An analysis of children with brucellosis associated with pancytopenia

Brucellosis produces a variety of nonspecific hematologic abnormalities. Hematologic complications of mild anemia and leukopenia have been frequently associated with acute brucellosis, but pancytopenia is less frequently seen. In this study, records of children with brucellosis aged under or equal to 16 years, admitted to Yuzuncu Yil University Hospital between 2004 and 2010, were analyzed retrospectively. Over this time period, 187 patients with brucellosis were diagnosed. Twenty-five (13.3%) of 187 patients had pancytopenia during admission to hospital. The diagnosis of brucellosis was confirmed by standard tube agglutination test in all patients; titers were 1:320 in 1 patient and 1:1280 in 24 patients. Blood culture was positive for Brucella melitensis in 3 patients (12%). Fever was the most common manifestation, followed by malaise, anorexia, sweating, and weight loss. Fever and splenomegaly were the common signs in most patients. In addition, arthritis was observed in 5 patients, and epistaxis, headache, and abdominal pain were observed in 3 patients. The common bone marrow aspiration findings consisted of increased megakaryocytes and hyperplasia of erythroid series, with a shift to the left of the granulocytic series. Histiocytic hyperplasia was observed in the bone marrow smear of 2 patients. Mild hemophagocytosis was observed in the bone marrow of 3 patients. All patients recovered completely, and their peripheral blood counts returned to normal by 2 to 6 weeks after antibiotic treatment of brucellosis. In conclusion, the authors would like to emphasize that brucellosis should be considered in the differential diagnosis of children with pancytopenia.     

Urinary tract infections owing to ESBL-producing bacteria: microorganisms change--clinical pattern does not

Aim: Urinary tract infections (UTIs) caused by extended‐spectrum beta lactamase (ESBL)‐producing bacteria have become a growing problem worldwide. The aim of this study was to investigate the clinical and radiological findings in patients with community‐acquired UTIs owing to ESBL‐producing bacteria. Methods: Files of the patients that had UTI owing to ESBL‐producing bacteria, between January 2008 and December 2009, were retrospectively evaluated. Results: One hundred and eleven UTI episodes in 94 patients were included. Seventy‐five per cent of the patients had recurrent UTIs. Ultrasound, dimercaptosuccinic acid (DMSA) scintigraphy and voiding cystourethrography (VCUG) were found abnormal in 36%, 46% and 31% of the patients, respectively. Overall, 68% of the patients had ≥1 underlying predisposing factor for UTI. Male patients and acute pyelonephritis (APN) episodes were more frequent at small ages. The rate of female patients and cystitis episodes predominated with increasing age. Ultrasound, DMSA scintigraphy, VSUG and UT abnormalities were more frequent in patients with APN, and lower UT disturbances were more frequent in patients with cystitis. Conclusion: UTIs owing to ESBL‐producing bacteria begin to replace UTIs owing to non‐ESBL‐producing bacteria. However, the clinical pattern of these infections does not seem to be different. Thus, our aim should be to correct underlying predisposing factors in general in order to prevent infections owing to ESBL‐producing bacteria.     

Brucellosis in children in Iraq

We studied 50 children with brucellosis. Diagnoses were made from clinical pictures and agglutination titres. Fevers, sweating and chills were common complaints. Hepatosplenomegaly and arthritis were usual findings. Tetracycline is an effective drug for management of childhood brucellosis. Seven patients with relapse were treated successfully with combination of tetracycline and co-trimoxazole.     

Fibromyalgia and chronic fatigue syndrome in children

Background: Fibromyalgia (FM) is characterized by widespread persistent pain and the presence of multiple discrete tender points. Chronic fatigue syndrome (CFS) is a syndrome characterized by debilitating fatigue associated with a variable number of non‐specific complaints. Because neither condition had necessarily been recognized in children until recently, those patients have been treated as having school refusal without being diagnosed as having either syndrome. There is a considerable overlap of clinical symptoms between these two syndromes. It is therefore controversial as to whether these syndromes have the same pathogenesis or not. The aim of the present study was to clarify the relationship between these syndromes in children. Methods: Fifteen patients with FM and 21 patients with CFS were investigated both clinically and immunologically. Immunological assessments included thorough analysis of autoantibodies using several techniques. Results: Anti‐nuclear antibody titers were higher and the prevalence of anti‐Sa antibody was far more frequent in CFS patients than in FM patients. Conclusion: CFS and FM are different from each other at least in childhood, from an immunological aspect, although some patients could have both conditions.     

