large medical centers in Serbia. ParasitolInt 2010;59:257-61.

7. Oral A, Yigiter M, Yildiz A, et al. Diagnosis and management ofhydatid liver disease in children: a report of 156 patients withhydatid disease. J Pediatr Surg 2012;47:528-34.

8. Celik M, Senol C, Keles M, et al. Surgical treatment of pulmonaryhydatid disease in children: report of 122 cases. J Pediatr Surg2000;35:1710-3.

9. Tiryaki T, enel E, Akblylk F, Mambet E, Livanelioôlu Z, AtayurtH. 10 years experience in hydatic cyst disease of childhood.Turkhis J Pediatr Dis 2008;2:19-25.

10. Ulkü R, Onen A, Onat S. Surgical treatment of pulmonary hydatidcysts in children: report of 66 cases. Eur J Pediatr Surg 2004;14:255-9.

11. Çaklr D, Çelebi S, Gürplnar A, A ln M, Bozdemir E . Evaluationof Cases with Hydatid Diseases. J Pediatr Inf 2009;3:104-8.

12. Öztürk H, Öztürk H, Otçu S, Önen A, Duran H. Çocuklarda hidatikhastallk: 49 olgunun analizi. Ulusal Cerrahi Dergisi 2006;22:17-20.


13. Ylldlz B, en S, Bal Z, Erdo an DD, Korkmaz M, Vardar F.Epidemiological, laboratory and clinical features of childhoodhydatid disease. J Pediatr Inf 2013;7:53-6.

14. Tantawy MI. Hydatid cysts in children. Ann Pediatr Surg 2010;6:98-104.

15. Chaouachi B, Nouri A, Ben Salah S, Lakhoua R, Saied H. Hydatidcyst of the lung in children. Apropos of 643 cases. Pediatrie 1988;43:769-73.

16. Gocen U, Atalay A, Basturk Y, Topcuoglu MS, Yaliniz H, SalihOK. Urgent surgery for cardiac hydatid cyst located ininterventricular septum. Asian Cardiovasc Thorac Ann 2014;22:965-7.

17. Kammerer WS, Schantz PM. Echinococcal disease. Infect DisClin North Am 1993;7:605-18.

18. WHO Informal Working Group. International classification ofultrasound images in cystic echinococcosis for application inclinical and field epidemiological settings. Acta Trop 2003;85:253-61.

19. Hesse AA, Nouri A, Hassan HS, Hashish AA. Parasiticinfestations requiring surgical interventions. Semin Pediatr Surg2012;21:142-50.

20. Zarzosa MP, Orduña Domingo A, Gutiérrez P, et al. Evaluationof six serological tests in diagnosis and postoperative control ofpulmonary hydatid disease patients. Diagn Microbiol Infect Dis1999;35:255-62.

21. Galitza Z, Bazarsky E, Sneier R, Peiser J, El-On J. Repeatedtreatment of cystic echinococcosis in patients with a long-termimmunological response after successful surgical cyst removal.Trans R Soc Trop Med Hyg 2006;100:126-33.

22. Brunetti E, Kern P, Vuitton DA. Writing Panel for the WHO-IWGE. Expert consensus for the diagnosis and treatment of cystic

and alveolar echinococcosis in humans. Acta Trop 2010;114:1-16.

23. Brunetti E, White AC Jr. Cestode infestations: hydatid diseaseand cysticercosis. Infect Dis Clin North Am 2012;26:421-35.

24. Mushtaque M, Mir MF, Malik AA, Arif SH, Khanday SA, DarRA. Atypical localizations of hydatid disease: experience from asingle institute. Niger J Surg 2012;18:2-7.

25. Manterola C, Mansilla JA, Fonseca F. Preoperative albendazoleand scolices viability in patients with hepatic echinococcosis.World J Surg 2005;29:750-3.

26. Junghanss T, da Silva AM, Horton J, Chiodini PL, Brunetti E.Clinical management of cystic echinococcosis: state of the art,problems, and perspectives. Am J Trop Med Hyg 2008;79:301-11.

27. World Health Organization (WHO) Informal Working Group ofEchinococcosis. Puncture, aspiration, injection, re-aspiration. Anoption for the treatment of cystic echinococcosis. Geneva: WorldHealth Organization 2001:1-40.

28. Ran B, Shao Y, Yimiti Y, et al. Surgical procedure choice forremoving hepatic cysts of Echinococcus granulosus in children.Eur J Pediatr Surg 2015. [Epub ahead of print] PubMed PMID:26479421.

29. Aleksic-Shihabi A, Vidolin EP. Cystic echinococcosis of the heartand brain: a case report. Acta Med Okayama 2008;62:341-4.

30. Ranjan R, Chowdhary P, Pandey A, Mishra S, Madan M.Recurrent hydatid cyst of liver with asymptomatic concomitanthydatid cyst of lung: an unusual presentation-case report. Iran JParasitol 2015;10:136-40.

31. Jordanova DP, Harizanov RN, Kaftandjiev IT, Rainova IG,Kantardjiev TV. Cystic echinococcosis in Bulgaria 1996-2013,with emphasis on childhood infections. Eur J Clin Microbiol InfectDis 2015;34:1423-8.


Overweight and Obesity in Children Under PhenylalanineRestricted Diet

Y OZTURK, P GENçPINAR, B ERDUR, Y TOKGöZ, I I IK, SB AKIN

Abstract Introduction: The aim of this study is to determine the obesity and overweight frequency in children withphenylketonuria (PKU) and hyperphenylalaninaemia (HPA). Methods: From the patients' demographicdata, diagnosis, type of diet, weight for height, body mass index, serum phenylalanine concentrationswere obtained and recorded. Results: Four hundred and forty charts were evaluated and 288 of themwere enrolled in the study. Two hundred and forty-six (85.4%) were under phenylalanine-restricted dietwith protein support. Of those, 23 (9.3%) were obese and 16 (6.5%) were overweight. When we comparedthe obesity ratio of 246 patients with PKU and HPA to the obesity ratio in the Turkish population, thedifference was statistically significant (p=0.025). Conclusion: The frequency of obesity was higher inPKU and HPA children who underwent phenylalanine-restricted diet treatment than in the normalpopulation in Turkey. Detailed studies are needed to increase the understanding of the obesity risk factorsin this special disorder group.

Key words Hyperphenylalaninaemia; Obesity; Overweight; Phenylalanine restricted medical diet; Phenylketonuria

Dokuz Eylul University, Department Pediatric Gastroenterologyand Metabolism, Izmir/Turkey

Y OZTURK Professor of Pediatrics, MDSB AKIN MD

Tepecik Training and Research Hospital, Department ofPediatric Neurology, Izmir/Turkey

P GENçPINAR MD

Behcet Uz Children Hospital, Department PediatricGastroenterology, Izmir/Turkey

B ERDUR MD

Adnan Menderes University, Department PediatricGastroenterology, Aydin/Turkey

Y TOKGöZ MD

Antalya Training and Research Hospital, DepartmentPediatric Gastroenterology, Antalya/Turkey

I I IK MD

Correspondence to: Prof. Dr. Y OZTURK


Received August 23, 2015

Original Article

Introduction

Phenylalanine is an essential amino acid and most of itis converted into tyrosine by phenylalanine hydroxylase. Forthis chemical reaction, oxygen and tetrahydrobiopterine areneeded, as well as the enzyme activity. If the enzyme orcofactor is deficient, phenylalanine levels are increased inthe blood and clinical symptoms such as motor and mentalretardation, convulsions, microcephaly and behaviouralproblems may develop. Phenylalanine-restricted diet isthe most effective treatment.1,2 It is thought that, obesityor overweight is a potential risk in these cases, sincethe daily calorie is supplied by fats and carbohydratesand, related eating behavioural problems in thisdisorder.3,4

The purpose of this study is to determine theobesity and overweight frequency in children withphenylketonuria (PKU) and hyperphenylalaninaemia(HPA), who are also under phenylalanine-restricted diettreatment.

Obesity in Phenylalanine-restricted Diet170

Methods

All patients with PKU and HPA, which were followedby Dokuz Eylul University Pediatric Metabolic DiseaseDepartment, were evaluated retrospectively. PKU definedas 'phenylalanine level is 6-10 mg/dl despite 400-600 mg/day phenyla lanine intake' , and HPA defined as'phenylalanine level is <10 mg/dl despite >600 mg/dayphenylalanine intake'. There was no patient, who wasdiagnosed with BH4 (tetrahydrobiopterin) metabolismdisorders. From the patients' medical records, demographicdata, diagnosis, type of medical diet, weight for height, bodymass index (BMI), serum phenylalanine, T4, TSH, insulinand cortisol levels were obtained and recorded. Weight forheight and BMI were evaluated by relevant percentiles ofthe gender.5 Weight for height was used for the patients0-36 months old and BMI was used for the patients olderthan 36 months. According to these evaluations, lower than85th percentile was considered as normal, 85-97th percentilewas considered as overweight and higher than 97th percentilewas considered as obese.

Statistical Analysis

Statistical evaluation was performed by using SPSSsoftware (version 15.0, SPSS Inc, Chicago, IL). Mann-Whitney U test was used to compare average values of thegroups, exact Chi-square test or Fisher's exact test was usedto compare rational values of the groups. Binominal testwas used to compare obesity or overweight data withpopulation data. p<0.05 values were regarded as statisticallysignificant.

Results

Four hundred and forty charts were evaluated and 288of them had complete records and were enrolled in thestudy. The follow-up duration was between 2.5-5 years.The rest of them were excluded because of missinginformation of patients such as anthropometricmeasurements and inadequate follow-up. All patients werereferred from the newborn screening program. There wasno responsive patient to 48-hour BH4 loading test. Thepatients were under phenylalanine-restricted diet by usingPKU-formula without support of BH4.

Of the 288 patients, 141 (49%) were female and 147(51%) were male. Two hundred and forty-six (85.4%) wereunder phenylalanine-restricted diet with protein support.Of those, 39 (15.9%) were obese (n=23) and overweight(n=16).

Mean age for obesity/overweight diagnosis was 7.50±5.10 years, and their PKU and HPA diagnosis age was1.7±0.8 months. Of the 23 obese patients, 22 were PKUand one was a HPA patient.

When the obese/overweight and non-obese PKU childrenwho underwent phenylalanine-restricted diet treatmentgroups were compared individually, no statisticalsignificance was present on gender, recommended proteinsupplement doses, phenylalanine and protein amounts ondiet (Table 1). When the obesity ratio of the 246 patientswith PKU and HPA was compared to the overall Turkishpopulation obesity ratio,6 the difference was statisticallysignificant (p=0.025). Mean blood phenylalanineconcentration in the obese/overweight group was 10.70±5.70 mg/dl, and this was 9.70±7.71 in the non-obese group.The difference was not statistically significant (p=0.156).

Table 1 Comparison of clinical, demographic features in obese and non-obese children with phenylketonuria (PKU)/hyperphenylalaninaemia (HPA) who underwent phenylalanine-restricted diet (n=246)

Obese/owerweight Non-obese p values

(n=39) (n=207)

Age of the children at the time of diagnosis PKU/HPA (mean±SD; months) 1.7±0.8 1.9±1.5 0.41

Gender (F/M) 99/108 20/19 0.60

Recommended PA concentration in dietary (mg/kg/day) 28,1±20,2 26,3±13,2 0,782

Recommended natural protein in dietary (g/day) 1,2±0,3 1,5±0,4 0,437

Mean serum phenylalanine concentrations (mg/dl) 10.7±5.7 9.7±7.7 0.156

Age of the children at the time of diagnosis obesity/overweight (mean±SD;years) 7.5±5.1

Ozturk et al 171

Regarding to blood phenylalanine level and increasedobesity risk, conflicting results have been obtained in theliterature. In Robertson et al's study, a positive correlationwas found between blood phenylalanine levels and BMI;however, no correlation was found in the study carried outon Spanish children with PKU.10,11 In our study, we alsohave found a correlation between blood phenylalanineconcentrations and BMI values in obese/overweightchildren with PKU/HPA who underwent phenylalanine-restricted diet treatment.

The effect of phenylalanine-restricted diet on patients'metabolism is not clear. One of the most popularexplanations is increased carbohydrate intake.10,12 Robertsonet al stated that they, especially adult patients, consume muchmore instant foods, prefer fatty food instead of freshvegetables and fruits and were not willing to exercise. Moreinterestingly, studies on patients on diet show that calorieintake were very close or lower than suggested calorieintake.1,13 But the latest data suggest patients' declarationsmay not be trustworthy. Therefore, dietary compliance maybe followed by growth charts, BMI and/or weight for height.Limitations of our study are the retrospective design, andlimited data about dietary compliance and daily exerciselevels.

The frequency of obesity, an important health problem,is increasing. In the literature, there are very few studiesevaluating obesity and overweight frequencies in PKUpatients. According to our results, children with PKU underphenylalanine-restricted diet are at risk for obesity.

Acknowledgments

This work was done at Dokuz Eylul University Schoolof Medicine. There was no assistance or efforts beyondthose of the primary authors. This work has not beenpresented or published elsewhere.

Authors Contributions

PG prepared the manuscript. BE, YT, I, SBA collectedthe data. YO is co-corresponding author.

There was a correlation between individual mean bloodphenylalanine concentration and individual mean BMI value(r=0.362; p=0.023) in the obese/overweight group.

Discussion

Obesity is a very important health problem and itsfrequency is increasing worldwide. According to dataprovided by the Ministry of Health of the Republic ofTurkey, the frequency of obesity among children hasincreased ten-fold compared with the frequency in theseventies. In a study named "The Pro Children", which wascarried out in 9 countries in Europe in 2003, the frequencyof overweight was found to be 17% in males and 14% infemales.7 In the United States, prevalence of obesity amongchildren 2-19 years old was reported to be 16.3-17%.8,9

There are few studies about obesity prevalence amongchildren with PKU and on a phenylalanine-restricted diet.In a study of 236 adults with PKU, the percentages ofparticipants reported having obesity or overweight, were31% and 24%, respectively.10 Although those ratios are inaccordance with their normal population values, they aretwo-fold the values that are obtained from previouslymentioned larger studies. In a study carried out in Spain,160 children with PKU were evaluated and, it was foundthat girls older than 13 years have significantly higherBMI.11 In a study that evaluates 87 PKU patients fromUnited States, it is reported that girls have two-fold thefrequency of obesity and overweight.12 In our study, we couldnot find difference between males and females.

