Letters to the Editor

9 May 2011Dear Editor,

TREATMENT OF ALLERGIC RHINITIS IN CHILDREN: WHAT’S NEW?

We read with great interest the article by Turner et al.1 There area few points on drug treatment of allergic rhinitis (AR) that needmention.

Seasonal AR in children per se might affect their learningability and concentration.2 Treatment with classical antihista-mines often had a further reducing effect upon cognitive func-tion. However, use of the newer antihistaminics counteracts thefeeling of malaise caused by AR and may improve learningability.2 Drugs interacting with the cytochrome-P450 enzymesystem (e.g. macrolide antibiotics, commonly prescribed inchildren) may reduce the metabolism of the antihistaminics inthe liver. Therefore, caution should be advised againstco-administration of these drugs. The use of intranasal anti-histaminics like levocabastine, azelastine and antazoline hasthe benefit of almost no side effects. These drugs are useful inchildren with symptoms limited to the nose or the eyes. In arecent multicentre trial, subjects using both fexofenadine andmontelukast showed significantly better control of nasal con-gestion (both subjectively and objectively), compared togroups using antihistaminic alone or with placebo.3 Theauthors hypothesized that because histamine and cysteinylleukotrienes produce different responses in the pathogenesisof AR, combination therapy would be more effective thanusing a single drug. A future study might make the pictureclearer.

Presently, the costs of newer-generation antihistaminics andleukotriene receptor antagonists are higher than those ofclassic antihistaminics. This could be problematic, especiallyif several other drugs must be prescribed for a particularscenario (e.g. subjects with concomitant allergic rhinitis andasthma). In high-income countries, insurance coverage foreach agent may vary and out-of-pocket costs of these medi-cations may be a concern for those who are uninsured.As such, this is an important concern in low-incomecountries.

The authors have not described about the role of probiotics inAR, though there are many clinical trials done on this, and sometrials also have found them to be useful including in children.We have conducted a systematic review on this and found that,probiotic intake improved the quality of life score (standardizedmean difference (SMD) -1.17 (95% CI -1.47 to -0.86;P < 0.00001)), and decreased the number of episodes per year insubjects with AR.4 Adverse events were not significant. Ourconclusion was although probiotic therapy might be useful inAR, present data do not allow any treatment recommendationsto be made. More good-quality trials measuring clinically rel-evant outcomes are needed before any firm recommendationcan be made.

References

1 Turner PJ, Kemp AS. Allergic rhinitis in children. J. Paediatr. Child Health2012; 48: 302–10.

2 Vuurman EF, van-Veggel LM, Uiterwijk MM, Leutner D, O’Hanlon JF.Seasonal allergic rhinitis and antihistamine effects on children’slearning. Ann. Allergy 1993; 71: 121–6.

3 Cingi C, Gunhan K, Gage-White L, Unlu H. Efficacy of leukotrieneantagonists as concomitant therapy in allergic rhinitis. Laryngoscope2010; 120: 1718–23.

4 Das RR, Singh M, Shafiq N. Probiotics in treatment of allergic rhinitis.World Allergy Organ. J. 2010; 3: 239–44.

Dr Rashmi Ranjan DasDepartment of Pediatrics

All India Institute of Medical Sciences (AIIMS)New Delhi-110029

India

24 May 2011Dear Editor,

T-CELL LYMPHOMA MASQUERADING AS JUVENILE RHEUMATOIDARTHRITIS

We thank McKay et al. for revealing findings at presentationpredicting a diagnosis of acute lymphoblastic leukaemia (ALL)in a child presenting with features consistent with juvenilerheumatoid arthritis (JRA).1 Diagnosis of JRA is made byexcluding other potential aetiologies of arthropathy, includingmalignancies. There is no single test to diagnose JRA, and thedisease is determined by physicians clinically. Acute lympho-blastic leukaemia is the most common malignancy seen inchildhood, and 15–30% of ALL patients may present withosteoarthritic manifestations.2 There is always a concern in phy-sicians diagnosing patients with JRA that ALL is misdiagnosed.