A Prospective Study of Brucellosis in Children: Relative Frequency of Pancytopenia

Objective

Hematological complications of brucellosis are common. Pancytopenia, although mainly reported in adults, has also been described in children with brucellosis. This investigation was conducted to estimate the relative frequency of pancytopenia in children with brucellosis.

Methods

The current study was conducted in Al-Khafji Joint Operations Hospital, Saudi Arabia. Sixty patients with brucellosis were enrolled in the study. Complete blood count (CBC) and blood culture were performed for all cases. Bone marrow (BM) aspiration was considered only in those with pancytopenia.

Findings

Out of 60 children with brucellosis, 50 (83%) ingested raw animal milk and 27 (45%) had a positive family history of brucellosis. The common presenting symptoms and signs included: excessive sweating (68%), bone aches (62%), chills (55%), arthritis (32%), hepatomegaly (18%) and splenomegaly (15%). The main hematological manifestations included: anemia (43%), leukopenia (38%) and leukocytosis (20%). Pancytopenia was detected in 11 (18%) patients. Blood culture for Brucella was positive in 38% (23 patients). B. melitensis from 21 patients was cultured in vitro. Out of 9 BM aspirate cultures, 3 were positive for B. melitensis. Out of 11 patients with pancytopenia, 9 (82%) patients had bone aches and weakness, 7 (64%) patients sweating and chills, 6 (55%) patients petechiae and purpura.

Conclusion

The current study concludes that although pancytopenia is an uncommon complication of brucellosis in children, it does occur. Therefore, brucellosis should be considered in the differential diagnosis of pancytopenia in children, particularly in endemic areas such as Saudi Arabia.     

Clinical and laboratory features, complications and treatment outcome of brucellosis in childhood and review of the literature

Brucellosis, whether in an endemic region or not, remains a diagnostic puzzle due to occasional misleading unusual presentations and non-specific symptoms. The aim of this study was to evaluate the clinical and laboratory findings, complications and treatment outcome of brucellosis in children in southeastern Anatolia, Turkey. This study focuses on the frequency of clinical and laboratory findings and complications in cases with brucellosis. Of 22 patients, 8 (36.3%) were female and 14 (63.7%) were male. Fever, malaise, lack of appetite, arthralgia, and night sweating were the main presenting symptoms overall. Hematologic complications (n=13, 59.1%) were most common, followed by skeletal (n=7, 31.8%) and cutaneous system (n=1, 4.5%). Brucellosis may affect any organ system and imitate a variety of clinical entities. Diagnosis of brucellosis should be considered whenever there is a febrile illness associated with rheumatological complaints. Consequently, early recognition of the infection, prolonged antibiotic treatment and careful long-term follow-up should improve the patient outcome.     

Hematological consequences of pandemic influenza H1N1 infection: a single center experience

Since its identification in April 2009, pandemic influenza H1N1 virus has affected thousands of people worldwide. Viruses, particularly Epstein-Barr virus, cytomegalovirus and parvovirus B19, may have diverse hematological consequences, including anemia, neutropenia, thrombocytopenia, lymphocytosis, hemophagocytic lymphohistiocytosis, and coagulation abnormalities. In this study, a total of 31 consecutive pediatric patients, with and without chronic diseases, who had flu symptoms and were confirmed to have pandemic influenza, were evaluated for hematological consequences upon presentation to hospital. Eight (25.8%) patients had leukopenia and six (19.4%) had thrombocytopenia at the time of diagnosis of H1N1 infection. Pandemic influenza H1N1 infection may cause diverse hematological findings, including cytopenias and hemophagocytosis.     