In a study that was carried out in 0-18 year-old children,in our country in 2010, the frequency of obesity was 6.9%,and overweight was 14.4%.6 Subsequent to comparison ofthese results, we found that obesity frequency is increasedin children with PKU. We speculate that, phenylalanine-restricted medical diet with protein supplements and eatingdisorders which are associated with PKU may beresponsible for this increased obesity frequency. However,we currently have no direct evidence to support this thought.Among important limitations of this study, there is noassessment of dietary energy intake of subjects. However,we can say for now, it should be kept in mind that generalrisk factors for obesity are also relevant for the PKU patientgroup.

Obesity in Phenylalanine-restricted Diet172

Declaration of Conflicting Interest

The authors declared no potential interest with respectto the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research,authorship, and or publication of this article.

Ethical Approval

The local ethics committee approved this study.

References

1. Schulz B, Bremer HJ. Nutrient intake and food consumption ofadolescents and young adults with phenylketonuria. Acta Paediatr1995;84:743-8.

2. Rose HJ, White F, Macdonald A, Rutherford PJ, Favre E. Fatintakes of children with PKU on low phenylalanine diets. J HumNutr Diet 2005;18:395-400.

3. MacDonald A, Harris G, Rylance G, Asplin DA, Booth IW.Abnormal feeding behaviours in phenylketonuria. J Hum NutrDiet 1997;10:163-70.

4. MacDonald A, Rylance GW, Asplin DA, Hall K, Harris G, BoothIW. Feeding problems in young PKU children. Acta Paediatr 1994;407:73-4.

5. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC GrowthCharts for the United States: methods and development. VitalHealth Stat 2002;11:1-190.

6. Türkiye Beslenme ve Sa llk Ara tlrmasl. Beslenme Durumu veAl kanllklarlnln De erlendirilmesi Sonuç Raporu. T.C. Sa llkBakanll l Yayln No:931;2010.

7. Yngve A, De Bourdeaudhuij I, Wolf A, et al. Differences inprevalence of overweight and stunting in 11-year olds acrossEurope: The Pro Children Study. Eur J Public Health 2008;18:126-30.

8. Centers for Disease Control and Prevention. National Health andNutrition Examination Survey 2003-2006. Hyattsville (MD): USDepartment of Health and Human Services. http://www.cdc.gov/nchs/nhanes.htm. Last access: 15 November 2014.

9. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ,Flegal KM. Prevalence of overweight and obesity in the UnitedStates, 1999-2004. JAMA 2006;295:1549-55.

10. Robertson LV, McStravick N, Ripley S, et al. Body mass index inadult patients with diet-treated phenylketonuria. J Hum Nutr Diet2013;26:1-6.

11. Belanger-Quintana A, Martinez-Pardo M. Physical developmentin patients with phenylketonuria on dietary treatment:a retrospective study. Mol Genet Metab 2011;104:480-4.

12. Burrage LC, McConnell J, Haesler R, et al. High prevalence ofoverweight and obesity in females with phenylketonuria. MolGenet Metab 2012;107:43-8.

13. Acosta PB, Yannicelli S, Singh R, et al. Rouse, Nutrient intakesand physical growth of children with phenylketonuria undergoingnutrition therapy. J Am Diet Assoc 2003;103:1167-73.


The Clinical and Molecular Spectrum of 15q DuplicationSyndrome in Chinese

HM LUK, IFM LO

Abstract 15q duplication syndrome (OMIM #608636) is a neurodevelopmental disease that characterised byhypotonia, developmental delay, intellectual disability, epilepsy and distinctive facial gestalt. A territory-wide study of 15q duplication syndrome is performed in Hong Kong with aim to examine its clinical andmolecular features among Chinese patients. There are total of 12 cytogenetically and molecularly confirmedindividuals between the period of January 2011 and December 2015. Four of them have interstitialduplication and 8 of them have isodicentric chromosome 15. The prevalence of 15q duplication syndromein our Chinese cohort with intellectual disability and autistic spectrum disease is estimated to be 1.0%and 2.9%, respectively. As compared with western population, epilepsy is less common while squint ismore prevalent in our Chinese patients. However, no genotype-phenotype correlation can be demonstratedin this study. Conclusion: The prevalence and clinical features of 15q duplication syndrome patients inHong Kong Chinese are comparable with other western populations. It is hope that by having the betterunderstanding of its underlying pathomechanism and their genotype-phenotype correlation would leadto better management and genetic counselling for patient with 15q duplication syndrome.

Key words 15q duplication syndrome; Chinese; Interstitial duplication 15q11-q13; Isodicentric chromosome 15

Clinical Genetic Service, Department of Health, 3/F,Cheung Sha Wan Jockey Club Clinic, 2 Kwong Lee Road,Shamshuipo, Kowloon, Hong Kong SAR, China

HM LUK MBBS(HK), FHKCPaed, FHKAM(Paed)IFM LO MBChB(HK), FHKCPaed, FHKAM(Paed)

Correspondence to: Dr HM LUK



Original Article

Introduction

The chromosome 15q11-q13 region is a compleximprinted region that prone to genomic rearrangement.Within this region, some genes are only expressed on thematernally inherited chromosome 15, like UBE3A andATP10C; while other genes are only expressed on thepaternally inherited chromosome 15, like MKRN3,MAGEL2, NDN, C15orf2, SNURF-SNRPN. Moreover, this

region harbours five duplicons or breakpoints (BP) thatconsisted of large segment low copy repeats (LCR).1,2

Through non-allelic homologous recombination andU-type crossover mechanism,3 various forms of deletion,duplications, triplications, translocations, and supernumerarymarker chromosomes (SMC) at proximal chromosome 15qregion would result. Depend on the parent-of-origin and thesize of rearrangement, such genomic rearrangement wouldlead to Angelman syndrome, Prader-Willi syndrome and 15qduplication syndrome.

15q duplication syndrome (OMIM #608636) is aclinically recognisable neurogenetic syndrome. It is causedby either interstitial duplication of chromosome 15q11.2or extra isodicentric chromosome 15(idic(15)(p11.2-13.3)).3The clinical features included hypotonia, developmentaldelay, intellectual disability, epilepsy and distinctive facialgestalt. Most affected individuals would meet the diagnosticcriteria of autism or autism spectrum disease. Apart fromthat, some would also develop behavioural problems likeanxiety disorder and attention deficit hyperactivity

15q Duplication Syndrome in Chinese174

disorder.3,4 The prevalence of 15q duplication syndromein autism cohort is estimated to be 1-3% in early studies.5,6

However, the prevalence, comprehensive clinical spectrumand molecular study of 15q duplication syndrome havenever been reported in Chinese.

The aim of this study is to summarise the clinical andgenetic findings of all cytogenetically and molecularlyconfirmed 15q duplication syndrome patients in Hong KongChinese.

Patients and Method

The Clinical Genetic Service (CGS) of Department ofHealth is the only government funded tertiary geneticreferral center that provides comprehensive geneticcounselling, diagnostic and laboratory service for the wholeof Hong Kong population. More than 95% of populationin Hong Kong is ethnic Chinese. Patients with suspectedgenetic or syndromic cause of intellectual disability andautism or autism spectrum disease (ASD) are referred forclinical assessment and genetic testing.

In this study, all records of patients with geneticallyconfirmed 15q duplication syndrome between January 2011and December 2015 under CGS are retrieved from thecomputer database system. The clinical and laboratory dataof these patients are being analysed. The diagnosis ofintellectual disability, autism and autistic spectrum diseaseare made by paediatricians, developmental paediatricians,clinical psychologists or child psychiatrists.

Cytogenetic and Molecular StudyThe diagnosis of 15q duplication syndrome is confirmed

either by standard cytogenetic G banding technique withfluorescence in situ hybridization (FISH) method or arrayComparative Genomic Hybridization (aCGH) study.Further molecular studies like microsatellite analysis withparental DNA or methylation-specific multiplex ligationdependent probe amplification (MS-MLPA) is used todelineate the parent-of-origin of the 15q duplication.

MLPAPatients are screened for rearrangements involving the

15q11-q13 region with the ME028 PWS/AS (MRC-Holland, Amsterdam, The Netherlands). The copy numberchange and methylation status is detected by methylation-sensitive restriction enzyme. Analysis of the MS-MLPAPCR products is performed on an ABI3500 Genetic Analyserusing the GeneMapper software (Applied Biosystems, FosterCity, Calif., USA). For copy number analysis, the datagenerated are being intra-normalised by dividing the peakarea of each amplification product by the total area of thereference probes. The ratios are then obtained by dividingthe intra-normalised probe ratio in a sample by the averageintra-normalised probe ratio of all reference runs. Formethylation analysis, the intra-normalised peak area of eachMS-MLPA probe from the digested sample is divided bythe value obtained for the undigested sample.

Fluorescence In Situ Hybridization (FISH)FISH is performed on metaphase chromosome spreads

preparations from peripheral blood. Three commercial DNAprobes that hybridize to the SNRPN locus at 15q11q13region, PML locus at 15q22 region and centromere ofchromosome 15 at 15p11.2 region from Vysis (Abbott) arebeing used. Ten metaphase cells are being examined to detectcells with loss or gain of specific signals.

Microsatellite AnalysisThe microsatellite analysis is studied by using standard

protocol. Haplotype analysis is being performed by usingeleven polymorphic markers in 15q regions (D15S219,Gabrb3, SC2, 14150, D15S217, M37, SC3, AFM262,AFM323, AFM291 and AFM164). PCR products arevisualised with a DNA sequencer and allele sizes aredetermined by using Genescan and Genotyper software(Applied Biosystems). A positive diagnosis requiredevidence of unique parental inheritance at ≥informative 2markers.

Figure 1 The diagnostic algorithm of 15q duplicationsyndrome in this study.

Luk et al 175

Array-CGHHigh-resolution whole genome analysis is performed by

using PerkinElmer CGXTM 8x60K Human Genomemicroarrays (Agilent Technologies, Santa Clara, CA). Thiscontains approximately 60 000 sixty-mer probes withresolution of 190Kb in the backbone and 28kb averageprobe spacing. Labelling is performed by using AgilentGenomic DNA enzymatic labelling kit (AgilentTechnologies, Santa Clara, CA, USA) and clean-up oflabelled genomic DNA is performed by using Amicon ultra0.5 ml centrifugal filters according to manufacturers'instructions (Millipore, Billerica, MA, USA). Slides arescanned on an Agilent scanner and processed with FeatureExtraction software (v10.7). Each patient DNA is labelledin Cy5 and sex matched reference DNA is labelled in Cy3,which then co-hybridized against the array chip. Resultsare analysed by using Agilent Genomic Workbench (v6.0and v6.5) software with the following settings: ADM2 asaberration algorithm, threshold of 6.0, moving average2 Mb. The results are according to Human Genome build19 and include imbalances with at least three consecutiveprobes with abnormal log2 ratios. All the imbalances areinterpreted by consulting the UCSC genome browser(http://genome.ucsc.edu), Decipher (Database of ChromosomalImbalance and Phenotype in Humans Using Ensembl Resources- http://decipher.sanger.ac.uk/), ClinGen (Clinical GenomeResource - https://www.clinicalgenome. org/), OMIM (OnlineMendelian Inheritance in Man - http://www.ncbi.nlm.nih.gov).

Data Analysis and Statistical CalculationEpidemiological data, physical characteristics, growth

records and molecular findings are then collected foranalysis. Clinical photographs are taken during consultationwith written consent. For statistical calculation, Fisher'sexact test is used for categorical variables. Two-tailedp-values are being computed. Differences are consideredto be statistically significant when the p-value is ≤0.05.

Results

During this 5 years' study period, a total of 1,116patients with intellectual disability and 313 patients withautism or ASD are being referred to our genetic clinicfor assessment. Twelve individuals among 10 familieswith 15q duplication syndrome are diagnosed. All areethnic Chinese. Their current age in year 2016 are rangedfrom 3 years 6 months to 34 years old, with a median of

8 years 2 months old. The male to female ratio was 1:2.Among them, 11 of them have intellectual disability and

9 of them have autism or ASD. Therefore the prevalence of15q duplication syndrome in our Chinese cohort withintellectual disability and autism or ASD is 1.0% and 2.9%,respectively.

Concerning the underlying genetic mechanism, 4 of themhave interstitial duplication and 8 have isodicentricchromosome 15. Two out of these 8 isodicentric cases arein mosaic pattern with abnormal cell lineage ranged from50% to 93%. The genomic aberration for all symptomaticcases are maternal inherited in origin, that mean theduplication occur in the maternal allele of chromosome 15.Two families with interstitial duplication are identified inthis study and the rest of the cases with genomic aberrationthat arise de novo. The clinical features of our 15qduplication cohort are summarised in Table 1. The facialprofiles of patients in this study are shown in Figure 2.

The clinical features of our Chinese patients arecompared with western populations in Table 2.7-17 It showedthat most of clinical features in our Chinese cohort includeddysmorphism, joint laxity, hypotonia, intellectual disabilityand autism are comparable with Caucasian. However,epilepsy is less common while squint is more prevalent inChinese patients with 15q duplication syndrome.

Discussion

15q duplication syndrome is a neurogenetic syndromethat frequently associated with neurodevelopmentaldisease. The prevalence of 15q11-q13 duplication inpatients with autism is widely assumed to be 1-3% basedon two early studies.5,6 With the advancement of genomictechnology like aCGH and better understanding in theassociation of copy number variation (CNV) with humandisease. It is now known that approximately 10-20% ofpatients with intellectual disability and 10% of autism orASD patients have clinical significant CNVs.18,19 In thelatest reviews and meta-analysis, it has found that 15q11-q13 duplication happened in 1% of patients with autismor ASD and 3% of patient with intellectual disability.20,21

The prevalence of 15q duplication in our Chinese cohortwith intellectual disability and autism or ASD is 1.0%and 2.9%, respectively.

