- Hyperimmunoglobulinemia D with periodic fever syndrome.

Hyperimmunoglobulinemia D with periodic fever syndrome (HIDS)

/ Mevalonate kinase deficiency (MKD)

INCIDENCE/AETIOLOGY

MKD/HIDS is extremely rare. Most patients are North European, many in Holland (it was called ‘Dutch fever’), but can occur in other ethnicities.

The disease is caused by mutations of MVK, a gene located on the long arm of chromosome 12 that encodes mevalonate kinase (MK).

CLINICAL PRESENTATION

• Onset of MKD/HIDS within the 1st 6 mo of life.
• Children experience irregular attacks that may be precipitated by vaccination, minor trauma, surgery or stress.
• Attacks last 4–7 days.
•  Fever, unilateral or bilateral cervical lymphadenopathy, abdominal pain with vomiting and diarrhea, headache, arthralgia, large joint arthritis, erythematous macules and papules and aphthous ulcers are common.
• A history of high fevers or a full attack with vaccination is often obtained

- TUMOUR NECROSIS FACTOR RECEPTOR ASSOCIATED PERIODIC SYNDROME (TRAPS).

TUMOUR NECROSIS FACTOR RECEPTOR ASSOCIATED PERIODIC SYNDROME

(TRAPS)

INCIDENCE/AETIOLOGY

It occurs in many ethnic groups with presentation in the 1st decade of life.

TRAPS is caused by AD, gene mutations in TNFRSF1A on chromosome 12.

Clinical Manifestations:-

Attacks are often far less distinct than in FMF, precipitated by minor stress, travel, menstrual cycle or diet.

Prolonged attacks occur, lasting 1–3 weeks (symptoms are near continuous in 30%). 50% give no clear family history.

Features include:

• Fever >95%.
• Arthralgia and myalgia in 80%, often with centripetal migration.
• Abdominal pain in 80%.
• Rash in 70%: erythematous, oedematous plaques, discrete reticulate or serpiginous lesions that on biopsy contains superficial and deep perivascular infiltrates of mononuclear cells.
• Headache, pleuritic pain, lymphadenopathy, conjunctivitis and periorbital oedema.
• Symptoms are accompanied by a marked acute phase response.

- FAMILIAL MEDITERRANEAN FEVER.

FAMILIAL MEDITERRANEAN FEVER

Def: Autosomal recessive autoinflammatory disease usually characterized by recurrent 1-3 day self-limited episodes of fever, serositis, mono- or pauciarticular arthritis, or an erysipeloid rash, sometimes complicated by AA amyloidosis.

Etiology:-

Caused by mutations in MEFV, a 10 exon gene located on the short arm of chromosome 16 encoding a 781 amino acid protein denoted pyrin.

FMF occurs primarily among ethnic groups of Mediterranean ancestry, most commonly Jews, Turks, Armenians, Arabs, and Italians.

Most patients present with symptoms in childhood, with 90% of patients presenting prior to the age of 20 yr.

Clinical Manifestations:-

Attacks occur irregularly, precipitated by minor physical or emotional stress, menstrual cycle, diet or infection. Attacks resolve within 72 hours.

Between flares, patients are generally symptom-free but may have persistent elevation of their inflammatory markers.

The attack frequency can vary from weekly to 1-2 flares/year.  

Clinical features includes:

•  Fever :- Temperatures rise rapidly to 38–40 °C (100.4–104 °F)..
• Serositis presenting as pleuritic chest pain or severe abdominal pain (peritonitis in 90% of patients and may mimic an acute surgical abdomen), arthritis, and rash. The pleural pain is typically unilateral, whereas the abdominal pain can be generalized or localized to 1 quadrant, similar to other forms of peritonitis.
• During an episode they often complain of constipation, secondary to the peritoneal inflammation leading to a temporary paralytic ileus, followed by diarrhea as the inflammation fades.
• Arthritis occurs primarily in the large joints, may be accompanied by large, neutrophil-rich effusions, and is usually nonerosive and nondestructive.
• The hallmark cutaneous finding is an erysipeloid erythematous rash that overlies the ankle or dorsum of the foot .
• Scrotal pain caused by inflammation of the tunica vaginalis testis,
• febrile myalgia,
• Exerciseinduced myalgia (particularly common in children),
• Association with various forms of vasculitis, including Henoch-Schönlein purpura in as many as 5% of pediatric patients.

