The Year book of perinatal/neonatal medicine, 2006
tion and clinical outcomes for other infectious agents, including herpes simplex virus and CMV. A... more tion and clinical outcomes for other infectious agents, including herpes simplex virus and CMV. As one might surmise, studies often find that a higher viral load tends to correlate with more severe disease or worse clinical outcomes. A major limitation of viral load assays is the use of different techniques and primers by laboratories utilizing these tests. This variability does not allow easy translation of research findings into clinical tools that can enhance our ability to better care for ill infants and children. University of Alabama investigators have consistently provided us with data that continue to refine our understanding of congenital CMV infection and its consequences. In this study, CMV viral load was found to be significantly higher in the urine and peripheral blood of infants with symptomatic congenital CMV than in asymptomatic infants, in those with sensorineural hearing loss (SNHL) than in those with normal hearing, and in asymptomatic infants with SNHL than in asymptomatic newborns with normal hearing. The apparent lack of difference in CMV viral loads in the urine and PB of infants with symptomatic congenital CMV who had SNHL and those with normal hearing may be due to the small sample size. The average viral loads were higher in those with SNHL, but the standard deviations were very wide. Particularly helpful is the knowledge that infants with low CMV viral burdens in the urine or PB are at almost no risk of developing SNHL. This can be reassuring to parents of congenitally infected children. Even infants with the highest viral loads had a better than 50% chance of having normal hearing. Understanding the relationship between virus burden and long-term outcome may allow us to better select candidates for antiviral therapy with ganciclovir or valganciclovir. These drugs have prominent adverse effects profiles and need to be administered for prolonged periods for CMV-related infections. Monitoring CMV viral loads during antiviral therapy can potentially provide guidance about virologic response, dosage adjustments, and duration of treatment. Will the day come when testing for CMV DNA becomes part of the newborn screening performed on dried blood spots? CMV-positive infants can have viral loads measured in urine or peripheral blood, and those with high CMV burdens can then be treated with antiviral drugs to eliminate or limit the risk of SNHL. This does not seem so far-fetched. B. J. Freij, MD Human Cytomegalovirus Reactivation During Lactation and Mother-to-Child Transmission in Preterm Infants
Toxoplasma gondii is an obligate intracellular parasite capable of infecting humans and a variety... more Toxoplasma gondii is an obligate intracellular parasite capable of infecting humans and a variety of other warm-blooded animals. The organism is distributed widely in nature and may infect as many as 1 of 3 persons worldwide. Most Toxoplasma infections are either asymptomatic or otherwise benign; notable exceptions include the infections of the developing fetus whose mother acquires an acute T gondii infection during gestation and of immunosuppressed patients, such as those with the acquired immunodeficiency syndrome (AIDS), in whom the illness may be severe or even fatal. The cat and other felines (such as the lynx) appear to be the only definitive hosts for this protozoan. The name Toxoplasma is derived from the Greek word toxon (meaning arc or bow) and is a reference to the shape of the organism. The gondi is a North African desert rodent related to the gerbil in whose splenic and hepatic mononuclear cells the parasite was observed initially. This article briefly reviews the biol...
Amalia Voureka was a physician, bacteriologist, and Greek Resistance activist who joined the labo... more Amalia Voureka was a physician, bacteriologist, and Greek Resistance activist who joined the laboratory of Sir Alexander Fleming in 1946 on a scholarship. She had nine research publications between May 1947 and August 1952, four of which were as the single author and three as the first author. Only three were coauthored with Sir Fleming. Her research focus was bacteria and antimicrobial agents. She demonstrated variable endpoints for the bacteriostatic power of streptomycin depending on media used, inoculum size, salt concentration, and atmospheric conditions. She worked on bacterial antibiotic resistance, demonstrating the induction of bacterial variants following chloramphenicol treatment. In another paper, she showed that penicillin-resistant bacteria can be made sensitive by coculture with other organisms that are either penicillin sensitive or insensitive. In a study of staphylococcal strains from the anterior nares of patients, she documented a low rate of penicillin resistance (7.6%). Elsewhere, she showed that toxin production by staphylococci is important for virulence. She determined that bacterial flagella can be critical for movement and not simply attachments resulting from cell distress. She refined and invented new laboratory techniques, improving on flagellar staining. Dr. Voureka married Sir Fleming in 1953, despite a 31-year age difference. Her marriage to Sir Fleming was brief (he died of a heart attack in 1955). She later returned to Greece but was exiled and stripped of her citizenship by the military junta for her political activities. After the junta fell, she returned to Greece and was elected to Parliament in 1977, 1981, and 1985. She died in 1986.