Concerning on the clinical phenotype, the mostconsistent features in our study are hypotonia andintellectual disability. About two third of them have facial


dysmorphism and autism. All these are comparable withother studies in the literatures.7-17 Epilepsy occurs in 60%of 15q duplication syndrome in the latest survey by Dup 15alliance with 80% has multiple seizure types and 40% hasinfantile spasm.22 In our cohort, only 33.3% (4/12) of themhave epilepsy with tonic-clonic and focal seizure as the mostcommon seizure semiology. Only one of our patients hasinfantile spasm with the onset at 3 months of age. Despitemultiple anticonvulsant, his epilepsy is refractory thatcurrently evolving into Lennox-Gastaut syndrome. For therest of the patients, the epilepsy is well controlled by oneanticonvulsant. Despite pseudosquint are common amongChinese, true squint happen in more than 90% of our patientsthat is statistically significant different from other ethnic

groups.Chromosome 15q11-q13 region imprinting patterns and

its long range gene expression are mediated by imprintingcontrol region (ICR) that located upstream of paternaltranscription unit SNRPN gene through the UBE3A geneinteraction.23 The imprinting and parent-of-origin effect hasbeen well demonstrated by our 2 families with interstitialduplication. By methylation specific-MLPA andmicrostatellite study, the interstitial 15q 11.2 duplication inthe mothers of family 6 and family 10 in our study haveconfirmed to locate at paternal and maternal allele ofchromosome 15, respectively. The mother in family 6 withinterstitial 15q11.2 duplication in the paternal allele hasnormal phenotype, while the mother in family 10 with

Table 1 The clinical features of our 15q duplication cohort

Family Sex/ Rearrangement Origin Autism Hypotonia Intellectual Epilepsy Dysmorphism Joint Squint Othersage disability laxity

1 F/5yr 4m idic(15) M Yes Yes Moderate No No Yes Yes(p11.2-13.3)

2 F/22yr 5m idic(15) M Yes Yes Mild Tonic-clonic, Yes yes Yes Behavioural(p11.2-13.3) focal seizure since 5 yr Problems

on SSRI3 F/17yr 1m mos. idic(15) M No Yes Mild Tonic-clonic, Yes Yes Yes

(p11.2-13.3)(93%) focal seizure since 4 yr4 F/7yr 2m idic(15) M Yes Yes Moderate Infantile no Yes No Arachnoid

(p11.2-13.3) spasm since 3 m, cyst inLennox-Gastaut syndrome now MRI brain

5 F/27yr 4m mos. idic(15) M Yes Yes Severe Tonic-clonic, myoclonic, Yes Yes Yes(p11.2-13.3)(50%) focal seizure since 15 yr

6 M/3yr 6m interstitial M No Yes Mild No Yes No Yes(son) duplication

15q11.2q11.2F/38 yr interstitial P No No No No No No Yes

(mother) duplication15q11.2q11.2

7 F/4yr 9m idic(15) M Yes Yes Moderate No Yes Yes Yes(p11.2-13.3)

8 M/7yr 11m interstitial M Yes Yes Moderate No No Yes Yesduplication

15q11.2q11.29 M/7yr 1m idic(15) M Yes Yes Moderate No Yes No Yes

(p11.2-13.3)10 M/8yr 4m interstitial M yes yes Moderate No Yes No Yes

(son) duplication15q11.2q11.2

F/34 yr interstitial M No yes Mild No Yes No Yes(mother) duplication

15q11.2q11.2M: maternal; P: paternal; mos: mosaic; SSRI: selective serotonin reuptake inhibitors

Luk et al 177

inherited interstitial 15q11.2 duplication in the maternalallele has hypotonia and mild intellectual disability. Maternalduplication of the UBE3A gene is the proposed mechanismfor such imprinting effect.24,25

For the genotype-phenotype correlation, a dosage effecton 15q11-q13 copies to clinical severity has beendemonstrated in previous studies.13,16,26 The clinicalpresentation for isodicentric chromosome 15 with 4 copiesof SNRPN gene is more severe than interstitial duplicationwith 3 copies of SNRPN gene. The mitigating effect ofmosaic 15q duplication has also been reported whichdepend on the percentage and type of cell line involved.However, such correlation cannot be shown in our Chinesecohort due to small sample size. The phenotypic spectrumand severity among those isodicentric chromosome 15,interstitial duplication and mosaic isodicentric chromosome15 are similar in this study.

Concerning on recurrence risk and genetic counselling,for isodicentric chromosome 15, it usually arise denovo thatrecurrence risk in family is negligible. For interstitialduplication, the inheritance risk to offspring from affected

Figure 2 The facial profile of patients with15q duplication syndrome in our study. Patients 6, 8 and 10 have interstitial 15q duplicationwhile the rest have isodicentric chromosome 15. The dysmorphic features included high forehead, epicanthic folds, squint, short noseand depressed nasal bridge (Consents have been obtained for publication).

Table 2 The prevalence of clinical features in our Chinesecohort and comparsion with other studies in the literature7-17

Our study (total 12) Literatures P value

Autism 9 (75%) 84% (25-100%) NS

Hypotonia 11 (91.7%) 82% (72-100%) NS

Intellectual delay 11 (91.7%) 100% NS

Epilepsy 4 (33.3%) 79% (50-100%) <0.05

Dysmorphism 8 (66.7%) 73% (20-100%) NS

Joint laxity 7 (58.3%) 50% (12.5-64%) NS

Squint 11 (91.7%) 41% (25-44%) <0.05

NS: not statistically significant

proband is 50%. Due to genomic imprinting, the phenotypiceffect depends on the parent-of-origin. Duplication in thematernal allele of chromosome 15 has high risk ofdeveloping neurodevelopmental disease and epilepsy, whileduplication in the paternal allele usually phenotypicallynormal.15,18


Conclusion

This 5 years' review is the first territory-wide study of15q duplication syndrome in Chinese. It showed that theincidence and clinical features of Chinese 15q duplicationare comparable with other western populations. Theprevalence of 15q duplication in our Chinese cohort withintellectual disability and autism or autistic spectrum diseaseis 1.0% and 2.9%, respectively. Early diagnosis is importantfor managing 15q duplication patients as they have highrisk of developing epilepsy and neurodevelopmentaldisorder that anticipatory guidance from differentspecialties is essential. Genetic confirmation on theunderlying mechanism for 15q duplication is also importantfor reproductive risk assessment.

Acknowledgement

We thank all the paediatricians and physicians who havereferred their 15q duplication syndrome patients to ourservice. We are also grateful to all the laboratory staff inCGS for their technical support.

Conflict of interest

We have no conflict of interest to declare.

References

1. Christian SL, Fantes JA, Mewborn SK, Huang B, Ledbetter DH.Large genomic duplicons map to sites of instability in the Prader-Willi/Angelman syndrome chromosome region (15q11-q13). HumMol Genet 1999;8:1025-37.

2. Robinson WP, Dutly F, Nicholls RD et al. The mechanismsinvolved in formation of deletions and duplications of 15q11-q13. J Med Genet 1998;35:130-6.

3. Battaglia A. The inv dup(15) or idic(15) syndrome: a clinicallyrecognizable neurogenetic disorder. Brain Dev 2005;27:365-9.

4. Makoff AJ, Flomen RH. Detailed analysis of 15q11-q14 sequencecorrects errors and gaps in the public access sequence to fullyreveal large segmental duplications at breakpoints for Prader-Willi, Angelman and inv dup(15) syndromes. Genome Biol 2007;8:R114.

5. Cook Jr EH, Courchesne RY, Cox NJ, et al. Linkage-disequilibrium mapping of autistic disorder, with 15q11-13markers. Am J Hum Genet 1998;62:1077-83.

6. Schroer RJ, Phelan MC, Michaelis RC, et al. Autism andmaternally derived aberrations of chromosome 15q. Am J MedGenet 1998;76:327-36.

7. Robinson WP, Binkert F, Gine R, et al. Clinical and molecular

analysis of five inv dup (15) patients. Eur J Hum Genet 1993;1:37-50.

8. Mignon C, Malzac P, Moncla A, et al. Clinical heterogeneity in16 patients with inv dup 15 chromosome: cytogenetic andmolecular studies, search for an imprinting effect. Eur J HumGenet 1996;4:88-100.

9. Battaglia A, Gurrieri F, Bertini E, et al. The inv dup(15) syndrome:A clinically recognizable syndrome with altered behavior, mentalretardation and epilepsy. Neurology 1997;48:1081-6.

10. Hou JW, Wang TR. Unusual features in children with inv dup(15) supernumerary marker: A study of genotype phenotypecorrelation in Taiwan. Eur J Pediatr 1998;157:122-7.

11. Webb T, Hardy CA, King M, Watkiss E, Mitchell C, Cole T.A clinical, cytogenetic and molecular study of ten probands withsupernumerary inv dup(15) marker chromosomes. Clin Genet1998;53:34-43.

12. Wolpert CM, Menold MM, Bass MP. Three probands with autisticdisorder and isodicentric chromosome 15. Am J Med Genet 2000;96:365-72.

13. Battaglia A. The inv dup (15) or idic (15) syndrome (Tetrasomy15q). Orphanet J Rare Dis 2008;3:30.

14. Borgatti R, Piccinelli P, Passoni D, et al. Relationship betweenclinical and genetic features in "inverted duplicated chromosome15" patients. Pediatr Neurol 2001;24:111-6.

15. Crolla JA, Youings SA, Ennis S, Jacobs PA. Supernumerarymarker chromosomes in man: Parental origin, mosaicism andmaternal age revisited. Eur J Hum Genet 2005;13:154-60.

16. Dennis NR, Veltman MW, Thompson R, et al. Clinical findingsin 33 patients with large supernumerary marker-(15)chromosomes and 3 patients with triplication of 15q11-15q13.AmJ Med Genet 2006;140:434-41.

17. Valente KD, Freitas A, Fridman C, et al. Inv dup (15): is theelectroclinical phenotype helpful for this challenging clinicaldiagnosis? Clin Neurophysiol 2006;117:803-9.

18. Shishido E, Aleksic B, Ozaki N. Copy-number variation in thepathogenesis of autism spectrum disorder. Psychiatry ClinNeurosci 2014;68:85-95.

19. Miller DT, Adam MP, Aradhya S, et al. Consensus statement:chromosomal microarray is a first-tier clinical diagnostic test forindividuals with developmental disabilities or congenitalanomalies. Am J Hum Genet 2010;14;86:749-64.

20. Devlin B, Scherer SW. Genetic architecture in autism spectrumdisorder. Curr Opin Genet Dev 2012;22:229-37.

21. Cooper GM, Coe BP, Girirajan S, et al. A copy number variationmorbidity map of developmental delay. Nat Genet 2011;14;43:838-46.

22. Conant KD, Finucane B, Cleary N, et al. A survey of seizures andcurrent treatments in 15q duplication syndrome. Epilepsia 2014;55:396-402.

23. Hogart A, Wu D, LaSalle JM, Schanen NC. The comorbidity ofautism with the genomic disorders of chromosome 15q11.2-q13.Neurobiol Dis 2010;38:181-91.

24. Marshall CR, Noor A, Vincent JB, et al. Structural variation ofchromosomes in autism spectrum disorder. Am J Hum Genet 2008;82:477-88.

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26. Schinzel AA, Brecevic L, Bernasconi F, et al. Intrachromosomaltriplication of 15q11-q13. J Med Genet 1994;31:798-803.


Rare Clinical Presentation of Intestinal Malrotation AfterNeonatal Period: Protein-losing Enteropathy Symptoms

Due to Chronic Midgut Malrotation

YH FANG, SQ SHANG, J CHEN

Abstract Protein-losing enteropathy is caused by a variety of diseases. However, it is rarely caused by chronicintestinal malrotation. A 1-year-11-month old male baby and a 12-year-old female presented with chronicdiarrhoea and hypoproteinaemia. Both of the patients underwent an exploratory laparotomy, in which amidgut malrotation was discovered. Intestinal malrotation should be considered as one of the differentialswhen diagnosing protein-losing enteropathy.

Key words Diarrhoea; Hypoproteinaemia; Intestinal malrotation; Laparotomy

Department of Gastroenterology, Children's Hospital,Zhejiang University School of Medicine, 3333 Bin ShengRoad, Hangzhou 310052, China

YH FANG MDJ CHEN MD

Department of Clinical Laboratory, Children's Hospital,Zhejiang University School of Medicine, 3333 Bin ShengRoad, Hangzhou 310051, China

SQ SHANG MSc

Correspondence to: Dr J CHEN, Dr SQ SHANG

Email: [email protected]; [email protected]

Received August 14, 2016

Case Report

Introduction

Intestinal malrotation is a congenital anomaly, whichis mainly diagnosed during infancy. The presentingmalrotation symptoms are mainly bilious vomiting,abdominal distention, and incomplete or complete intestinalobstruction. Protein-losing enteropathy (PLE) is rarelycaused by chronic intestinal malrotation. Here, we presenttwo cases, a 1-year-11-month old male baby and a 12-year-old female, who presented with chronic diarrhoea andhypoproteinaemia. Both of the patients underwent anexploratory laparotomy, which confirmed midgutmalrotation.

Case Report

Case one was a 1-year-11-month old male baby with achief complaint of recurrent diarrhoea for six months and adecreased level of serum albumin for five months. Thepatient had watery diarrhoea for six months, with 5-6 bowelmovements per day, which was accompanied by a mildfever. After being admitted into the ward, the laboratoryexaminations revealed a decreased level of serum albumin(17.6 g/L), while the complete blood count was normal.The faecal tests for pathogens were all negative, and theliver and renal functions were normal. There was nosignificant finding during gastroendoscopy or colonoscopy.A gastrointestinal contrast indicated intestinal malrotation.An abdominal computed tomography (CT) scan confirmedthat the mesenteric vessels presenting as a "whirl sign"(Figure 1). During the physical examination, his vital signswere stable, the weight of the patient was 12.4 kg, and theheight was 89 cm. Lung and cardiac auscultation werenormal. No abdominal tenderness was present duringabdominal palpation, nor was there evidence ofhepatosplenomegaly or oedema of the lower limbs. And thenhe underwent an exploratory laparotomy, in which a midgutmalrotation with mesenteric swelling and narrowingwas discovered. He underwent the Ladd procedure andrecovered.

Case two was a 12-year-old female who presented witha primary complaint of an intermittent fever and diarrhoeaoccurring for six months and lower limbs oedema over a

Rare presentation of Midgut Malrotation180

period of 12 days. The patient had intermittent feveraccompanied with diarrhoea for six months, 2-3 mushystools per day, and mild abdominal pain. The laboratorytest showed decreased serum albumin level 20 days ago,and she presented with lower limbs oedema 12 days ago.During the physical examination, her vital signs were stableat the time of admission, the weight of the patient was33 kg. The lung and heart sounds were normal. The patienthad abdominal distension with a positive shifting dullness.Her face, abdominal skin, and lower limbs had pittingoedema. The albumin level was 8.5 g/L, while the completeblood count was normal. The electrolyte analysis revealedmild hypokalaemia and hyponatraemia. There were nosignificant findings during the gastroendoscopy and thecolonoscopy. She underwent surgery, which confirmed amidgut rotation with volvulus; the duodenum and ascendingcolon were compressed by Ladd's bands.