We report a T-cell lymphoma case initially diagnosed as JRAand treated with steroids and cytotoxic agents causing tumourlysis syndrome. The literature on children with lymphoma pre-senting as JRA is scarce, and this case emphasises the impor-tance of excluding malignancies other than ALL in thesepatients.

A 5-year-old boy was admitted because of cough, fever,arthralgia and bone pain. He was first evaluated at anothercentre 3 weeks ago, and a bone marrow aspiration performedwas normal. He was diagnosed as JRA, and methylprednisoloneand methotrexate treatments were initiated. Physical examina-tion showed diffuse lymphadenopathies and a swollen rightknee. Blood count revealed only leucocytosis; blood chemistrywas consistent with tumour lysis syndrome and a chest X-rayshowed mediastinal mass with pleural effusion. Bone marrowaspiration showed 20% blasts; immunophenotype was

doi:10.1111/j.1440-1754.2012.02462.x

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Journal of Paediatrics and Child Health 48 (2012) 366–368© 2012 The Authors

Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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consistent with T cell leukaemia/lymphoma. The boy is treatedaccording to Berlin-Frankfurt-Munster-95 ALL protocol.

Children with malignancies other than leukaemia may alsopresent with rheumatological manifestations; however, there isscarce data on rheumatological presentations of other malig-nancies. A retrospective review of 29 children who werereferred to paediatric rheumatology centres showed a finaldiagnosis of leukaemia, neuroblastoma, lymphoma, Ewing’ssarcoma, ependymoma, thalamic glioma, epithelioma and sar-coma.3 A high index of suspicion is needed in patients diagnosedas JRA, and further studies such chest x-ray and abdominalultrasonography may be warranted in suspected cases. Painlocalised to bone more than joint, night-time pain, significantweight loss and night sweats, bruising, back pain, abnormalblood count and elevated lactate dehydrogenase level shouldalert the physician.1 In conclusion, children with musculoskela-tal complaints should be carefully evaluated before a diagnosisof JRA is made. An oncologist may be involved in the manage-ment of these patients especially in children with atypical fea-tures. An early blood count and even bone marrow aspiration isnot comforting enough to exclude malignancy.

Dr Nihal Ozdemir1

Professor Dr Rejin Kebudi1

Dr Gulen Tuysuz1

Professor Dr Ozgur Kasapcopur2

1Pediatric Hematology-Oncology DepartmentCerrahpasa Medical Faculty and Oncology Institute

Istanbul University2Pediatric Rheumatology Department

Cerrahpasa Medical FacultyIstanbul University

IstanbulTurkey

References

1 McKay D, Adams L, Ostring G, Singh-Grewal D. In a child presentingwith features consistent with a diagnosis of juvenile idiopathic arthritis,what clinical features or laboratory findings (at presentation) predict adiagnosis of acute lymphoblastic leukaemia? J. Paediatr. Child Health2010; 46: 442–5.

2 Marwaha RK, Kulkarni KP, Bansal D, Trehan A. Acute lymphoblasticleukemia masquerading as juvenile rheumatoid arthritis: diagnosticpitfall and association with survival. Ann. Hematol. 2010; 89: 249–54.

3 Cabral DA, Tucker LB. Malignancies in children who initially presentwith rheumatic complaints. J. Pediatr. 1999; 134: 53–7.

7 February 2012Dear Editor,

TELECONFERENCE ETIQUETTE

Your editorial on teleconferences1 made me laugh and remindedme of a teleconference I was involved in when on call for theNSW Genetic Metabolic Disorders Service. It was during schoolholidays and not one of my regular work days. My two children,aged 9 and 6 years, and I were having a lovely time in a local