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is rare, however potentially severe diseas... more Introduction: Hemophagocytic lymphohistiocytosis (HLH) is rare, however potentially severe disease. Case Description: A 33 y.o. woman presented with a >1yr history of frequent infections. She had history of pneumonia at age eight, atopic dermatitis, and human papillomavirus. Initially, she had an Epstein-Barr virus (EBV) infection which resolved. Subsequently, she experienced URIs, sinusitis, streptococcal pharyngitis, otitis externa, and otitis media. Her atopic dermatitis had been well controlled from about age 18. However, in the year prior to presentation she developed erythematous, pruritic lesions on her trunk. Workup revealed normal CBC, IgM 29 mg/dl, IgA 213 mg/dl, IgG 905 mg/dl, and IgE >23,000 mg/dl. Eleven of fourteen pneumococcal antibody titers were protective. Antibodies to strongyloides and toxocara were negative. Flow cytometry revealed low NK cells (54 cells/mm3). Genetic analysis did not reveal abnormality in TYK2, STAT3, DOCK8, or SPINK5. About two months later, her eczema had worsened to involve >90% of body surface area. Recurrent upper respiratory infections continued and extensive primary immunodeficiency genetic panel revealed UNC13D heterozygous variant. Discussion: UNC13D is usually associated with hemophagocytic lymphohistiocytosis (HLH), however, significance in this patient is not clear. While she does have recurrent infections, potentially precipitated by EBV, she has no cytopenias. She has low NK cells and IgM, but does not meet criteria for established immunodeficiency disorder. This case highlights the need to consider HLH and genetic testing in unclassified immunodeficiencies. Mild HLH could be diagnosed with NK cell function testing showing decreased or no function, hypofibrinogenemia, hypertriglyceridemia, elevated ferritin, or elevated soluble IL-2 receptor.
The role of Aeromonas (&) in the etiology of pediatric diarrhea is incompletely defined. It is un... more The role of Aeromonas (&) in the etiology of pediatric diarrhea is incompletely defined. It is unclear whether identification of isolates a t the species level or performance of toxigenicity studies help distinguish pathogenic from non-pathogenic strains. We isolated Aer from 33 of 704 children whose fecal specimens were submitted to the Microbiology Laboratory of Children's Medical Center, Dallas, over a I-year period. Isolates were identified as & using the API 20E system. Additional tests performed on 29 strains included gas from glucose, salicin fermentation, growth in KCN, esculin hydrolysis, and elastase production. A. caviae was the predominant species (n = 19, 66%). A. sobria and A. hydrophila accounted for 3 each and 4 (14%) strains could not be speciated. Toxin production by Aer was studied
About 1.5 per 1000 women giving birth in the United States are infected with the human immunodefi... more About 1.5 per 1000 women giving birth in the United States are infected with the human immunodeficiency virus. Mother-to-infant human immunodeficiency virus transmission rates in the United States are about 30% on average. Intrapartum exposure to infected maternal blood and genital secretions seems to be the most important route for perinatal human immunodeficiency virus acquisition. A first-born twin is at higher risk of infection compared with the second-born twin. Multiple human immunodeficiency virus variants exist in infected mothers, but only small subsets are transmitted to their infants. Primary maternal cytomegalovirus infection is associated with symptomatic congenital infection and significant residual neurodevelopmental abnormalities. Canciclovir has been used to treat a few infants with symptomatic congenital cytomegalovirus infections, but the benefits have been marginal. A third of asymptomatic women shedding herpes simplex virus at delivery have evidence of recent primary infections and their infants are 10 times more likely to develop neonatal herpes. About 5% of pregnant women are unaware of their risk of acquiring a primary herpes simplex virus-2 infection through sexual contact with their seropositive spouses who have no histories of genital herpes. Acyclovir and vidarabine have comparable efficacies in treating neonatal herpes. The case-fatality and morbidity rates for infants with encephalitis or disseminated herpes simplex virus infections continue to be high despite early therapy. Intrauterine diagnosis of fetal parvovirus B19 infection through B19 DNA detection in amniotic fluid and fetal blood has a better yield than serologic methods. B19-related hydrops is not uniformly fatal and may resolve spontaneously without specific therapy. Fetal adverse effects such as prematurity, stillbirth, or spontaneous abortion occur in 30% of pregnant women with measles.