Discussion

PLE is caused by a variety of diseases, such as primaryand secondary lymphangiectasia, intestinal inflammation,vasculitic disorders, and tumour.1 Intestinal malrotation isa congenital anomaly that results from an abnormal orincomplete rotation and fixation of the midgut duringembryonic development.2 Approximately 75% to 85% ofthese patients are diagnosed during infancy.3 The symptomsof malrotation include bilious vomiting, abdominaldistention, and incomplete or complete intestinal

obstruction. About one-third of intestinal malrotation casesare diagnosed beyond the period of infancy. The chronicpresentation is a diagnostic challenge. The chronic intestinalmalrotation symptoms in older patients usually includeeither atypical symptoms, such as abdominal pain,nonillions vomiting, failure to thrive,4 malabsorption,5

anaemia, chylous diarrhoea or a lack of any clinicalsymptoms, and is only discovered during surgery for otherdiseases. The pathophysiology of these chronic symptomsmay relate to the compressive effects of the peritoneal bandsrunning from cecum and ascending colon to the right lateralwall.6 In the study of Nilesh G,2 recurrent colicky abdominalpain (61.9%), nonbilious vomiting (38.1%), and failure tothrive/weight loss (33.3%) were the most commonpresentations of the older patients. Other older patients inthis study presented with early satiety, abdominal bloating,acute pancreatitis or acute small intestinal obstruction, andsome were diagnosed with malrotation intraoperatively.

The diagnosis of intestinal malrotation is mainly basedon the typical clinical manifestations. An uppergastrointestinal contrast study is diagnostic for malrotationin most patients. Ultrasonography can reveal either anabnormal relationship of the superior mesenteric artery(SMA) and vein or a classic whirlpool sign of the midgutvolvulus for some patients. Contrast CT scan is needed toconfirm or differentiate a diagnosis, and sometimes is helpfulin assessing mesenteric ischaemia. The characteristicappearance of a twisted mesentery, collapsed small bowelloops, and mesenteric fat wrapped around the SMA ispathognomonic for malrotation and is commonly referredto as the "whirl sign" or "clockwise whirlpool sign".7 Intestinalmalrotation with chronic symptoms usually need surgery assoon as possible in case of intestinal volvulus. Emergencesurgery would be more complicate than elective operation,including life-threatening bowel necrosis requiring anextensive small intestinal resection.

It is rare that intestinal malrotation presents with proteinlosing enteropathy symptoms. Protein losing enteropathycan be caused secondary to either lymphatic obstruction orintestinal lymphangiectasia as a result of malrotation. Toour knowledge, there are only two case reports documentinga malrotation-induced protein-losing enteropathy. One casewas a 17-month-old boy presenting with hypoalbuminaemia,peripheral oedema, diarrhoea, and failure to thrive since 9months of age. His laboratory analyses revealed a low serumlevel of albumin and a lymphopenia without sings oflymphangiectasia. A CT of the abdomen revealed a whirlpoolsign and suggested an incomplete vascular volvulus. Duringthe laparotomy, chronic midgut volvulus was discovered

Figure 1 Abdominal CT scan: Part of the vessels branchesare dilated obviously, mesenteric vessels presenting typical "whirlsign".

Fang et al 181

with a 180° twisting of the jejunum and the superiormesenteric vessels causing a lymphatic obstruction andleakage of milky white lymph into the cut surfaces of themesentery.1 Morozov et al reported a young Russian malepatient with protein-losing enteropathy, who was diagnoseda malrotation of the duodenum with recurrent midgutvolvulus causing secondary intestinal lymphangiectasia.8

The two cases reported identified either lymphaticobstruction or lymphangiectasia. However, in our cases, wedid not find any evidence of lymphangiectasia or lymphaticobstruction. Although intestinal malrotation is rare beyondthe age of infancy, it should be considered as an atypicalmanifestation. For protein losing enteropathy, intestinalmalrotation should be added as one of the causes of thedisease.

Conclusion

To conclude, an intestinal malrotation should besuspected in all patients presenting with varied acute orchronic abdominal symptoms. Intestinal malrotation shouldbe considered as one of the differentials when diagnosingprotein losing enteropathy.

Acknowledgements

This work was supported by Zhejiang Province MedicalPlatform Backbone (2017KY436).

Conflicts of Interest

The author(s) declared no potential conflicts of interestwith respect to the research, authorship, and/or publicationof this article.

References

1. Zellos A, Zarganis D, Ypsiladis S, Chatzis D, Papaioannou G,Bartsocas C. Malrotation of the intestine and chronic volvulus asa cause of protein-losing enteropathy in infancy. Pediatrics 2012;129:e515-8.

2. Nagdeve NG, Qureshi AM, Bhingare P D,Shinde S K. Malrotationbeyond infancy. J Pediatr Surg 2012;47:2026-32.

3. Andrassy RJ,Mahour GH. Malrotation of the midgut in infantsand children: a 25-year review. Arch Surg 1981;116:158-60.

4. Kapfer SA,Rappold JF. Intestinal malrotation-not just the pediatricsurgeon's problem. J Am Coll Surg 2004;199:628-35.

5. Imamoglu M, Cay A, Sarihan H, Sen Y. Rare clinical presentationmode of intestinal malrotation after neonatal period:Malabsorption-like symptoms due to chronic midgut volvulus.Pediatr Int 2004;46:167-70.

6. Wanjari A K, Deshmukh A J, Tayde P S, Lonkar Y. Midgutmalrotation with chronic abdominal pain. N Am J Med Sci 2012;4:196-8.

7. Watkins BP, Patel NY, Gundersen SB 3rd. Midgut volvulus.J Am Coll Surg 2003;196:986.

8. Morozov DA, Pimenova ES, Tatochenko VK, et al. Surgicaltreatment of rare combination of intestinal malrotation withsecondary lymphangiectasia. Vestn Ross Akad Med Nauk 2015:56-62.


An Extramural Duodenal Ectopic Pancreas Mimicking anExophytic Pancreatic Tumour in an Adolescent

YH WU, CW CHEN, YT CHANG

Abstract Ectopic pancreatic tissues are rare anomalies and are usually submucosal lesions most commonly locatedin the stomach and proximal small intestine. The authors herein describe an uncommon case of anextramural duodenal ectopic pancreatic tissue, which was misinterpreted as an exophytic pancreatic tumouron imaging examination. Laparoscopy was undertaken because of unresolved symptoms, and the ectopicpancreatic tissue was located beyond the duodenal submucosal and muscular layer on pathologicexamination.

Key words Adolescent; Duodenal ectopic pancreatic tissue; Laparoscopy

Department of Family Medicine, Kaohsiung MedicalUniversity Hospital, Kaohsiung, Taiwan

YH WU MD

Department of Emergency Medicine, Kaohsiung MedicalUniversity Hospital, Kaohsiung, Taiwan

CW CHEN MD

Department of Surgery, Kaohsiung Medical UniversityHospital; Graduate Institute of Medicine, College of Medicine,Kaohsiung Medical University; Faculty of Medical School,College of Medicine, Kaohsiung Medical University,Kaohsiung, Taiwan

YT CHANG MD

Correspondence to: Dr YT CHANG


Received December 27, 2016

Case Report

Introduction

Ectopic duodenal pancreatic tissues account forapproximately 17%-36.3% of all ectopic pancreatic tissues,and usually appear as intraluminal protrusions with normaloverlying mucosa.1,2 The description of an extramurallocation has been rarely reported in the literature. Hereinwe present such a case, of a female adolescent, successfullymanaged by laparoscopic excision of an extramural duodenalpancreatic tissue.

Case Report

A 15-year-old female had suffered from recurrentepisodes of moderate to severe epigastralgia and feedingintolerance for the past two years. She was admitted withthe complaint of these symptoms increasing in intensityover the recent week. Physical examination of the abdomennoted marked tenderness localised to the upper abdomenwithout pain radiation to the back. There was neitherdistention nor any palpable masses observed. Thehaemoglobin level was 14.4 g/dL, and total white bloodcell count was 6.70 × 109/L. The platelet count was 221 ×109/L, and C-reactive protein was undetectable. Serumamylase was 136 U/L, and lipase was 22 IU/L. The uppergastrointestinal X-ray series showed normal filling andgastric and duodenal mucosal folds. Endoscopic ultrasounddisclosed a narrowing of the first portion of the duodenum.A nodular lesion with calcified change was noted at thehead of the pancreas close to the portal vein. Abdominalcomputed tomography showed a soft tissue lesion belowduodenal bulb which similar enhancement pattern as thepancreas (Figure 1). Magnetic resonance image showed thatthere was an exophytic pancreatic tissue at pancreas headwith compression to adjacent gastrointestinal tract.

Because of persistent symptoms and the abnormal imagefindings, it was decided that a surgical intervention shouldbe performed; and a laparoscopic approach was elected.The patient was placed in a supine modified lithotomy

Wu et al 183

position with the surgeon standing between the legs.Laparoscopy was performed with a 5-mm Hasson port atthe umbilicus, and video laparoscopy was performed witha 5-mm 30-degree laparoscope (Karl Storz GmbH,Tuttlingen, Germany). Two additional 5-mm working portsat the right and left middle subcostal regions were placed.Initially, Harmonic scalpel (Ethicon Endosurgery,Cincinnati, Ohio, USA) was used for the division of thegastrocolic ligament to expose the lesion. However, the masswas found to be located over the first portion of theduodenum (Figure 2). Therefore, resection of the tumourand wedge resection of the duodenum were performed. Theanas tomosis of the duodenum was per formed

intracorporeally. Operative time was 80 minutes, and bloodloss was estimated as 10 mL without blood transfusion.The patient was discharged 10 days after operation andcontinued to remain free of epigastric pain on two-yearfollow-up at our outpatient clinic.

Histology confirmed the diagnosis of heterotopicpancreas. Macroscopically, the specimen consisted of onetissue fragment measuring 4 cm × 2 cm × 0.7 cm indiameter. Cut sections of the specimen displayed a normalpancreas with lobular arrangement. On microscopicexamination, it showed an ectopic pancreatic tissue beyondthe duodenal submucosal and muscular layers, composedof typical islets of Langerhans scattered in the exocrinepancreas (Figure 2).

Discussion

Heterotopic pancreatic tissue, first described by JeanSchultz in 1727,3 is a relatively uncommon tumour,accounting for 1% to 2% in an autopsy series.4 It usuallyremains asymptomatic throughout life and is foundincidentally during gastroendoscopy or other imagingmodalities in patients between 40 and 70 years of age, andsometimes has nonspecific clinical manifestations.1,5

According to Heinrich classification system, ectopicpancreas can be classified into three types under microscopy:type 1 (endocrine and exocrine element: acini, ducts, andislet cells), type 2 (exocrine element: acini and ducts) andtype 3 (only ducts).6 Our case was considered to be thetype 1 heterotopic pancreas which contains all components

Figure 2 (a) Operative photograph showing a solid mass (asterisk) from the first portion of the duodenum in close association with thepancreas. (b) Photomicrograph of the mass showing a heterotopic pancreas situated beyond the duodenal submucosal and muscular layer.(Haematoxylin and eosin stain, x 40)

Figure 1 Computed tomography of the abdomen showing asolid lesion (arrow) suspected to arise from the pancreatic head.

(a) (b)

Duodenal Ectopic Pancreas184

of pancreas. Although previously considered benign, reportsof ductal adenocarcinoma arising in ectopic pancreas havebeen published.7

The most common sites of the ectopic pancreas includethe stomach (25%-38.2%), duodenum (17%-36.3%) andjejunum (15%-21.7%).1,2 However, it has also been reportedin the lungs, gallbladder, mediastinum, mesentery,oesophagus, bile ducts and umbilical cord.1 Of thealimentary tract, ectopic pancreas is typically a submucosalmass covered by normal mucosa. 1 Endoscopicultrasonography is the mainstay of imaging modalities inthe detection the neoplasm located in the stomach and firstand second portions of the duodenum.1 Unlike submucosallocalisation of other reported ectopic pancreatic tissues, thelesion at our present case originated from the submucosallayer and extended extramurally.

Some papers have mentioned that the operationtechnique and patient selection might be made on the basisof location and size of lesion and the patient's comorbidities.The optimal treatment for asymptomatic lesions of ectopicpancreatic tissue is not well defined. Also, laparotomyshould be considered if there are emergency complicationssecondary to ectopic pancreas such as intussusception orperitonitis.8 However, these reports relate mostly to gastricectopic pancreas. Currently, there is still no clear consensusguideline for the treatment of duodenal ectopic pancreas.With refinements in minimally invasive surgery,laparoscopy in the treatment of ectopic pancreas was firstreported in 2002.9 This, however, appears to be the firstreport of complete laparoscopic excision of a duodenalectopic pancreas in an adolescent.

The detailed pre-operative examination includingimaging survey and video magnification of the endoscopycan offer surgeons better exposure of the extramuralduodenal mass and its surrounding vessels and nerves.Therefore, delicate manoeuvres can be performed to protectnearby important structures during surgery. Despite thepresent case representing experience within the learningcurve and was a time-consuming operation, the laparoscopicapproach holds promise for providing advantages seen withminimally invasive approaches in other procedures, such aspostoperative recovery and cosmetic considerations.10

Conclusions

This case presents a relatively uncommon clinicalproblem and is the first case report of successfullaparoscopic management in an adolescent with anextramural duodenal ectopic pancreas. Laparoscopic wedgeresection for duodenal ectopic pancreas appears to be safeand feasible.



References

1. Harold KL, Sturdevant M, Matthews BD, et al. Ectopic pancreatictissue presenting as submucosal gastric mass. J LaparoendoscAdv Surg Tech A 2002;12:333-8.

2. De Vogelaere K, Buydens P, Reynaert H, et al. Laparoscopicwedge resection for gastric ectopic pancreas. Surg LaparoscEndosc Percutan Tech 2005;15:166-8.

3. Fam S, O'Briain DS, Borger JA. Ectopic pancreas with acuteinflammation. J Pediatr Surg 1982;17:86-7.

4. Kaneda M, Yano T, Yamamoto T, et al. Ectopic pancreas in thestomach presenting as an inflammatory abdominal mass. Am JGastroenterol 1989;84:663-6.

5. Rubbia-Brandt L, Huber O, Hadengue A, et al. An unusual caseof gastric heterotopic pancreas. JOP 2004;5:484-7.

6. von Heinrich H. Ein Beitrag zur Histologie des Sogen:akzessorischen Pankreas. Virchows Arch A Pathol AnatHistopathol 1909;198:392-401.

7. Matsuki M, Gouda Y, Ando T, et al. Adenocarcinoma arisingfrom aberrant pancreas in the stomach. J Gastroenterol 2005;40:652-6.