- Cystinosis (liginac Syndrome).

Cystinosis (liginac Syndrome)

A/E:  defect in the metabolism of cysteine that results in accumulation of cystine crystals in most of the major organs of the body, notably the kidney, liver, eye, and brain.

Incidence:

-       It occurs at an incidence of 1 : 100,000 to 1 : 200,000.

-       Is the most common cause of Fanconi syndrome in children.

-       In certain populations, such as French Canadians, the incidence is much higher.

clinical patterns:

1.    Infantile or nephropathic cystinosis: the most severe form present in the 1st 2 yr of life with severe tubular dysfunction and growth failure. If the disease is not treated, the children develop end-stage renal disease by the end of their 1^st decade.

2.    A milder form of the disease manifests in adolescents and is characterized by less-severe tubular abnormalities and a slower progression to renal failure.

3.    A benign adult form with no renal involvement also exists.

-  Patients with nephropathic cystinosis present with clinical manifestations reflecting their pronounced tubular dysfunction and Fanconi syndrome…?

-  Patients are typically fair skinned and blond because of diminished pigmentation.

-  Ocular presentations include photophobia, retinopathy, and impaired visual acuity.

-  Patients also can develop hypothyroidism, HSM, and delayed sexual maturation.

-  With progressive tubulointerstitial fibrosis, renal insufficiency is invariant.

- Lowe Syndrome.

Lowe Syndrome

Lowe syndrome (oculocerebrorenal syndrome of Lowe) is a rare X-linked disorder characterized by:

-       congenital cataracts , glaucoma and blindness often develop.

-       mental retardation, hypotonia and hyporeflexia,

-       The renal abnormalities are tubular and include: hypophosphatemic rickets with ↓ serum phosphorus levels, low to normal serum calcium Levels,↑ serum alkaline phosphatase levels,pRTA, and aminoaciduria.

-  Significant proteinuria is common.

-  The disease is caused by mutations in the OCRL1 gene, which codes for a Golgi aparatus phosphatase.

-  There is no specific therapy for the renal disease or neurologic deficits.

-  Renal treatment may include alkali therapy, phosphate replacement, and vitamin D support.

-  Cataract removal is generally required.

-  Genetic counselling.

Death occur during childhood.

- Indication of urine culture in UTI in Paediatric.

 Indication of urine culture in cases of UTI in Paediatric.

 

Urine samples should be sent for culture in:

1. having a diagnosis of acute pyelonephritis/upper urinary tract infection
2. high to intermediate risk of serious illness
3. < 3 years.
4. single positive result for leukocyte esterase or nitrite
5. Recurrent UTI.
6. Infection that does not respond to treatment within 24–48 hours, if no sample has already been sent.
7. when clinical symptoms and dipstick tests do not correlate.

- Risk factors for UTI in Children.

Risk factors for UTI (urinary tract infection) in Children.

1.  Uncircumcised male have 10 times > circumcised males . 
2. Abnormal urinary tract: Children with vesicoureteral reflux (VUR) and obstruction are at higher risk for UTI. 
3. Any condition that interferes with complete emptying of the bladder increasing the risk of bacterial colonization, such as Voiding dysfunction ,constipation,neurogenic bladder,VUR. 
4. Poor perineal hygiene. 
5. Wiping from back to front in girls 
6. Bubble bath? and Tight clothing (underwear).
7. Pinworm infestation.
8. Requiring frequent catheterization.
9. Sexual activity.