CT findings of plastic bronchitis in children after a Fontan operation

BACKGROUND: Plastic bronchitis is a rare cause of acute obstructive respiratory failure in children. Life-threatening events are much more frequent in patients with repaired cyanotic congenital heart disease, and most frequent following a Fontan operation. Commonly, the diagnosis is not made until bronchial casts are expectorated. Detailed CT findings in plastic bronchitis have not been described. OBJECTIVE: To describe the CT findings in plastic bronchitis in children after a Fontan operation. MATERIALS AND METHODS: Three children with plastic bronchitis after a Fontan operation were evaluated by chest CT. Bronchial casts were spontaneously expectorated and/or extracted by bronchoscopy. Airway and lung abnormalities seen on CT were analyzed in the three children. RESULTS: CT demonstrated bronchial casts in the central airways with associated atelectasis and consolidation in all children. The affected airways were completely or partially obstructed by the bronchial casts without associated bronchiectasis. The airway and lung abnormalities rapidly improved after removal of the bronchial casts. CONCLUSION: CT can identify airway and lung abnormalities in children with plastic bronchitis after a Fontan operation. In addition, CT can be used to guide bronchoscopy and to monitor treatment responses, and thereby may improve clinical outcomes.     

Itraconazole for invasive fungal infection with pediatric malignancies

Background: Invasive fungal infection (IFI) is an increasingly common and often fatal infection in children with hematological malignancies and solid tumor. Prophylactic therapy with anti‐fungal agents is very important for these patients, because the early diagnosis of IFI is very difficult. Procedure: A total of 0.5 mL/kg per day of itraconazole oral solution (ITCZ‐OS) was administered in twice‐daily doses to 22 children with hematological malignancies who had received chemotherapy, and its usefulness and safety regarding the prevention of IFI were examined. Result: Prophylactic therapy with ITCZ‐OS was completed in 18 (81.8%) of the 22 children. Of these, IFI was not strongly suspected in any child. Side‐effects included non‐alcoholic steatohepatitis in two children, syndrome of inappropriate anti‐diuretic hormone secretion in one, and liver dysfunction in one. The administration of ITCZ‐OS was discontinued in these cases. These four children had received vincristine sulfate (VCR) or irinotecan hydrochloride, which were reported to interact with ITCZ. In most children the plasma levels of ITCZ were satisfactory. The plasma levels, however, were slightly increased in VCR‐treated children; ITCZ should be carefully administered. Conclusion: Although the number of subjects was small in the present study, the plasma concentrations of ITCZ‐OS favorably increased in the children with hematological malignancies, suggesting that this agent exhibits prophylactic effects on IFI. It must be considered, however, that some combined agents cause side‐effects via their interactions with ITCZ.     

Myeloid neoplasm with prominent eosinophilia and PDGFRA rearrangement treated with imatinib mesylate

The FIP1L1–PDGFRA fusion gene is the most frequent genetic aberration in myeloid neoplasms associated with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1. Affected patients in adult populations are very sensitive to imatinib therapy. Pediatric cases are rare and so far only one case of FIP1L1–PDGFRA positive disease has been reported. We report a 2‐year‐old female with a myeloid neoplasm associated with eosinophilia and rearrangement of PDGFRA. Treatment with imatinib resulted in complete and durable clinical, hematological, and molecular remission within 3 months after starting treatment. Pediatr Blood Cancer. 2010;55:730–732. © 2010 Wiley‐Liss, Inc.     