8. Nasser HA, Sleiman YA, Hassoun ZA, et al. Bowel obstructionsecondary to an ectopic pancreas in the small bowels: About 2cases. Int J Surg Case Rep 2017;31:72-4.

9. Paolucci P, Brasesco OE, Rosin D, et al. Laparoscopic resectionof ectopic pancreas in the gastric antrum: case report and literaturereview. J Laparoendosc Adv Surg Tech A 2002;12:139-41.

10. K e n d r i c k M L , C u s a t i D . To t a l l a p a r o s c o p i cpancreaticoduodenectomy: Feasibility and outcome in an earlyexperience. Arch Surg 2010;145:19-23.


Reye's Syndrome Arising from the Treatment ofKawasaki Disease

EJ SU, JH HSIEH, CC HSU, KT CHEN

Abstract We report on a 20-month-old girl who presented with vomiting and lethargy after being discharged fromthe ward following treatment for Kawasaki disease. The symptoms occurred after five days of aspirintherapy. The clinical features and laboratory tests proved the presence of Reye's syndrome and sherecovered after intensive treatment. In addition, we collected three similar reported cases. All the patientscame from East Asia and the mortality rate reached 50%. Since salicylate is an effective and imperativetreatment for Kawasaki disease, paediatricians and emergency physicians can consider using a low doseof aspirin (3-5 mg/kg) as maintenance therapy, discontinuing aspirin for a short period or replace it withdipyridamole during influenza or varicella epidemics, and having a high index of suspicion of Reye'ssyndrome in patients with Kawasaki disease.

Key words Aspirin; Complication; Kawasaki disease; Reye's syndrome; Salicylate

Emergency Department, Chi-Mei Medical Center, Tainan,Taiwan

EJ SU MDJH HSIEH MDCC HSU MD, PhDKT CHEN MD

Department of Biotechnology, Southern Tainan Universityof Technology, Tainan, Taiwan

CC HSU MD, PhD

Department of Emergency Medicine, School of Medicine,College of Medicine, Taipei Medical University, Taipei,Taiwan

KT CHEN MD

Correspondence to: Dr KT CHEN


Received September 5, 2016

Case Report

Introduction

Reye's syndrome is an acute failure of mitochondriaand occurs mainly in childhood. The cause of this severedisease is still uncertain; however, the affected child

usually presents with a prodrome of acute viral infectionand the use of salicylate during the prodromal illness,followed by an acute encephalopathy, fatty degeneration ofthe liver, and metabolic decompensation.1-4 In addition,salicylate consumption is correlated with severity of Reye'ssyndrome.2 After warnings had been issued about the use ofsalicylates in children with those viral infections, theincidence of Reye's syndrome in the United States declineddramatically.2

However, some children still require long-term use ofsalicylate, such as those with connective tissue disorders,and these patients run a greater risk of developing Reye'ssyndrome.2 We report on a 20-month-old girl who developedReye's syndrome after treatment for Kawasaki disease andreview three case reports to demonstrate the unique featuresof the involved children.

Case

This 20-month-old girl, who was previously well, hadsuffered from high fever for 5 days and was admitted toChi-Mei Medical Center. She had a normal birth history(birth weight: 3070 gm, gestation age: full term, via normal

Reye's Syndrome and Kawasaki Disease186

spontaneous delivery), regular vaccinations, negative resultsof newborn screening for metabolic diseases, and normalgrowth and development. She was the second child in thefamily (G2P2A0) with no family history of sudden infantdeath or inborn errors of metabolism. After admission, shewas diagnosed as having Kawasaki disease due to thepresence of wheal-like exanthema on the palms and buttocks,erythematous fissured lips and bilateral conjunctivitis as wellas leukocytosis (white cell count: 16000/µL) and elevationof C-reactive protein (62.6 mg/dL) in laboratory tests.5 Thepaediatricians initiated intravenous immunoglobulin at adose of 2 g/kg and a high dose of oral aspirin of 88/mg/kgper day. The patient's fever subsided after the initiation oftreatment and her appetite and activity improved.Echocardiography showed normal coronary arterioleswithout dilatation. Subsequently, the aspirin dose wasreduced to 55 mg/kg per day and she was discharged after15 days of hospitalisation.

On the next day after discharge, about the fifteenth dayafter administering the first dose of aspirin, the patient wasfound with persistent vomiting, drowsiness and fever andwas admitted to Chi-Mei Medical Center again. Physicalexamination of the patient revealed fever, tachycardia,lethargy, decreased muscle tone, and decreased urine output.A computed tomographic scan of the head demonstratedbilateral basal ganglia lesions and cortical swelling. Serumtests revealed hyperammonaemia (214 µg/dL), and elevationsof aspartate aminotransferase and alanine aminotransferase(AST: 461 IU/L, ALT: 255 IU/L). Initial differentialdiagnosis included aspirin intoxication and Reye's syndrome,and therefore aspirin was discontinued immediately. Thepatient was transferred to National Cheng Kung UniversityHospital because of progression to coma status. Asubsequent lumbar puncture found increased intracranialpressure (35 cm H2O) and the analysis of cerebral spinalfluid showed negative results for bacterial or viral infection.A hepatic biopsy demonstrated typical manifestations ofReye's syndrome. The patient underwent tracheal intubationand mechanical ventilation for coma, supportive treatmentfor metabolic derangement, intravenous mannitol for cerebraloedema, and continuous veno-venous haemofiltration toeliminate aspirin. After intensive care, the patient recoveredand was discharged after two weeks of hospitalisationwithout permanent sequelae.

Discussion

Nowadays, high-dose aspirin (80 to 100 mg/kg per day)

and intravenous immunoglobulin are recommended as theinitial treatment for Kawasaki disease, followed by areduction of the aspirin dose after the child has been afebrilefor 48 to 72 hours. The therapy effectively reduces the rateof subsequent ischaemic heart disease and sudden death5

However, children who undergo aspirin treatment carryadditional risk of Reye's syndrome. Except this presentedcase, we discovered another three patients with Reye'ssyndrome arising from the treatment of Kawasaki disease.All the reported patients were found in East Asia, threein Taiwan and one in Japan6-8 All the affected childrenwere under two years of age, and included three femalesand one male. The symptoms of Reye's syndromeappeared within 15 days after the initiation of salicylatetherapy. The presented symptoms included vomiting,poor appetite, decreased activity, hepatomegaly, andlethargy. Two of the four reported cases died (50%mortality rate) (Table 1).

Takahashi and Mason indicated that the subset ofchildren most susceptible to Kawasaki disease (Asiansyounger than four years of age) and the subset mostsusceptible to Reye's syndrome (white children older thansix years of age) do not overlap.9 The lack of overlap inthe two groups of affected children might explain thelow incidence of Reye's syndrome occurring in Kawasakidisease. With regard to the benefit of cardiovasculareffects, children with Kawasaki disease should stillundergo salicylate treatment. Though the absence ofevidence concerning the correlation between incidenceof Reye's syndrome and dosage of aspirin, the authorsproposed that the dosage of salicylate should be kept aslow as possible. In addition, the study by Saulsbury et alshowed that low-dose aspirin (3-5 mg/kg) is as effective

Table 1 The clinical manifestations among three reportedcases (Nejihashi 1980, Lee 1991 and Wei 2005) and our presentedpatient (Su 2012)

Clinical Nejihashi Lee Wei Su

manifestations 1980 1991 2005 2012

Age (month) 9 7 10 20

Gender F F M F

Aspirin administration (day)* 14 4 3 15

Dose of aspirin (mg/kg/day)† Unknown 10 3-5 55

Mortality Expired Expired Alive Alive

*symptoms of Reye's syndrome after the initiation of aspirin therapy†maintenance dose of aspirin

Su et al 187

as high-dose aspirin therapy.9 Because most Reye'ssyndrome children have a prodrome of viral infection,those who undergo long-term salicylate treatment candiscontinue aspirin for a short period or replace it withdipyridamole during influenza or varicella epidemics. Inaddition, those children who undergo salicylate therapyshould be observing closely for symptoms of Reye'ssyndrome within 15 days after initiation treatment.

Though rare, Reye's syndrome arising from the treatmentof Kawasaki disease does occur. Since salicylate is aneffective and imperative treatment for Kawasaki disease,paediatricians and emergency physicians can consider usinglow doses of aspirin (3-5 mg/kg) as maintenance therapy,discontinuing aspirin for a short period or replace it withdipyridamole during influenza or varicella epidemics, andhaving a high index of suspicion of Reye's syndrome inpatients with Kawasaki disease.



References

1. Starko KM, Ray CG, Dominguez LB, Stromberg WL, WoodallDF. Reye's syndrome and salicylate use. Pediatrics 1980;66:859-64.

2. McGovern MC, Glasgow JF, Stewart MC. Reye's and aspirin:lest we forget. BMJ 2001;332:1591-2.

3. Pugliese A, Beltramo T, Torre D. Reye's and Reye's-likesyndromes. Cell Biochem Funct 2008;26:741-6.

4. Newburger JW, Takhashi M, Gerbert MA, et al. Diagnosis,treatment, and long-term management of Kawasaki disease: astatement for health professionals from the Committee onRheumatic fever, Endocarditis, and Kawasaki disease, Councilon Cardiovascular Disease in the Young, American HeartAssociation. Pediatrics 2004;114:1708-33.

5. Nejihashi Y, Takada Y, Okazaki T, et al. An autopsied case ofReye's syndrome in progress of MCLS. Shonika Shinryo (J PediatrPractice) 1980; 43:960-2.

6. Lee JH, Hung HY, Huang FY. Kawasaki disease with Reye'ssyndrome: report of one case. Zhongghua Min Guo Xiao Er KeYi Xue Hui Za Zhi 1992;33:67-71.

7. Wei CM, Chen HL, Lee PI, et al. Reye's syndrome developing inan infant on treatment of Kawasaki syndrome. J Paediatr ChildHealth 2005;41:303-4.

8. Takahashi M, Mason W. Kawasaki syndrome, Reye's syndrome,and aspirin. Pediatrics 1986;77:616-7.

9. Saulsbury FT. Comparison of high-dose and low-dose aspirin plusintravenous immunoglobulin in the treatment of Kawasakisyndrome. Clin Pediatr (Phila). 2002;41:597-601.


Denys Drash Syndrome, What PaediatricianShould Know About?

AKH KWOK, SMY WONG, MT LEUNG, WKY CHAN

Abstract We report on a boy with known bilateral undescended testes who was incidentally detected to haveproteinuria on a routine pre-operative assessment. Further investigations confirmed childhood nephroticsyndrome. Because of atypical features, an early ultrasound kidney was arranged and it showed bilateralnephroblastomatosis. His karyotype was 46XY. Further DNA analysis showed a heterozygous mutation inWilms tumour suppressor gene 1 (WT1 gene). A diagnosis of Denys Drash syndrome was made and heunderwent treatment for Wilm's tumour.

Key words Denys-Drash syndrome; Genes, Nephrotic syndrome; Pseudohermaphroditism; Wilms tumour; WT1proteins

Department of Paediatrics, Queen Elizabeth Hospital,30 Gascoigne Road, Kowloon, Hong Kong SAR, China

AKH KWOK MBBS, MRCPCH

SMY WONG MBBS, FHKCPaed, FHKAM

WKY CHAN MBBS, MRCP(UK), FHKAM

Department of Pathology, Queen Elizabeth Hospital,30 Gascoigne Road, Kowloon, Hong Kong SAR, ChinaMT LEUNG MBBS

Correspondence to: Dr. AKH KWOK


Received November 21, 2016

Case Report

Case Report

LCY, an 18-month-old boy, was born full term withnormal spontaneous delivery. His neonatal history wasuneventful except he was noted to have bilateralundescended testes. His scrotum was well formed and penilelength was normal. Both testes were high in the inguinalcanals. He was well until 14 months of age. He was admittedfor bilateral orchidopexy. Pre-operative assessment showedpuffy eyelids with blood pressure 130/90 mmHg and urine

albustix 3+ for protein. His body weight was above 97thpercentile and body height was 75th percentile. Subsequentwork up showed serum albumin 18 gram/L (normal range:38-54 gram/L). 24-hour urine protein was 3.49 gram/day(normal range: <0.1 gram/ day). Cholesterol was 4.9 mmol/L.Serum urea was 6.0 mmol/L (normal range: 1.8-6.4 mmol/L),serum creatinine was 36 umol/L (normal range:21-36 umol/L). Anti-nuclear antibody, anti-neutrophilcytoplasmic antibody and anti-dsDNA were negative.C3 and C4 levels were normal. Ultrasound of kidneysshowed multiple hypoechoic nodules on bilateral kidneyssuggestive of nephroblastomatosis. CT abdomen showedmultiple hypodense hypoenhancing mass lesions in bothkidneys, the largest hypodense lesion measures 3.8 cm inright lower pole. The findings were consistent with bilateralnephroblastomatosis. In view of early onset nephroticsyndrome with bilateral renal tumour and undescendedtestes, karyotype study and genetic work up for WT1mutation were performed. It showed heterozygous mutationin WT1 gene (NM_024426.3(WT1):c.1384C>T, changingcodon 462 from arginine to tryptophan, i.e. p.Arg462Trp)(Figure 1). Karyotyping of patient was 46XY. WT1 mutationscreenings for parents were negative. Our patient was startedon angiotensin-converting enzyme inhibitor, calciumchannel blocker and vasodilator for hypertension and heavyproteinuria. Options of prophylactic bilateral nephrectomy,

Kwok et al 189

versus renal salvage approach for nephroblastomatosis withadjuvant chemotherapy were discussed with parents.

In view of the rapid growth in renal mass, LCY underwent4 cycles of neo-adjuvant chemotherapy with intravenousActinomycin D 550 microgram and intravenous Vincristine0.75 mg once per week. MRI abdomen afterwards showedresolved lesions over left kidney but mild enlargement inright lower pole lesion. Right total nephrectomy was done2 months after presentation, an 8x7 cm right renal tumourwith multiple lymph nodes on the inferior vena cava (IVC)excised. Pathology showed triphasic nephroblastoma withclear margins. There were no malignant cells in the lymphnodes. Renal histology confirmed diffuse mesangial sclerosis

with mild global glomerulosclerosis and mild chronictubulointerstitial injury (Figure 2).