Objectives To characterize the clinical course and outcomes of children 12-18 years of age who de... more Objectives To characterize the clinical course and outcomes of children 12-18 years of age who developed probable myopericarditis after vaccination with the Pfizer-BioNTech (BNT162b2) coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccine. Study design A cross-sectional study of 25 children, aged 12-18 years, diagnosed with probable myopericarditis after COVID-19 mRNA vaccination as per the Centers for Disease Control and Prevention criteria for myopericarditis at 8 US centers between May 10, 2021, and June 20, 2021. We retrospectively collected the following data: demographics, severe acute respiratory syndrome coronavirus 2 virus detection or serologic testing, clinical manifestations, laboratory test results, imaging study results, treatment, and time to resolutions of symptoms. Results Most (88%) cases followed the second dose of vaccine, and chest pain (100%) was the most common presenting symptom. Patients came to medical attention a median of 2 days (range, <1-20 days) after receipt of Pfizer mRNA COVID-19 vaccination. All adolescents had an elevated plasma troponin concentration. Echocardiographic abnormalities were infrequent, and 92% showed normal cardiac function at presentation. However, cardiac magnetic resonance imaging, obtained in 16 patients (64%), revealed that 15 (94%) had late gadolinium enhancement consistent with myopericarditis. Most were treated with ibuprofen or an equivalent nonsteroidal anti-inflammatory drug for symptomatic relief. One patient was given a corticosteroid orally after the initial administration of ibuprofen or an nonsteroidal anti-inflammatory drug; 2 patients also received intravenous immune globulin. Symptom resolution was observed within 7 days in all patients. Conclusions Our data suggest that symptoms owing to myopericarditis after the mRNA COVID-19 vaccination tend to be mild and transient. Approximately two-thirds of patients underwent cardiac magnetic resonance imaging, which revealed evidence of myocardial inflammation despite a lack of echocardiographic abnormalities.
Background Sequence type 131 (EC-ST131) is a prevalent cause of extraintestinal Escherichia coli ... more Background Sequence type 131 (EC-ST131) is a prevalent cause of extraintestinal Escherichia coli infection, including in neonates, and accounts for a majority of multidrug-resistant strains. Rare reports of neonatal unit outbreaks have emerged, with one linking the source to freshly expressed breast milk (BM) sharing. We report on premature twin girls whose infection was linked to their mother’s contaminated frozen BM. Methods Blood culture isolates were from twin girls born at 24–1/7 weeks’ gestation who developed severe sepsis caused by ampicillin- and gentamicin-resistant E. coli on days 11 (Baby A; died) and 8 (Baby B; survived) of life; both neonates had sterile blood cultures at birth, and received orogastric feeds using frozen BM provided by their mother. Five remaining frozen BM samples predating onset of sepsis were thawed and cultured; E. coli resistant to ampicillin and gentamicin was recovered from 1 collected on day 5 of life. DNA was extracted from cultured isolates us...
Introduction: Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. The clas... more Introduction: Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. The classic triad of HSP consists of nonthrombocytopenic purpura, arthritis/arthralgia, and gastrointestinal complaints. Pulmonary hemorrhage and cardiac involvement are rare complications of HSP. Case Report: We report the case of a 10-yearold girl with HSP complicated by both severe mitral regurgitation and pulmonary hemorrhage. Discussion: HSP is typically a self-limited illness with an excellent prognosis in children. Pulmonary hemorrhage is a rare complication that increases morbidity and mortality; it generally indicates the presence of severe vasculitis. Cardiac involvement in HSP is extremely rare and associated with a poor prognosis. Conclusion: Cardiac involvement in HSP may be more common than believed. Because of the increased morbidity and mortality associated with HSP complicated by pulmonary hemorrhage and cardiac involvement, it is important for clinicians to be aware of these potential complications.