park when I received a call from the NSW Newborn ScreeningProgramme to inform me that a baby in Canberra had just beenidentified as having Maple Syrup Urine Disease. I contacted thelocal neonatologist to outline a management plan until the babycould be transferred to the intensive care unit of our hospital forcontinuous veno-venous haemofiltration. I then took part in aNewborn Emergency Transport Service (NETS) teleconferenceto coordinate the baby’s management and urgent transfer. Assoon as I started the NETS teleconference, my two children,who had been playing together very well until that point,became embroiled in a wrestling match over whose turn it wasto ride the one scooter we had taken to the park. I too had noidea there was a mute button on my fancy iPhone, so inbetween giving my management advice, I was signalling to mychildren using very creative sign language and gestures, that Iwas on an important phone call, to move away from each otherand to share the scooter, otherwise there would be no visit tothe ice cream shop. They actually stopped when they saw theexpression on my face and my pathetic attempt at charades andstarted laughing at me. The people walking by were also staringat me and must have been thinking what a terrible mother notgetting off the phone to attend to her children. What could be soimportant? If they only knew. The infant survived and is nowdoing very well with a serious lifelong genetic metabolic disor-der. I have learned now that that there is a mute button on myphone and to always take two scooters to the park.

Dr Carolyn Ellaway1,2

1Senior Staff SpecialistGenetic Metabolic Disorders Service

The Children’s Hospital at Westmead2Senior Clinical Lecturer

University of SydneySydney, Australia

Reference

1 Isaacs D. Teleconference etiquette. J. Paediatr. Child Health 2012; 48:1.

7 February 2012Dear Editor,

TELECONFERENCE ETIQUETTE: JOB INTERVIEW

A friend of mine was shortlisted for a consultant job in anothercity. He arranged to do the interview by teleconference.1 Heawaited the call rather anxiously. About 10 min after the sched-uled time, they had still not called him, but he developed apowerful urge to empty his bowels – probably the result of hisnerves and the large helping of lentil curry he had enjoyed theevening before.

He took the cordless telephone into the bathroom. Of coursethe moment he had taken his seat they called him. The wholeinterview was conducted with him sitting on the toilet. He hadto cover the mouthpiece at various points to maintain thedignity of the occasion.

Letters to the Editor

Journal of Paediatrics and Child Health 48 (2012) 366–368© 2012 The AuthorsJournal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

367

A small ironic twist – he got the job and is now working as asuccessful gastroenterologist.

Professor Mike South1,2

1DirectorDepartment of General Medicine

Royal Children’s Hospital2Professor

Department of PaediatricsUniversity of Melbourne

Melbourne, VictoriaAustralia

Reference

1 Isaacs D. Teleconference etiquette. J. Paediatr. Child Health 2012; 48:1.

Image of the Month: Answer

This is a nasal tip infantile haemangioma. Unlike such haemangiomas in other locations, nasal tip haemangiomas are slow to regressand usually do not return to normality. Treatment of these conditions is difficult because of its location and complications: psychosocialimpact, severe skin infiltration and consequences on nasal growth. Systemic steroids have high efficacy rates, but in large haeman-giomas, such as our case, 35% of patients develop complications including cushingoid appearance, Hypertension and adrenalsuppression.1 Although propanolol has its value, it has a potential risk of haemodynamic compromise and death in newborn infants.2

Early surgery to remove the affected tissue seems to be the best therapy in these lesions.3 However, pulsed dye laser may be consideredin the management of mild to moderate degrees of haemangioma.4 In our patient, laser approach was performed after obtainingparents’ consent. Post-operative result was satisfactory.

References

1 Schwartz RA, Sidor MI, Musumeci ML, Lin RL, Micali G. Infantile haemangiomas: a challenge in paediatric dermatology. J. Eur. Acad. Dermatol. Venereol.2010; 24: 631–8.

2 Leaute-Labreze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo J-B, Taieb A. Propranolol for severe hemangiomas of infancy. N. Engl. J. Med.2008; 17: 2649–51.

3 Hamou C, Diner PA, Dalmonte P et al. Nasal tip haemangiomas: guidelines for an early surgical approach. J. Plast. Reconstr. Aesthet. Surg. 2010; 63:934–9.

4 Cho S, Lee SY, Choi JH, Sung KJ, Moon KC, Koh JK. Treatment of ‘Cyrano’ angioma with pulsed dye laser. Dermatol. Surg. 2001; 27: 670–2.

Letters to the Editor

Journal of Paediatrics and Child Health 48 (2012) 366–368© 2012 The Authors

Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

368