Patient was put on chemotherapy according to theSIOP (International Society of Pediatric Oncology)nephroblastoma clinical trial 2001 protocol, intermediaterisk arm. His chemotherapy comprises of weekly injectionof intravenous actinomycin D and/or vincristine. He sufferedfrom several infective complications. His nephroticsyndrome was treated with regular albumin transfusion andACEI. Renal function however, was noted to be graduallydeteriorating over a few months. His creatinine rose frombaseline of 25-35 umol/L to 100-110 umol/L over 5 months.His latest estimated glomerular filtration rate by Schwartzformula is 28 ml/min/1.73 m2. His condition remained stableinitially but progressive renal failure is anticipated and he ishaving his scheduled chemotherapy with close monitoringof renal function.

Discussion

Denys-Drash syndrome (OMIM 194080) was first describedin 1967 as a triad of 46XY pseudohermaphroditism, nephroticsyndrome due to diffuse mesangial sclerosis andpredisposition to unilateral or bilateral Wilms tumour andgonadoblastomas.1,2 All of the patients were infants withheavy proteinuria progressing rapidly to renal failure. In1991, Pelletier et al described a direct role for WT1 in Denys-Drash syndrome (DDS).3

The WT1 gene is located on chromosome 11p13 andcomprises 10 exons which encode a zinc-finger DNA-binding protein that acts as a transcriptional activator orrepressor. The gene is expressed in a wide variety ofembryonic tissue including the mesenchymal cells of thefoetal kidney, and the stromal cells of the gonads and spleen.It is thus essential in normal formation of the kidney andgenitourinary system.4 Different mutations in WT1 gene leadto a spectrum of different phenotypes including DDS, Frasiersyndrome (FS) or isolated steroid-resistant nephroticsyndrome.2,5

Classically, DDS and FS are two separate entities withdifferent clinical features. DDS patients have early onsetnephrotic syndrome during infancy due to diffuse mesangialsclerosis, with rapid progression to renal failure. In contrast,FS patients have nephrotic syndrome due to focal segmentalglomerulosclerosis in the second to third decade of life. DDSpatients are prone to Wilms' tumour whilst FS patients areprone to gonadoblastoma. DDS and FS are both known tobe related to gonadal dysgenesis. DDS patients have 46XY

Figure 1 Showed the Missense mutation in codon 462 at exon9 of WT1 gene of the patient.Genomic DNA was extracted from peripheral blood leukocytesusing QIAamp DNA Blood Mini Kit according to themanufacturer's instruction (Qiagen). Exons 1-10 of the WT1 geneand their flanking intron sequences were amplified individuallyby PCR, performed in the GeneAmp PCR System 9700 (AppliedBiosystems). All reagents used in the PCR reactions are suppliedby Applied Biosystems. Sequencing reactions were performedforward and reverse, by Applied Biosystems Genetic Analyser3500. Nucleotide changes and allelic variants were detected usingthe Mutation Surveyor software as well as manual inspection.One heterozygous missense mutation was identified in this patient.This mutation is situated in codon 462 at exon 9 and causes aCGG to TGG transformation (the red rectangle), changing theamino acid from arginine to tryptophan. This occurs within azinc finger domain of the mature WT1 protein and has beenreported in about half of the patients with complete Denys-Drashsyndrome.

Denys Drash Syndrome190

partial gonadal dysgenesis, with variable external phenotypedepending on the degree of testicular function. Thephenotype can range from ambiguous genitalia, under-virilized male to normal male phenotype with reduced spermproduction. In contrast, FS patients have 46XY completegonadal dysgenesis. They have normal Mullerian structureswith bilateral streak gonads due to the lack of gonadal steroidproduction.6,7 Our DDS patient is genetically XY and hehad bilateral undescended testes. In a local case report byChan et al,8 a post-renal transplant patient presented withdelayed pubertal development at the age of 15 years. Shehad a normal female phenotype but karyotype was 46XY.DNA analysis confirmed diagnosis of Frasier syndrome.

Since the 1990s, more than 80 mutations have beenreported in DDS patients. Missense mutations in exons

8 and 9 are the commonest identified mutations, withtruncating mutations also described. There is significantevidence to suggest genotype/phenotype correlation in DDSmutation patients. Patients with missense mutations in exonshave onset of proteinuria at median age of 6 months, whichis much earlier than those with truncating mutations andintron mutations. They also progress more rapidly towardend stage renal disease (ESRD), with need for renalreplacement therapy (RRT) at median age of 1.1 years.5

Our patient has the classical genotype and phenotypedescribed in DDS. However, he presented to us withundescended testes which is a common paediatric problemwhich could hardly be linked to this rare disorder at thebeginning. His nephrotic syndrome was subtle too as he wasasymptomatic and was only picked up by a careful physical

(a) (b)

(c)(d)

Figure 2 (a) The pale looking circumscribed tumour was seen in the lower pole of right bivalved kidney. (b) H&E 4x view showedthe intralobar nephroblastomatosis which was a feature of nephroblastoma seen in patients with WT1 mutation. (c) H&E 10x viewshowed the immature glomeruli which were of smaller size as compared with "normally developed glomeruli" and had parietal epithelialcells with high nuclei-cytoplasma ratio in the periphery of the glomeruli. (d) H&E 20x view showed the diffuse mesangial sclerosis in thisglomerulus with parietal epithelial cells proliferation and these cells composed of podocytes with vacuolated nuclei.

Kwok et al 191

examination and laboratory test. DDS only came to our mindwhen he was detected to have early onset of nephroticsyndrome. The presentation was subtle and an earlyultrasound helped to pick up the renal tumour which pointedto the rare diagnosis of DDS.

Genetic test was arranged after detection of nephroticsyndrome and bilateral nephroblastomatosis. Within a fewdays' time, DDS was confirmed by detection of the missensemutation c.1384C>T, which is one of the most describedmutations amongst DDS patients.5 The genetic test resultsufficed to imaging findings suggestive of Wilm's tumour.It also provides a realistic expectation towards managementgoal and parent counselling during the gradual deteriorationof renal disease.

The management of renal condition in DDS patients ischallenging. Diffuse mesangial sclerosis is reported to beresistant to steroids and immunosuppressive drugs. Carefulmonitoring of disease, adequate nutrition, medical treatmentfor hypertension and proteinuria are all important to slowthe declining renal function.

Nephrectomy with adjuvant chemotherapy is the mainstayof treatment for DDS patients with Wilms' tumour. Bilateralnephrectomy is recommended for DDS patients withESRD. For those without Wilm's tumour or ESRD upondiagnosis, timing for nephrectomy is debatable. Someauthors prefer "early" bilateral nephrectomy in view ofthe high risk for Wilms' tumour. Other authors suggestdelaying nephrectomy until onset of ESRD, with carefulmonitoring of patients every 4 to 6 months by abdominalultrasonography.9

Both diffuse mesangial sclerosis and Wilms' tumourcontribute to an inevitable progression to ESRD in DDSpatients. Renal replacement therapy is eventually needed.Outcomes of children with Wilms' tumour and DDS whoproceeded to renal transplantation are comparable withchildren with other diagnoses, with no graft failures becauseof recurrence.10 It is generally recommended to wait 1 to 2years after completion of chemotherapy for Wilms' tumour.However, studies have shown a high early mortality beforerenal transplant. Questions have thus been raised upon theoptimal timing of renal transplant.

DDS is a complex disease which requires goodcollaboration amongst various disciplines, includingpaediatrician, nephrologist, oncologist, endocrinologist,geneticist, and vast nursing and social support. Thoroughcounseling with the family on management options ismandatory.

Conclusion

DDS is a rare but important entity that should not bemissed. Our patient illustrates that, while nephroticsyndrome is common in children, clinicians should beparticularly aware of the possibility of rare causes like DDS,especially in those with early onset nephrotic syndrome andambiguous external genitalia. DNA analysis is a useful meansof confirming the diagnosis.


All authors do not have any financial and personalrelationships with other people or organisations that couldinappropriately influence their work.

References

1. Denys P, Malvaux P, Van Den Berghe H, Tanghe W, ProesmansW. [Association of an anatomo-pathological syndrome of malepseudohermaphroditism, Wilms' tumor, parenchymatousnephropathy and XX/XY mosaicism]. [Article in French]. ArchFr Pediatr 1967;24:729-39.

2. Drash A, Sherman F, Hartmann WH, Blizzard RM. A syndromeof pseudohermaphroditism, Wilms' tumor, hypertension, anddegenerative renal disease. J Pediatr 1970;76:585-93.

3. Pelletier J, Bruening W, Kashtan CE, et al. Germline mutationsin the Wilms' tumor suppressor gene are associated with abnormalurogenital development in Denys-Drash syndrome. Cell 1991;67:437-47.

4. Hossain A, Saunders GF. The human sex-determining gene SRYis a direct target of WT1. J Biol Chem 2001;276:16817-23.

5. Lehnhardt A, Karnatz C, Ahlenstiel-Grunow T, et al. Clinicaland molecular characterization of patients with heterozygousmutations in Wilms Tumor suppressor gene 1. Clin J Am SocNephrol 2015;10:825-31.

6. McCann-Crosby B, Mansouri R, Dietrich JE, et al. State of theart review in gonadal dysgenesis: challenges in diagnosis andmanagement. Int J Pediatr Endocrinol 2014;2014:4.

7. Cetinkaya E, Ocal G, Berberoglu M, et al. Association of PartialGonadal Dysgenesis, Nephropathy and WT1 Gene MutationWithout Wilms' Tumor: Incomplete Denys-Drash Syndrome.J Pediatr Endocrinol Metab 2001;14:561-4.

8. Chan WK, To KF, But WM, Lee KW. Frasier syndrome: a rarecause of delayed puberty. Hong Kong Med J 2006;12:225-7.

9. Malkan AD, Loh A, Bahrami A, et al. An approach to renal massesin pediatrics. Pediatrics 2015;135:142-58.

10. Kist-van Holthe JE, Ho PL, Stablein D, Harmon WE, Baum MA.Outcome of renal transplantation for Wilms' tumor and Denys-Drash syndrome: a report of the North American Pediatric RenalTransplant Cooperative Study. Pediatr Transplant 2005;9:305-10.


Integrative, Integrated Medicine But No Integration:Tarnishing Steroid and Chinese Medicine is Vanity

KL HON, AKC LEUNG

Department of Paediatrics, The Chinese University of HongKong, Prince of Wales Hospital, 30-32 Ngan Shing Street,Shatin, N.T., Hong Kong SAR, China

KL HON MD, FAAP

Department of Pediatrics, The University of Calgary, AlbertaChildren's Hospital, Calgary, Alberta, CanadaAKC LEUNG FRCP(UK&Irel), FRCPCH

Correspondence to: Prof. KL HON



Commentary

On June 21, 2017, the Department of Health (DH) of theHong Kong Government urged clients who consulted aregistered Chinese medicine practitioner (CMP) not to usecreams prescribed by that CMP as the creams were suspectedto contain undeclared Western medicine (WM) ingredients.1The invest igat ion fol lowed complaints of skinhypopigmentation of two 6-month-old male infants whoseparents had applied on their infants unlabeled bottles ofbrownish grey cream prescribed by the CMP for thetreatment of eczema. Part 1 poisons clobetasol propionateand miconazole were detected in the cream. The DH'sofficers conducted investigations in the premises concernedfor the possible source of the ingredients. Compared withadults, children are at higher risk of both local and systemiceffects.2,3 According to the Pharmacy and Poisons Ordinance(Cap 138), illegal sale or possession of Part I poisons arecriminal offences. The maximum penalty for each offenceis a fine of HK$100,000 and two years' imprisonment. TheDH has set up a hotline and has referred the case to theChinese Medicine Council of Hong Kong for possibledisciplinary actions. The CMP responded to reporters thatthe cream would not have been prescribed if he knew that itcontained corticosteroid (CS), indirect implying that CS is

an evil product and he was also a victim. Within the sameperiod, another CMP in the same district was reported toprescribe CS to young children with eczema. A mini-outbreak of CS phobia occurred involving over two hundredanxious parents phoning DH for consultation. The DH issuedletters to all CMPs and Chinese medicine associations toalert them to these recent cases. They were again remindedthat CMPs must not prescribe Chinese medicines (CM)which contain WM to their patients as such act violates thelaws and endangers public safety and health.4

The incidents reflect the ongoing dilemma of non-integration of medical disciplines.

From time to time, the local media report cases of illegalprescription of CS to children with eczema by CMPs, someof them were depicted figuratively as "divine doctor forchildbirth", "holy hand for eczema" and "father ofnaturopathy" etc.2 Physicians should be aware thatunregistered CM can contain potent drugs such as CS.

Like asthma and allergic rhinitis, childhood eczema is acommon atopic disease which is associated with chronicityand impaired quality of life of the patients and theirfamilies.2,5 Management includes patient education,avoidance of triggers, optimal skin care through the regularuse of emollient, appropriate use of topical CS,antihistamines, and even immunotherapy.5 Nevertheless,fears and non-adherence on various therapeutic aspects ofWM prevail and management of this disease remainssuboptimal.6 CS is the cornerstone of treatment duringdisease flare.5 Steroid phobia, however, has overwhelminglycounter-benefited the therapeutic efficacy of CS.7,8 In HongKong, many parents would seek alternative and folkloretreatment of unproven efficacy, possibly because of theirdissatisfaction with current WM treatment.2,6 Paradoxically,some of these alternative treatments may knowingly orunknowingly contain potent CS, and definitely unknowinglyused by steroid-phobic parents.6,9 Many steroid-phobicparents are very skeptical about WM.2-4 In parallel to this

Hon et al 193

skeptism and non-trust, many citizens idolize complementaryand alternative medicine (CAM) and believe that traditionalChinese medicine (TCM) and herbs are without much sideeffects.2,5 Many parents would purchase proprietary topicaland oral preparations without knowing what they are,and use them liberally and indiscriminately on theirchildren.2,5,7,8 Pressed by public's quest for efficacious andsafe treatment and lucrative profits, CAM practitioners mayrisk prescribing CS and "WM" in the name of TCM. Hence,despite the prevalence of "steroid phobia" which may leadto the suboptimal use of prescribed topical CS, parents mightunknowingly use over-the-counter potent CS and TCMwhich contains CS.2,9

Eminent CMPs are especially tempted to prescribe CSto preserve their reputation that CM is efficacious as panaceatreatment of any disease. It is difficult to convince anxioussteroid-phobic parents to be vigilant in the use of oftenadulterated proprietary CM. Nevertheless, government andthe media play important roles not to disgrace CM and tarnishCS usage. Scientifically, CM is an important branch ofmedicine, and topical or systemic CS is a very importantclass of immunomodulating and anti-inflammatorymedication.10 The authors believe that in Hong Kong, bothCM and CS have complementary roles in diseasemanagement and that the important and fashionable conceptof integrative medicine (IM) is worth promoting. TarnishingCS or CM usage certainly does not help with the alreadyevil image of CS among steroid phobic parents. As a matterof fact, combining treatment with WM and CM has benefitsin the treatment of atopic dermatitis because such treatmentmay prevent the adverse reactions induced by WM, whileimproving the efficacy of WM.11 WM and CM practitionersand the media should therefore work together to promotecorrect public health education on this important class ofmedicine. Western medicine practitioners should be moreknowledgeable about CM and vice versa for CMPs. BothWestern medicine practitioners and CMPs should payattention to the interactions between WMs and CMs becauseCMs can affect the pharmacokinetic properties of WMs. Ourcommon enemy is the naive belief by the naive parents thatexclusive CM is the ultimate and safe solution for eczema.Money is not evil but the love of money is the root of allevil. In this regard, CS is definitely not an evil.2

Notorious Examples of Non-integration

Attention of Hong Kong physicians was aroused whennews broke out on December 17, 2015 that a 23-year-old

man with eczema jumped off his apartment window andfound dead whilst his mother was preparing herbal medicinedecoction for him in the sitting room.12 There is no lack ofdermatologists, allergists, internists, family medicinepractitioners, CAM practitioners, and CMPs in Hong Kongfor this common childhood condition. It is unacceptable thatthe patient should suffer and die of this miserable conditionwhere treatment is readily available.

