Thrombocytopenia‐associated multi‐organ failure caused by diabetic ketoacidosis

Thrombocytopenia‐associated multi‐organ failure (TAMOF) is an increasingly reported entity in the pediatric intensive care unit. The clinical presentation is similar to thrombotic thrombocytopenic purpura, but with no evidence of hemolysis and no schistocytes on peripheral smear. We report a case of TAMOF induced by diabetic ketoacidosis and treated with therapeutic plasma exchange (TPE). Early diagnosis and initiation of TPE significantly decrease the morbidity associated with TAMOF.     

Diverse multi‐organ histopathologic changes in a failed Fontan patient

We report multi‐organ histopathological changes in a patient with protein‐losing enteropathy (PLE) over 12 years after Fontan operation. A 14‐year‐old boy with right isomerism heart and single ventricle had undergone Fontan procedure at 19 months of age, and PLE was diagnosed at 28 months. He had several episodes of intestinal bleeding and pre‐renal failure with elevated creatine, and eventually died of pneumonia. The intrapulmonary small arteries showed medial and intimal thickening resembling pulmonary hypertension. No major ulcerative lesions were found in the small or large intestines. Dilated lymph ducts, one of the characteristic features of PLE, were not seen in mucosal and submucosal areas. Liver cirrhosis was obvious despite little increase in liver enzymes. Histological changes in bilateral kidneys were subtle despite repeated episodes of renal failure. Thus, there may be significant discrepancies between clinical manifestations and multi‐organ histological changes in failed Fontan patients.     

Two decades of pediatric kidney transplantation in a multi‐ethnic cohort

Muneeruddin S, Chandar J, Abitbol CL, Seeherunvong W, Freundlich M, Ciancio G, Burke GW, Zilleruelo G. Two decades of pediatric kidney transplantation in a multi‐ethnic cohort.
Pediatr Transplantation 2010: 14:667–674. © 2010 John Wiley & Sons A/S. Abstract: This study evaluated a 20‐yr experience in kidney transplantation in children from a predominantly Hispanic community. A retrospective analysis was carried out in children who received kidney transplants from 1985 to 2005. Of 124 kidney transplants, 81 (65%) were from LD. Racial distribution was Hispanic (48%), followed by AA (24%) and Caucasian (26%). First yr allograft survival was similar in LD and DD and significantly better in LD until seven yr post transplant. eGFR <60 mL/min/1.73 m² at one yr post transplant was associated with a median allograft survival of 3.3 yr, compared to 16 yr in those with eGFR ≥ 60 mL/min/1.73 m² (p < 0.0001). Graft loss in the first five yr was from non‐adherence, recurrence of disease, and infections. Those of AA race were more likely to receive a DD and have low socioeconomic status and the poorest median allograft survival compared to Hispanics and Caucasians (6 vs. ≥15 yr; p < 0.001). In conclusion, this predominantly Hispanic cohort emphasizes the disadvantaged profile of AAs compared to other racial groups. Strategies to improve supportive services and living donations in minority populations need to be developed. Long‐term renal allograft survival is achievable if GFR is maintained >60 mL/min/1.73 m².     

Thrombocytopenia‐associated multi‐organ failure secondary to hyperglycemic,hyperosmolar non‐ketotic syndrome: A case report

Thrombocytopenia associated multi‐organ failure (TAMOF) is a clinical syndrome with features of new onset thrombocytopenia, increased lactate dehydrogenase, and multi‐organ failure in critically ill patients. TAMOF can be the initial presentation of an underlying disease process or can develop during the course of illness either during the hospital stay. TAMOF has a high mortality rate if not treated; therefore, early detection is critical. TAMOF has been rarely reported in diabetic ketoacidosis. We are describing the first case of a patient diagnosed with hyperglycemic, hyperosmolar non‐ketotic syndrome who developed TAMOF on the third day of his hospital course. In addition to supportive care in the intensive care unit the patient received serial therapeutic plasma exchanges and improved quickly after treatment. Early diagnosis and treatment of TAMOF decreases morbidity and mortality.     

Predictors of breastfeeding exclusivity among migrant and Canadian‐born women: results from a multi‐centre study

The objective of this study was to examine and compare predictors of breastfeeding exclusivity among migrant and Canadian‐born women. As part of a longitudinal study, a sample of 1184 mothers were recruited from 12 hospitals in Canada and completed questionnaires at 1 and 16 weeks post‐partum that included diverse questions from the following domains: demographic, social, migration, obstetrical, breastfeeding and maternal mood. After bivariate analysis, multivariate logistic regression analysis was completed to examine and compare predictors of exclusive breastfeeding at 16 weeks post‐partum. Among migrant women, factors predictive of breastfeeding exclusivity included non‐refugee immigrant or asylum‐seeking status, residence in Toronto or Vancouver, maternal age of ≥35 years, feels most comfortable in the country of origin or nowhere and higher Gender‐related Development Index of the country of origin. Factors predictive of not exclusively breastfeeding included maternal age of <20 years, not planning to exclusively breastfeed, not making the decision to breastfeed before pregnancy and not exclusively breastfeeding at 1 week post‐partum. Among Canadian‐born women, factors predictive of a lower likelihood of breastfeeding exclusivity included not living with father of infant, infant neonatal intensive care unit admission, planned duration of exclusive breastfeeding for <6 months, not exclusively breastfeeding at 1 week post‐partum and Edinburgh Postnatal Depression Scale score of ≥10. The only similar risk factor predicting a lower likelihood of breastfeeding exclusivity between migrant and Canadian‐born women was not exclusively breastfeeding at 1 week post‐partum; all other risk factors were dissimilar, suggesting that these groups might benefit from different strategies to optimise breastfeeding outcomes.     

Severe Evans syndrome with multi‐system involvement is a distinct immunodeficiency disorder

A female infant who presented with autoimmune hemolytic anemia and thrombocytopenia subsequently developed hepatic, dermatologic, renal, pulmonary, gastrointestinal, endocrine, and nervous system involvement. Prolonged and intensive treatment with prednisone, IVIG, mycophenolate mofetil, and anti‐CD20 and anti‐CD52 antibodies was necessary to control the symptoms. Laboratory evaluation showed normal lymphocyte subsets and function. There was normal Foxp3 and CD25 expression, no increased CD4^?CD8^? T‐cell population, and the AIRE and Fas genes were without mutations. These features place the patient at the most severe portion of the Evans syndrome spectrum, and suggest that this case may represent a rare, new immunodeficiency disorder. Pediatr Blood Cancer 2009;52:659–661. © 2009 Wiley‐Liss, Inc.     

Tigecycline treatment of multi‐drug‐resistant Corynebacterium jeikeium infection in a child with relapsing and refractory acute lymphoblastic leukemia

Corynebacterium jeikeium has been recognized as an important cause of infection, particularly among neutropenic patients who have central venous catheter (CVC). Routine use of tigecycline in children is not yet approved. Here in we present a child with relapsed‐refractory lymphoblastic leukemia who was successfully treated with tigecyline due to multi‐drug‐resistant C. jeikeium sepsis without removal of CVC. Our case highlights the use of tigecycline where there are no alternatives. Further studies regarding the efficacy and safety of tigecycline in pediatric patients are needed. Pediatr Blood Cancer. 2010;55:349–351. © 2010 Wiley–Liss, Inc.