Nutritional copper deficiency. Apropos of a case

Copper deficiency developed in a five-month-old prematurely born infant with an abdominal wall closure defect and a small bowel fistula under long-term parenteral nutrition. The first manifestations were typical bone changes including diffuse osteoporosis, delayed bone age, widened cupped metaphyses with beaks and a fracture, subperiosteal hematomas and ossifications in the shafts of long bones, and a diaphyseal fracture. Other findings that confirmed the diagnosis included edema of the limbs with pseudoparalysis, neurologic abnormalities, anemia, leukoneutropenia, and very low serum levels of copper and ceruloplasmin. Following initiation of copper supplementation, clinical, hematological and biological disorders resolved within a few days and roentgenologic bone abnormalities within four months. Copper deficiency develops only in the presence of specific risk factors, that are often combined in a single patient: inadequate stores due to prematurity, excessive loss due to chronic diarrhea, exudative enteropathy, a proximal stoma, or a biliodigestive fistula; and inadequate intake due to malabsorption or long-term exclusive parenteral nutrition (EPN). Appropriate copper supplementation is needed in all these high risk situations. Early, continuous copper supplementation is required for young children under EPN. Serum copper assays should be included among the periodically monitored biochemical parameters.     

Clinical characteristics of neonates With VACTERL association

Background: The VACTERL association (VA) is the non‐random co‐occurrence of vertebral anomalies, anal atresia, cardiovascular malformations, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and/or limb anomalies, and is referred to by the first letters of its components. Studies investigating the clinical characteristics of VA patients and probing of the observed current six component types are limited, and none of them is focused on neonates. We investigated the clinical characteristics of our patients diagnosed as having VA in the newborn period. Methods: We retrospectively reviewed the neonates whose final diagnosis was VACTERL association. Presence of at least three components of previously reported six anomalies was accepted as VACTERL association. Sex, birthweight, gestational age, postnatal age, anomalies of the systems that are included in VA, and the other features were recorded. Results: There was a male predominance (14/11) of 28 patients; and there were three patients with ambiguous genitalia. The most common observed VACTERL component was vertebral anomalies (n= 26), followed by anal atresia (n= 19), tracheoesophageal fistula/esophageal atresia (n= 17), renal anomalies (n= 15), limb anomalies (n= 15) and cardiac anomalies (n= 14). The most frequent combination was VCTL (n= 4). Fifteen (57%) patients had non‐VACTERL anomalies and the most frequent of these was ambiguous genitalia (n= 3). Conclusion: VA patients may have different clinical characteristics in different populations, and clinicians may miss some component features if the patients are evaluated after the neonatal period.     

Leptomeningeal metastases in pediatrics: magnetic resonance image manifestations and correlation with cerebral spinal fluid cytology

Background: Detection of leptomeningeal metastases is fundamental to a complete evaluation of central nervous system (CNS) or non‐CNS tumor with suspected involvement of the neuroaxis. Our purpose was to assess the appearances of different magnetic resonance (MR) sequences in the diagnosis of leptomeningeal metastases and correlate those positive findings with the cerebral spinal fluid (CSF) cytology results. Methods: The authors reviewed the medical records and MR image manifestations of leptomeningeal metastases from 18 children who had positive MR findings and retrospectively correlated them with CSF cytologic results. There was a uniform MR protocol and the patients were examined with the same sequences. Results: The abnormalities included pial‐arachnoid disease (n= 16), disease coating the nerves (n= 12), hydrocephalus (n= 3) and subependymal metastases (n= 2). Enhanced T1 images were better than unenhanced fluid attenuated inversion recovery (FLAIR) and T2 to delineate cranial and spinal leptomeningeal metastases. In our sample, seven out of 18 cases were cytologically negative on a single lumbar puncture. Conclusions: Contrast‐enhanced MR imaging can be invaluable, detecting the false‐negative lumbar punctures. FLAIR and diffusion images can be helpful in diagnosing leptomeningeal metastases of non‐enhancing primary tumors. Prognosis was more related to the primary tumor type than to the leptomeningeal enhancement MR pattern.     