In Australia, an infant with eczema was denied WM andthe parents exclusively used CAM.13 The homeopathycouple was jailed over their daughter's death. The daughterdied of malnutrition and sepsis after the parents chose touse homeopathic remedies rather than conventionalmedicine to treat their daughter's severe skin disorder.Similarly, a tragic case was reported of an infant with eczemawho died of group B streptococcus septicemia andmalnutrition despite expensive dietary supplements.14 Thesetragic cases of "status eczematicus", defined arbitrarily aseczema exacerbation that does not respond adequately toordinary therapeutic measures and usually requireshospitalisation, serve to remind us the grave consequencesof inappropriately managed cases of eczema.

If either CM or WM is not "efficacious" in certaindiseases, notably chronic and terminal illnesses, the idealtreatment will be integrative or combined CM and WM. Inprinciple, integrative medicine will minimise side effectsand maximise efficacy.15-17 CM and WM disciplines share alot of similarities. Indeed, perhaps disagreed by somepractitioners, the two branches of medicine are very similarin that both have long history of tradition, and boththerapeutic processes involve detailed history taking andphysical examination to arrive at a diagnosis and treatmentdiscussed with patients based on the diagnosis. However,there is often no detail on clinical pharmacology on CM.IM may offer some benefits but well-designed scientificstudies are lacking.18-21 Despite its advocacy, genuine IM isseldom practiced in the city of Hong Kong. CM and WMoften go in parallel or exclusive rather than integrative.Local Hospital Authority and the two medical schools inHong Kong have established certificate and diploma coursesof CM for medical practitioners and allied health. This is away in bridging the knowledge for WMPs. CMPs claim totreat pre-disease (i.e. preventive medicine) primarily.Contrary to common fallacies, CM can be potentand efficacious, but may not cure many diseases. In modernCM training, practitioners are more receptive to WM.Non-herbal medicines are commonly used too, such asinsect exo-skeleton, animal body parts, minerals, and arsenic.

Steroid Phobia and Integrative Medicine194

The authors consider eczema a mental or psycho-socialdisease, rendering WM, CM, TCM, traditional Chineseherbal medicine, food avoidance, food supplementation,acupuncture and any CAM alone sub-optimal in efficacy.We need to be unified and join hands to create a holisticpsycho-educational approach for this disease. The onlychance for a successful management of complexpsychosocial disease is to complement the strength andweakness of the two medical disciplines to make this trulyintegrative. The real problem often lies within the patient.Parents/patients generally do not want combined or IM.Many of them believe that CM has to be used alone.Even with an integrative approach, many parents/patientswould demand to remove the WM component andrequest pure herbal ingredients (pure Han formula, purelyherbal). Hence, our common "enemies" are the myths("mind devils"), fallacies, fake or pseudo-CM, and theparent(s).

References

1. h t t p : / / w w w. i n f o . g o v. h k / g ia / g e n e r a l / 2 0 1 7 0 6 / 2 1 /P2017062101004.htm (accessed May 9, 2017).

2. Hon KL, Lee VW, Leung TF. Stop tarnishing steroid and Chinesemedicine. World J Pediatr 2016;12:133-4.

3. Franke V, Scholtens WF, von Rosenstiel IA, Walenkamp MJ.Exogenous Cushing's syndrome due to a Chinese herbalist'sprescription of ointment containing dexamethasone. BMJ CaseRep 2017;2017. pii: bcr-2016-218721.

4. https://www.consumer.org.hk/ws_en/consumer_alerts/recalls_and_alerts/20170627.htm (accessed May 9, 2017).

5. Leung AK, Hon KL, Robson WL. Atopic dermatitis. Adv Pediatr2007;54:241-73.

6. Hon KL, Leung TF, Yau HC, Chan T. Paradoxical use of oral andtopical steroids in steroid-phobic patients resorting to traditionalChinese medicines. World J Pediatr 2012;8:263-7.

7. Aubert-Wastiaux H, Moret L, Le Rhun A, et al. Topicalcorticosteroid phobia in atopic dermatitis: a study of its nature,origins and frequency. Brit J Dermatol 2011;165:808-14.

8. Hon KL, Tsang YC, Pong NH, et al. Correlations among

steroid fear, acceptability, usage frequency, quality of lifeand disease severity in childhood eczema. J Dermatolog Treat2015;26:418-25.

9. Hon KL, Burd A. 999 abuse: do mothers know what they areusing? J Dermatolog Treat 2008;19:241-5.

10. Hon KL, Chan BC, Leung PC. Chinese herbal medicine researchin eczema treatment. Chin Med 2011;6:17.

11. Kim JH, Kim H. Combination treatment with herbal medicinesand Western medicines in atopic dermatitis: Benefits andconsiderations. Chin J Integr Med 2016;22:323-7.

12. http://hongkong.coconuts.co/2015/12/22/long-term-eczema-sufferer-plunges-death-hong-kong-after-condition-worsens;http://orientaldaily.on.cc/cnt/news/20151218/00176_051.html;http://www.ejinsight.com/20151218-long-term-eczema-sufferer-ends-it-all/ (accessed May 9, 2017).

13. https://www.theguardian.com/world/2009/sep/28/homeopathy-baby-death-couple-jailed; http://www.smh.com.au/national/parents-guilty-of-manslaughter-over-daughters-eczema-death-20090605-bxvx.html (accessed May 9, 2017).

14. Hon KL, Ying NS, Cheung KL. A tragic case of atopic eczema:malnutrition and infections despite multivitamins and supplements.Iran J Allergy Asthma Immunol 2012;11:267-70.

15. Chung VC, Ma PH, Hong LC, Griffiths SM. Organizationaldeterminants of interprofessional collaboration in integrativehealth care: systematic review of qualitative studies. PLoS One2012;7:e50022.

16. Robinson N. Integrated traditional Chinese medicine. ComplementTher Clin Pract 2006;12:132-40.

17. Zhao L, Chan K. Patient-reported outcomes (PROs): an approachto evaluate treatment efficacy of Chinese medicine or integrativemedicine. Chin J Integr Med 2005;11:151-3.

18. Bukutu C, Deol J, Shamseer L, Vohra S; American Academy ofPediatrics Provisional Section on Complementary, Holistic, andIntegrative Medicine. Complementary, holistic, and integrativemedicine: atopic dermatitis. Pediatr Rev 2007;28:e87-e94.

19. DiNicola C, Kekevian A, Chang C. Integrative medicine as adjuncttherapy in the treatment of atopic dermatitis-the role of traditionalChinese medicine, dietary supplements, and other modalities. ClinRev Allergy Immunol 2013;44:242-53.

20. Boneberger S, Rupec RA, Ruzicka T. Complementary therapyfor atopic dermatitis and other allergic skin diseases: facts andcontroversies. Clin Dermatol 2010;28:57-61.

21. Hon KL, Leung AKC, Leung TNH, Lee VWY. Complementary,Alternative and Integrative Medicine for Childhood AtopicDermatitis. Recent Pat Inflamm Allergy Drug Discov 2017;11:114-24.

HK J Paediatr (new series) 2018;23:195

Dear Editor,

Ethical Issue in Use of Expensive Drugs for Treatmentof Rare Metabolic Diseases in Hong Kong

In the past forty years, we have witnessed the dramaticchange in the clinical management of rare metabolicdiseases in Hong Kong. Before specific drug treatment wasavailable, families with children with rare metabolicdiseases had under great difficulty and experienced theinevitable downhill course and death of these children. Withthe advent of specific and new drug treatment, the prognosisof these unfortunate children has changed but an ethicalissue arises as to who should pay for the cost of thetreatment. Most if not all of these families cannot afford topay for the huge cost involved and should public resourcebe used to treat just a small number of patients. It is known

Letter to the Editor

that public resource is used to treat these patients in Taiwanand Japan and Parents' Support Group in Hong Kong hasurged the local Government to do likewise. I think thereshould be more public and open discussion on the issuebefore a concensus is reached and as a child advocate, ourCollege might consider whether it should be involved inthis hot subject.

R YUEN

Associate Director,Holy Spirit Seminary College Bioethics Resource Centre,

Hong Kong

Correspondence to: Dr R YUEN



What is the Diagnosis?

JLF FUNG, MKL WONG, BHY CHUNG

The clinical quiz was prepared by:MKL WONG

JLF FUNG

BHY CHUNG

Department of Paediatrics & Adolescent Medicine, The Universityof Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong

Our patient is a 28-year-old female who was referredto the Genetics Clinic for pre-marital counselling. Thepatient has generally good past health except she wasalways commented by her family doctor to have laxjoints and loose skin. Upon examination, patient wasnoted to have hyper-extensibility, laxed skin, easy

Answer to "Clinical Quiz" on Pages 204-205N.B. The Editors invite contributions of illustrative clinical casesor materials to this section of the journal.

Clinical Quiz

Figure 1 Clinical photos of the patient. (Consent forpublication has been obtained).

bruising, poor wound healing and a history of contusionof knee. Apart from the above characteristics, herphysical health is unremarkable. Her cervical smear isnegative and family history is uncertain. She is planningto have an IVF and Preimplantation Genetic Diagnosisin the future.


Abstracts of Articles in Chinese

JS Jeon, HS Song, JK Kim. Diagnosing Enteroviral Meningitis Using Real-time RT-PCR with Cerebrospinal Fluidand Stool Specimens. HK J Paediatr (new series) 2018;23:157-161

CSF CSF2011-2015 Cheonan Dankook

≤18 PCR 942 1,884114 CSF 14 101

T Tural-Kara, H Özdemir, A Karbuz, BA Kocaba , A Yah i, T Erat, M Bingöl-Kolo lu, S Fitöz, E Tutar, E Çiftçi,E nce. Clinical Characteristics of Childhood Hydatid Disease: A Single Tertiary Centre Experience from Turkey.HK J Paediatr (new series) 2018;23:162-168

2009 1 2015 12134

55-197 71.4% 57.1%

198

Y Ozturk, P Gençpinar, B Erdur, Y Tokgöz, I I ik, SB Akin. Overweight and Obesity in Children Under PhenylalanineRestricted Diet. HK J Paediatr (new series) 2018;23:169-172

PKU HPABMI 480

288 246 85.4% 23 9.3%16 6.5% 246 PKU HPA

p=0.025

15q

HM Luk, IFM Lo. The Clinical and Molecular Spectrum of 15q Duplication Syndrome in Chinese. HK J Paediatr(new series) 2018;23:173-178

15q OMIM # 60863615q

2011 1 2015 12 12 48 15 15q 1% 2.9%

-15q

- 15q

15q 15q11-q13 15

YH Fang, SQ Shang, J Chen. Rare Clinical Presentation of Intestinal Malrotation After Neonatal Period: Protein-losing Enteropathy Symptoms Due to Chronic Midgut Malrotation. HK J Paediatr (new series) 2018;23:179-181

PLE 1 1112

199

YH Wu, CW Chen, YT Chang. An Extramural Duodenal Ectopic Pancreas Mimicking an Exophytic PancreaticTumour in an Adolescent. HK J Paediatr (new series) 2018;23:182-184

EJ Su, JH Hsieh, CC Hsu, KT Chen. Reye's Syndrome Arising from the Treatment of Kawasaki Disease. HK JPaediatr (new series) 2018;23:185-187

20 5

50%3-5

Denys-Drash

AKH Kwok, SMY Wong, MT Leung, WKY Chan. Denys Drash Syndrome, What Paediatrician Should Know About?HK J Paediatr (new series) 2018;23:188-191

46XY DNA1 WT1 Denys-Drash

Denys-Drash WT1


MCQs

Instruction:1. Please use pencil to shade the box for the best and correct answer (only one answer for each question).2. Send back the answer sheet (see loose leaf page) to the Hong Kong College of Paediatricians. One point will be awarded

to each article if ≥3 of the 5 answers are correct. The total score of the 4 articles will be 4 CME points.