The Year book of perinatal/neonatal medicine, 2006
tion and clinical outcomes for other infectious agents, including herpes simplex virus and CMV. A... more tion and clinical outcomes for other infectious agents, including herpes simplex virus and CMV. As one might surmise, studies often find that a higher viral load tends to correlate with more severe disease or worse clinical outcomes. A major limitation of viral load assays is the use of different techniques and primers by laboratories utilizing these tests. This variability does not allow easy translation of research findings into clinical tools that can enhance our ability to better care for ill infants and children. University of Alabama investigators have consistently provided us with data that continue to refine our understanding of congenital CMV infection and its consequences. In this study, CMV viral load was found to be significantly higher in the urine and peripheral blood of infants with symptomatic congenital CMV than in asymptomatic infants, in those with sensorineural hearing loss (SNHL) than in those with normal hearing, and in asymptomatic infants with SNHL than in asymptomatic newborns with normal hearing. The apparent lack of difference in CMV viral loads in the urine and PB of infants with symptomatic congenital CMV who had SNHL and those with normal hearing may be due to the small sample size. The average viral loads were higher in those with SNHL, but the standard deviations were very wide. Particularly helpful is the knowledge that infants with low CMV viral burdens in the urine or PB are at almost no risk of developing SNHL. This can be reassuring to parents of congenitally infected children. Even infants with the highest viral loads had a better than 50% chance of having normal hearing. Understanding the relationship between virus burden and long-term outcome may allow us to better select candidates for antiviral therapy with ganciclovir or valganciclovir. These drugs have prominent adverse effects profiles and need to be administered for prolonged periods for CMV-related infections. Monitoring CMV viral loads during antiviral therapy can potentially provide guidance about virologic response, dosage adjustments, and duration of treatment. Will the day come when testing for CMV DNA becomes part of the newborn screening performed on dried blood spots? CMV-positive infants can have viral loads measured in urine or peripheral blood, and those with high CMV burdens can then be treated with antiviral drugs to eliminate or limit the risk of SNHL. This does not seem so far-fetched. B. J. Freij, MD Human Cytomegalovirus Reactivation During Lactation and Mother-to-Child Transmission in Preterm Infants
Toxoplasma gondii is an obligate intracellular parasite capable of infecting humans and a variety... more Toxoplasma gondii is an obligate intracellular parasite capable of infecting humans and a variety of other warm-blooded animals. The organism is distributed widely in nature and may infect as many as 1 of 3 persons worldwide. Most Toxoplasma infections are either asymptomatic or otherwise benign; notable exceptions include the infections of the developing fetus whose mother acquires an acute T gondii infection during gestation and of immunosuppressed patients, such as those with the acquired immunodeficiency syndrome (AIDS), in whom the illness may be severe or even fatal. The cat and other felines (such as the lynx) appear to be the only definitive hosts for this protozoan. The name Toxoplasma is derived from the Greek word toxon (meaning arc or bow) and is a reference to the shape of the organism. The gondi is a North African desert rodent related to the gerbil in whose splenic and hepatic mononuclear cells the parasite was observed initially. This article briefly reviews the biol...
Amalia Voureka was a physician, bacteriologist, and Greek Resistance activist who joined the labo... more Amalia Voureka was a physician, bacteriologist, and Greek Resistance activist who joined the laboratory of Sir Alexander Fleming in 1946 on a scholarship. She had nine research publications between May 1947 and August 1952, four of which were as the single author and three as the first author. Only three were coauthored with Sir Fleming. Her research focus was bacteria and antimicrobial agents. She demonstrated variable endpoints for the bacteriostatic power of streptomycin depending on media used, inoculum size, salt concentration, and atmospheric conditions. She worked on bacterial antibiotic resistance, demonstrating the induction of bacterial variants following chloramphenicol treatment. In another paper, she showed that penicillin-resistant bacteria can be made sensitive by coculture with other organisms that are either penicillin sensitive or insensitive. In a study of staphylococcal strains from the anterior nares of patients, she documented a low rate of penicillin resistance (7.6%). Elsewhere, she showed that toxin production by staphylococci is important for virulence. She determined that bacterial flagella can be critical for movement and not simply attachments resulting from cell distress. She refined and invented new laboratory techniques, improving on flagellar staining. Dr. Voureka married Sir Fleming in 1953, despite a 31-year age difference. Her marriage to Sir Fleming was brief (he died of a heart attack in 1955). She later returned to Greece but was exiled and stripped of her citizenship by the military junta for her political activities. After the junta fell, she returned to Greece and was elected to Parliament in 1977, 1981, and 1985. She died in 1986.