CBT for childhood anxiety disorders: differential changes in selective attention between treatment responders and non‐responders

Background: This study examined whether treatment response to stepped‐care cognitive‐behavioural treatment (CBT) is associated with changes in threat‐related selective attention and its specific components in a large clinical sample of anxiety‐disordered children. Methods: Ninety‐one children with an anxiety disorder were included in the present study. Children received a standardized stepped‐care CBT. Three treatment response groups were distinguished: initial responders (anxiety disorder free after phase one: child‐focused CBT), secondary responders (anxiety disorder free after phase two: child–parent‐focused CBT), and treatment non‐responders. Treatment response was determined using a semi‐structured clinical interview. Children performed a pictorial dot‐probe task before and after stepped‐care CBT (i.e., before phase one and after phase two CBT). Results: Changes in selective attention to severely threatening pictures, but not to mildly threatening pictures, were significantly associated with treatment success. At pre‐treatment assessment, initial responders selectively attended away from severely threatening pictures, whereas secondary responders selectively attended toward severely threatening pictures. After stepped‐care CBT, initial and secondary responders did not show any selectivity in the attentional processing of severely threatening pictures. Treatment non‐responders did not show any changes in selective attention due to CBT. Conclusions: Initial and secondary treatment responders showed a reduction of their predisposition to selectively attend away or toward severely threatening pictures, respectively. Treatment non‐responders did not show any changes in selective attention. The pictorial dot‐probe task can be considered a potentially valuable tool in assigning children to appropriate treatment formats as well as for monitoring changes in selective attention during the course of CBT.     

Simple hematological tests for diagnosis of neonatal sepsis

Simple hematological tests, TLC, DLC, mESR, platelet count, were performed in 128 neonates of which 50 were controls and 78 were cases of suspected septicemia. Thirty three had positive blood cultures and were taken as 'proved' and remaining as 'probable' sepsis. A band cell neutrophil (B/N) ratio of greater than 0.2 was most sensitive index (92%) followed by raised mESR of greater than 8 mm for 1st hour, whereas leukopenia of greater than 5 x 10(3)/mm3 was most specific index (88%) for the diagnosis of sepsis. Thrombocytopenia of less than 1.5 x 10(5)/cu mm was also taken as positive test for sepsis. A combination of three positive tests had highest positive predictive accuracy (94%) for early diagnosis of sepsis, when compared to single test or two positive test combinations. The best combination of tests was B/N ratio, leukopenia and mESR which can be easily done in a side laboratory.     

The effect of MMF dose and trough levels on adverse effects in pediatric heart transplant recipients

Limited pharmacokinetic and safety data exist for MMF in pediatric HTR. Previously targeted MPA‐TL are 1.5–3.0 μg/mL. The objective of this study was to assess the outcomes targeting MPA‐TL of 0.8–2.0 μg/mL in pediatric HTR. MPA‐TL were retrospectively collected 2–12 months post‐transplant. Acute rejection, infection, leukopenia, and GI complaints were then correlated with MPA‐TL. A total of 355 MPA‐TL from 22 HTR were included. Median age was 2.5 yr. Primary indication for transplant was dilated cardiomyopathy (64%). Mean MPA‐TL was 1.7 ± 0.9 μg/mL. African American patients received significantly higher doses (702 ± 235 mg/m²) compared with other races (p = 0.035). Leukopenia was less common in patients with SUB MPA vs. others (p = 0.01). MMF was discontinued for GI complaints in one patient and leukopenia in two patients. One SUB patient had acute rejection, and one SUP patient had infection. One‐yr survival was 100%. Targeting a lower range for MPA‐TL was not associated with significant rejection or infection. Despite lower MPA‐TL, MMF was discontinued in 3/22 patients for adverse effects.     