(A) Diagnosing Enteroviral Meningitis Using Real-time RT-PCR with Cerebrospinal Fluid and StoolSpecimens

1. What kinds of viruses belongs to Picornaviridae familyand has more than 70 different serotypes and containcoxsackieviruses?a. Papillomavirusb. Norovirusc. Enterovirusd. Poxviruse. Rhinovirus

2. Which of the following is NOT a clinical symptom ofEnterovirus infection disease?a. Guillain-Barre syndromeb. central nervous system infectionsc. heart failured. meningitise. transverse myelitis

3. What is the traditional way to detect aseptic meningitis?a. Cerebrospinal fluid analysisb. Respiratory specimen culturec. Sputum cultured. Urine culturee. Blood culture

4. What are the most relevant viruses causing Asepticmeningitis?a. Poxvirusb. Enterovirusc. Paramyxovirusd. Papillomaviruse. Coronavirus

5. How old is the age group most vulnerable to enterovirusinfection?a. 40 ~ 50 year oldb. 30 ~ 40 year oldc. 20 ~ 30 year oldd. 10 ~ 20 year olde. 0 ~ 10 year old

(B) Clinical Characteristics of Childhood HydatidDisease: A Single Tertiary Centre Experiencefrom Turkey

1. The patient was admitted to hospital with cough, shortnessof breath and pain in the chest. Radiologic examinationof thorax showed "meniscus sign and snake sign". Whichof the following is the most likely diagnosis?a. Tuberculosisb. Hydatid cystc. Pulmonary embolismd. Hodgkin's lymphomae. Metastatic cancer

2. Which of the following may be symptoms of pulmonaryhydatid disease?a. Coughb. Chest painc. Dyspnoead. Haemoptysise. All of them

3. Which of the following is the most common organ thathydatid cysts localised in humans?a. Lungb. Liverc. Bone marrowd. Spleene. Kidneys

201

4. Which of the following drug is used to first choicetreatment of Echinococcus granulosus induced hydatidcysts?a. Albendazoleb. Metronidazolec. Ornidazoled. Dehydroemetinee. Pyrimethamine

5. Which of the following parasite is used to human as anintermediate host?a. Taenia saginatab. Echinococcus granulosusc. Fasciola hepaticad. Enterobius vermicularise. Ascaris lumbricoides

(C) Overweight and Obesity in Children underPhenylalanine Restricted Diet

1. Phenylketonuria:a. Is an inborn error of amino acid metabolism disorderb. Is a genetic autosomal dominant disorderc. Is presented by elevated tyrosine levelsd. Can not be treatede. Is an X-linked disorder

2. What is the molecular defect that produces classicphenylketonuria?a. Decreased activity of Tyrosine Aminotransferase

enzymeb. Decreased activity of Phenylalanine Hydroxylase

enzymec. Defect of metabolism in neutral amino acid pathwayd. Decreased activity of Dihydropteridine Reductase

enzymee. Decreased activity of Hystidine Decarboxylase

enzyme

3. Gold standard therapy for phenylketonuria includes:a. A life-long diet with limited intake of phenylalanineb. Enzyme replacement treatmentc. Liver transplantationd. Bone-marrow transplantatione. None

4. Obesity,a. is an important health problemb. its frequency is increasing worldwidec. may be related to increased carbohydrate intake in

phenylketonuria (PKU) patientsd. is a potential risk in PKU patientse. All

5. How can Phenylketonuria clinically present?a. Mental retardationb. Macrocephalyc. Status epilepticus in the newborn periodd. Metabolic crisis with lactic acidosise. Short Stature

(D) The Clinical and Molecular Spectrum of 15qDuplication Syndrome in Chinese

1. Which of the following is not a common feature of 15qduplication syndrome?a. Hypotoniab. Intellectual disabilityc. Epilepsyd. Distinctive facial gestalte. Diaphragmatic hernia

2. What are the molecular mechanism(s) for 15q duplicationsyndrome?a. Interstitial duplication of chromosome 15q11.2b. Extra isodicentric chromosome 15(idic(15)(p11.2-13.

3))c. UBE3A mutationd. a and be. a, b and c

3. Which of the following molecular test(s) can be usefulfor diagnosis of 15q duplication syndrome?a. Karyotypeb. FISH studyc. Chromosomal microarrayd. Microsatellite studye. All of above

202

Answers of January issue 2018

(A) 1. c; 2. a; 3. d; 4. e; 5. b

(B) 1. c; 2. a; 3. e; 4. c; 5. a

(C) 1. e; 2. e; 3. e; 4. a; 5. a

(D) 1. a; 2. a; 3. e; 4. c; 5. c

4. Which of the following clinical features is more commonin our Chinese cohort of 15q duplication when comparedwith western populations?a. Squintb. Autismc. Intellectual disabilityd. Epilepsye. Joint laxity

5. Concerning the outcome and prognosis of 15q duplicationsyndrome, which of following statements is false?a. Duplication in maternal allele of chromosome 15 has

better neurological outcomeb. Interstitial duplication of chromosome 15q11.2 is

better than extra isodicentric chromosome 15(idic(15)(p11.2-13.3))

c. The recurrence risk for isodicentric chromosome 15in subsequent siblings of proband is low.

d. a and be. All of above


Announcements from the Hong Kong Paediatric Society56th Annual General Meeting & 11th Oration on Child Health

56th Annual General MeetingThe 56th annual general meeting of the Hong Kong Paediatric Society (HKPS) will be held on at 7:00PMon 17th May 2018 (Thursday) at The Ballroom, One -Three, 18/F. The Mira Hong Kong, 118 NathanRoad, Tsimshatsui, Kowloon. Members will receive agenda and related documents for the meeting by post.

The 11th Oration on Child HealthThe Council of HKPS endorsed the setting up of the HKPS Medal on Child Health in 2007. The Medalis awarded to a notable person who has contributed significantly to the advancement of knowledge, bettermentof services, health education, and advocacy on child health (including medical, social and educational sectors)in Hong Kong. The Awardee will be the orator to deliver a keynote lecture at the time of annual generalmeeting.

The Council of the HKPS resolved in the 4th council meeting held on 21st December 2017 that we wouldaward Mrs. Priscilla Lui Tsang Sun Kai, B.B.S. ( ) the HKPS Medal on Child Health 2018.Mrs. Lui is the chairperson of the Hong Kong Committee on Children's Rights (2016- present) and theformer director of the Against Child Abuse (1979, 1983-2011). She is one of the founders of theHong Kong Committee on Children's Rights in 1995 and the Macau Against Child Abuse in 2006.

Mrs. Lui has been invited as keynote speaker in international conferences including the 17th ISPCANInternational Conference on Child Abuse in Hong Kong. She also served as trainer in Taiwan, Singapore,Macau and China. The awards she received include the Ten Outstanding Young Persons Award (1990),Bronze Bauhinia Star Award (2000), the Outstanding Community Services Leaders Award from the LionsClub (2001), the Outstanding Services Award from International Society of the Prevention of Child Abuse& Neglect (2006), The Hong Kong Humanity Award from the Red Cross (2009).

She contributed numerous articles to different journals and has published two books: Listen to the Voiceof the Wounded Children in 2011, and the Child at Heart in 2017.

We are pleased to announce that Mrs. Lui would receive the award and deliver the oration titled "FromChild Welfare to Child Rights: the Importance of a Child Perspective" on 17th May 2018 after ourAnnual General Meeting.


CLINICAL QUIZ (p196) ANSWER

What is the Diagnosis?

With indication in hyper-extensibility, laxed skin, easy bruising and poor wound healing, genetic testing onEhlers-Danlos syndrome is immediately performed. Genetic panel test on Ehlers-Danlos syndrome reveals ac.1502delC change in exon 12 of the COL5A1 gene, which led to frameshift of the DNA and resulted in abnormalmRNA production. The genetic test also reveals that the patient is heterozygous for COL5A1 gene. Inheritance ofEhlers-Danlos Syndrome is autosomal dominant, the recurrence risk for offspring is 50% with a COL5A1 mutation.1

What is Ehlers-Danlos Syndrome?

Ehlers-Danlos syndrome (EDS), classic type (also known as EDS type I or II) is an autosomal dominant diseasethat affects connective tissues that support skin, bones, blood vessels and many other organs. The classic type ofEDS is characterised by skin hyper-extensibility, abnormal wound healing and joint hyper-extensibility.

The skin of EDS patient is hyper-elastic and fragile. Its hyper-elastic features are demonstrated in both easyextension of skin and immediate snapping back after release. For area that is prone to minor trauma (e.g. forehead orchin) and joints (e.g. knees and elbows), splitting of dermis will be resulted. Continuous stretching of scars afterprimary wound healing and the lack of Type V collagen, therefore, lead to abnormal wound healing. Joint hyper-extensibility can be assessed using the below Beighton score (Table 1).2 Dislocations of shoulder, patellar digitships, radius, and clavicle are usually observed. Apart from the above phenotype, patients suffer from hypotonia,muscle cramps and fatigue, and easy bruising.

The following diagnostic criteria could be used when there is suspicion on individual suffering from classicalEDS. The combination of the first three major diagnostic criteria should have a high specificity for classic type EDS.The presence of one or more minor criteria contributes to the diagnosis of classic type EDS but is not sufficient toestablish the diagnosis. The patient satisfied 3 of the major and 1 of the minor diagnostic criteria: skin hyper-extensibility, widened atrophic scars, joint hyper-mobility and easy bruising.

Table 1 Beighton score for joint hyper-mobility

Joint Negative Unilateral Bilateral Patient's score

Passive dorsiflexion of the 5th finger >90º 0 1 2 2

Passive flexion of thumbs to the forearm 0 1 2 2

Hyperextension of the elbows beyond 10º 0 1 2 2

Hyperextension of the knees beyond 10º 0 1 2 2

Forward flexion of the trunk with knees fully extended and 0 1 1 1palms resting on the floor

# Total Score ≥≥≥≥≥5 defines joint hyper-mobility 9

205

Major Diagnostic Criteria• Skin Hyper-extensibility• Widened Atrophic Scars• Joint Hyper-mobility• Positive Family History

Minor Diagnostic Criteria• Smooth, Velvety Skin• Molluscoid pseudotumours• Subcutaneous spheroids• Complications of Joint Hyper-mobility• Muscle Hypotonia• Easy Bruising• Manifestations of tissue extensibility and fragility• Surgical complications

Traditionally, Ehlers-Danlos syndrome is tested by taking skin biopsy for electron microscopy and biochemicaltesting, but the diagnostics is sometimes not definite. Molecular genetic diagnosis by sequencing and deletion/duplication analysis is now a less invasive option that could account of ≥50% affected individuals.

What is the Molecular Genetics behind Elhers-Danlos Syndrome?

Mutations in a numerous of genes are found to be corresponded to EDS. Currently, it is estimated that around 50%of EDS classic type patients have mutations in COL5A1 and/or COL5A2 gene. A large proportion of them arecharacterised by a mutation leading to a non-functional COL5A1 gene, while the others have a mutation that lead toproduction of functionally defective COL5A1 allele.2 The severity of phenotype among patients could vary greatly.

COL5A1 and COL5A2 code for Type V collagen alpha 1 or alpha 2 respectively. The production of collageninvolves a complicated 6-step synthesis. Defects in formation of one of the intermediates: tropocollagen will lead toEhlers-Danlos syndrome.

What is the Management of Ehlers-Danlos Syndrome?

Clinical examination should be given immediately after diagnosis of Ehlers-Danlos syndrome to assess skinhyper-extensibility, presence of atrophic scars and bruises, and other manifestations of classic type EDS.

Physiotherapeutic program and non-weight-bearing muscular exercise should be given to classic EDS childrenwho are suffering from delayed motor developed and hypotonia. For individuals with muscle hypotonia and jointinstability with chronic pain, advice should be given to adjust their lifestyles, which behaviour and psychologicaltherapy will also be practical.3 Anti-inflammatory drugs may also help in relieving joint pain. Since EDS patientsdemonstrate abnormal wound healing, dermal wounds should be closed without tension, in two layers and withapplication of deep stitches.

As aforementioned, the patient in the clinical quiz aimed to carry a child. Therefore, management measures forpregnancy were also given. Ehler-Danlos syndrome has an autosomal dominant inheritance. There is a 50% chancefor the patient to pass the pathogenic mutation down to her offspring in each pregnancy. The availability of prenataldiagnosis or preimplantation genetic diagnosis should be discussed with the care physician and obstetrician beforepregnancy.

206 Clinical Quiz Answer

Moreover, Ehlers-Danlos mothers are more vulnerable to premature rupture of membranes, which results inprematurity.4 Since EDS patients are affected by hypotonia, probability of breech presentation will be more frequent.Dislocation of hips or shoulder of the newborn will result if the newborn is also affected by EDS. While and afterdelivery, tearing of perineal skin by forceps, extension of episiotomy incisions and prolapse of uterus and/or bladdermay also occur. Therefore, pregnant women should be closely monitored throughout pregnancy and in the postpartumperiod. Vitamin C (Ascorbic acid) should also be given to relieve easy bruising.

Acknowledgments

We would like to express our gratitude to the patient and his family for their contribution. Informed consent wasobtained for publication.

References

1. Byers PH, Murray ML. Heritable collagen disorders: The paradigm of the Ehlers-Danlos syndrome. J Invest Dermatol 2012;132:E6-11.2. Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS).

J Rheumatol 2000;27:1777-9.3. Holmes DF, Gilpin CJ, Baldock C, Ziese U, Koster AJ, Kadler KE. Corneal collagen fibril structure in three dimensions: Structural

insights into fibril assembly, mechanical properties, and tissue organization. Proc Natl Acad Sci U S A 2001;98:7307-12.4. Oderich GS, Panneton JM, Bower TC, et al. The spectrum, management and clinical outcome of Ehlers-Danlos syndrome type IV:

a 30-year experience. J Vasc Surg 2005;42:98-106.


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making by analogy. N Engl J Med 1995;332:592-6.2. Organisation as author The Royal Marsden Hospital Bone-

Marrow Transplantation Team. Failure of syngeneic bone-marrow graft without preconditioning in post-hepatitismarrow aplasia. Lancet 1977;2:742-4.

3. No author given Coffee drinking and cancer of the pancreas[editorial]. BMJ 1981;283:628.

4. Issue with supplement Gardos G, Cole JO, Haskell D, MarbyD, Paine SS, Moore P. The natural history of tardive dyskinesia.J Clin Psychopharmacol 1988;8(4 Suppl):31S-37S.

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208

5. Type of article indicated as needed [i] Fuhrman SA, JoinerKA. Binding of the third component of complement C3 byToxoplasma gondii [abstract]. Clin Res 1987;35:475A. [ii]Feldman N. Laparoscopic nephrectomy [letter]. N Engl J Med1991;325:1110.

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and their treatment. 2nd ed. London: S. Paul, 1986.7. Editor(s), compiler as author Dausset J, Colombani J,

editors. Histocompatibility testing 1972. Copenhagen:Munksgaard, 1973.

8. Chapter in a book Steiner RE, Bydder GM. Clinical nuclearmagnetic resonance imaging. In: Dawaon AM, CompstonND, Besser GM, editors. Recent advances in medicine no.19. Edinburgh: Churchill Livingston, 1984:39-56.

9. Conference paper Harley NH. Comparing radon daughterdosimetric and risk models. In: Gammage RB, Kaye SV,editors. Indoor air and human health. Proceedings of theSeventh Life Sciences Symposium; 1984 Oct 29-31;Knoxville(TN). Chelsea(MI): Lewis, 1985:69-78.

10. Dissertation Cairns R.B Infrared spectroscopic studies ofsolid oxygen [dissertation]. Berkeley, (CA): Univ. ofCalifornia, 1965.

11. Scientific and technical report Akutsu T. Total heartreplacement device. Bethesda (MD): National Institutes ofHealth, National Heart and Lung Institute; 1974 Apr ReportNo: NIH-NHLI-69-2185-4.

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Hong Kong Journal of PaediatricsApril Issue 2018

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