Introduction: Hemophagocytic lymphohistiocytosis (HLH) is rare, however potentially severe diseas... more Introduction: Hemophagocytic lymphohistiocytosis (HLH) is rare, however potentially severe disease. Case Description: A 33 y.o. woman presented with a >1yr history of frequent infections. She had history of pneumonia at age eight, atopic dermatitis, and human papillomavirus. Initially, she had an Epstein-Barr virus (EBV) infection which resolved. Subsequently, she experienced URIs, sinusitis, streptococcal pharyngitis, otitis externa, and otitis media. Her atopic dermatitis had been well controlled from about age 18. However, in the year prior to presentation she developed erythematous, pruritic lesions on her trunk. Workup revealed normal CBC, IgM 29 mg/dl, IgA 213 mg/dl, IgG 905 mg/dl, and IgE >23,000 mg/dl. Eleven of fourteen pneumococcal antibody titers were protective. Antibodies to strongyloides and toxocara were negative. Flow cytometry revealed low NK cells (54 cells/mm3). Genetic analysis did not reveal abnormality in TYK2, STAT3, DOCK8, or SPINK5. About two months later, her eczema had worsened to involve >90% of body surface area. Recurrent upper respiratory infections continued and extensive primary immunodeficiency genetic panel revealed UNC13D heterozygous variant. Discussion: UNC13D is usually associated with hemophagocytic lymphohistiocytosis (HLH), however, significance in this patient is not clear. While she does have recurrent infections, potentially precipitated by EBV, she has no cytopenias. She has low NK cells and IgM, but does not meet criteria for established immunodeficiency disorder. This case highlights the need to consider HLH and genetic testing in unclassified immunodeficiencies. Mild HLH could be diagnosed with NK cell function testing showing decreased or no function, hypofibrinogenemia, hypertriglyceridemia, elevated ferritin, or elevated soluble IL-2 receptor.
The role of Aeromonas (&) in the etiology of pediatric diarrhea is incompletely defined. It is un... more The role of Aeromonas (&) in the etiology of pediatric diarrhea is incompletely defined. It is unclear whether identification of isolates a t the species level or performance of toxigenicity studies help distinguish pathogenic from non-pathogenic strains. We isolated Aer from 33 of 704 children whose fecal specimens were submitted to the Microbiology Laboratory of Children's Medical Center, Dallas, over a I-year period. Isolates were identified as & using the API 20E system. Additional tests performed on 29 strains included gas from glucose, salicin fermentation, growth in KCN, esculin hydrolysis, and elastase production. A. caviae was the predominant species (n = 19, 66%). A. sobria and A. hydrophila accounted for 3 each and 4 (14%) strains could not be speciated. Toxin production by Aer was studied
About 1.5 per 1000 women giving birth in the United States are infected with the human immunodefi... more About 1.5 per 1000 women giving birth in the United States are infected with the human immunodeficiency virus. Mother-to-infant human immunodeficiency virus transmission rates in the United States are about 30% on average. Intrapartum exposure to infected maternal blood and genital secretions seems to be the most important route for perinatal human immunodeficiency virus acquisition. A first-born twin is at higher risk of infection compared with the second-born twin. Multiple human immunodeficiency virus variants exist in infected mothers, but only small subsets are transmitted to their infants. Primary maternal cytomegalovirus infection is associated with symptomatic congenital infection and significant residual neurodevelopmental abnormalities. Canciclovir has been used to treat a few infants with symptomatic congenital cytomegalovirus infections, but the benefits have been marginal. A third of asymptomatic women shedding herpes simplex virus at delivery have evidence of recent primary infections and their infants are 10 times more likely to develop neonatal herpes. About 5% of pregnant women are unaware of their risk of acquiring a primary herpes simplex virus-2 infection through sexual contact with their seropositive spouses who have no histories of genital herpes. Acyclovir and vidarabine have comparable efficacies in treating neonatal herpes. The case-fatality and morbidity rates for infants with encephalitis or disseminated herpes simplex virus infections continue to be high despite early therapy. Intrauterine diagnosis of fetal parvovirus B19 infection through B19 DNA detection in amniotic fluid and fetal blood has a better yield than serologic methods. B19-related hydrops is not uniformly fatal and may resolve spontaneously without specific therapy. Fetal adverse effects such as prematurity, stillbirth, or spontaneous abortion occur in 30% of pregnant women with measles.