Fish allergy in childhood

Fish and its derived products play an important role in human nutrition, but they may also be a potent food allergen. Fish can be an ingested, contact, and inhalant allergen. Gad c I, a Parvalbumin, the major allergen in codfish, is considered as fish and amphibian pan‐allergen. Prevalence of fish allergy appears to depend on the amount of fish eaten in the local diet. In Europe, the highest consumption occurs in Scandinavian countries, Spain and Portugal. In Spain, fish is the third most frequent allergen in children under 2 yr of age after egg and cow’s milk. An adverse reaction to fish may be of non‐allergic origin, due to food contamination or newly formed toxic products, but the most frequent type of adverse reactions to fish are immunologic‐mediated reactions (allergic reactions). Such allergic reactions may be both IgE‐mediated and non‐IgE‐mediated. Most cases are IgE‐mediated, due to ingestion or contact with fish or as a result of inhalation of cooking vapors. Some children develop non‐IgE‐mediated type allergies such as food protein induced enterocolitis syndrome. The clinical symptoms related to IgE‐mediated fish allergy are most frequently acute urticaria and angioedema as well as mild oral symptoms, worsening of atopic dermatitis, respiratory symptoms such as rhinitis or asthma, and gastrointestinal symptoms such as nausea and vomiting. Anaphylaxis may also occur. Among all the species studied, those from the Tunidae and Xiphiidae families appear to be the least allergenic.     

Odontostomatologic involvement in juvenile localised scleroderma of the face

Aim: Localised scleroderma of the face (LSF) can lead to significant aesthetical and functional abnormalities. Despite their quite frequent clinical observation, the odontostomatologic complications are not thoroughly described. Aim of the study was to describe the clinical features of the most frequent odontostomatologic abnormalities of LSF and to propose clinical and radiologic criteria for the assessment and follow‐up of these complications. Methods: We performed a cross‐sectional, multicenter study involving a multidisciplinary team formed by paediatric rheumatologists, orthodontists and radiologists. Patients with a diagnosis of LSF underwent a comprehensive rheumatologic evaluation, dental examination, conventional radiology (orthopantomography, teleradiography) and cone beam computed tomography. Results: 16 patients, nine F, seven M, aged 6.5–21.9 years, were investigated. The mean disease duration was 7.7 years, 62.5% had extracutaneous complications. All patients reported at least one odontostomatologic complication. The main alterations were: malocclusion (94%), overgrowth tendency of the anterior lower third of the face (82%), gnatologic alterations (69%), dental anomalies (63%), skeletal asymmetry (56%), bone involvement (50%) and temporomandibular joint involvement (19%). Conclusions: We found a high incidence of odontostomatologic abnormalities in LSF. Cone beam computed tomography represents a new feasible technique to evaluate and monitor soft and hard tissue changes in LSF. The observed findings highlight the importance of a multidisciplinary and standardised management of this challenging and rare condition.     

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of ‘prodromal’ or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as ‘clinical high risk’ (CHR), or ‘ultra‐high risk’ (UHR), or ‘prodromal’. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second‐generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non‐specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, ‘multisite’ projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non‐antipsychotic, neuroprotective and low‐risk pharmacologic and non‐pharmacologic interventions; 3) testing of potentially phase‐specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow‐up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia‐spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.     

Early cardiac evaluation in children with non‐specific mitochondrial disease with isolated mitochondrial respiratory chain complex I defect

Aims: We evaluated echocardiography and electrocardiography (ECG) results in children with non‐specific mitochondrial disease (MD) in order to study early cardiac involvement, a well‐known complication of the disease. Methods: Among non‐specific MD children whose isolated mitochondrial respiratory chain complex I defect was confirmed by muscle biopsy and satisfied the criteria of MD, 27 who had no cardiac symptoms were evaluated by echocardiography and ECG. Results: Three (11.1%) out of the 27 non‐specific MD patients had left ventricular ejection fraction of less than 55% and two of them (7.4%) had fractional shortening of less than 26%. ECG abnormalities were observed in 16 of the non‐specific MD patients (59.3%). Prolongation of heart rate‐corrected QT interval was seen in 11 (40.7%) and widening of the QRS interval in eight (29.6%). Left ventricular ejection fraction and fractional shortening of the patients were significantly decreased compared with those in the control group while heart rate‐corrected QT interval was prolonged in the former group. QRS interval was more widened in non‐specific MD patients, but without statistical significance. Conclusion: The potentially severe cardiac involvement observed in our subjects suggests that early cardiac evaluation after confirming the diagnosis of MD and regular follow‐up tests should be strongly recommended in children even in cases without typical cardiac manifestations.