Objectives To characterize the clinical course and outcomes of children 12-18 years of age who de... more Objectives To characterize the clinical course and outcomes of children 12-18 years of age who developed probable myopericarditis after vaccination with the Pfizer-BioNTech (BNT162b2) coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccine. Study design A cross-sectional study of 25 children, aged 12-18 years, diagnosed with probable myopericarditis after COVID-19 mRNA vaccination as per the Centers for Disease Control and Prevention criteria for myopericarditis at 8 US centers between May 10, 2021, and June 20, 2021. We retrospectively collected the following data: demographics, severe acute respiratory syndrome coronavirus 2 virus detection or serologic testing, clinical manifestations, laboratory test results, imaging study results, treatment, and time to resolutions of symptoms. Results Most (88%) cases followed the second dose of vaccine, and chest pain (100%) was the most common presenting symptom. Patients came to medical attention a median of 2 days (range, <1-20 days) after receipt of Pfizer mRNA COVID-19 vaccination. All adolescents had an elevated plasma troponin concentration. Echocardiographic abnormalities were infrequent, and 92% showed normal cardiac function at presentation. However, cardiac magnetic resonance imaging, obtained in 16 patients (64%), revealed that 15 (94%) had late gadolinium enhancement consistent with myopericarditis. Most were treated with ibuprofen or an equivalent nonsteroidal anti-inflammatory drug for symptomatic relief. One patient was given a corticosteroid orally after the initial administration of ibuprofen or an nonsteroidal anti-inflammatory drug; 2 patients also received intravenous immune globulin. Symptom resolution was observed within 7 days in all patients. Conclusions Our data suggest that symptoms owing to myopericarditis after the mRNA COVID-19 vaccination tend to be mild and transient. Approximately two-thirds of patients underwent cardiac magnetic resonance imaging, which revealed evidence of myocardial inflammation despite a lack of echocardiographic abnormalities.
Background Sequence type 131 (EC-ST131) is a prevalent cause of extraintestinal Escherichia coli ... more Background Sequence type 131 (EC-ST131) is a prevalent cause of extraintestinal Escherichia coli infection, including in neonates, and accounts for a majority of multidrug-resistant strains. Rare reports of neonatal unit outbreaks have emerged, with one linking the source to freshly expressed breast milk (BM) sharing. We report on premature twin girls whose infection was linked to their mother’s contaminated frozen BM. Methods Blood culture isolates were from twin girls born at 24–1/7 weeks’ gestation who developed severe sepsis caused by ampicillin- and gentamicin-resistant E. coli on days 11 (Baby A; died) and 8 (Baby B; survived) of life; both neonates had sterile blood cultures at birth, and received orogastric feeds using frozen BM provided by their mother. Five remaining frozen BM samples predating onset of sepsis were thawed and cultured; E. coli resistant to ampicillin and gentamicin was recovered from 1 collected on day 5 of life. DNA was extracted from cultured isolates us...
Introduction: Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. The clas... more Introduction: Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. The classic triad of HSP consists of nonthrombocytopenic purpura, arthritis/arthralgia, and gastrointestinal complaints. Pulmonary hemorrhage and cardiac involvement are rare complications of HSP. Case Report: We report the case of a 10-yearold girl with HSP complicated by both severe mitral regurgitation and pulmonary hemorrhage. Discussion: HSP is typically a self-limited illness with an excellent prognosis in children. Pulmonary hemorrhage is a rare complication that increases morbidity and mortality; it generally indicates the presence of severe vasculitis. Cardiac involvement in HSP is extremely rare and associated with a poor prognosis. Conclusion: Cardiac involvement in HSP may be more common than believed. Because of the increased morbidity and mortality associated with HSP complicated by pulmonary hemorrhage and cardiac involvement, it is important for clinicians to be aware of these potential complications.
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