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Int J Mol Sci 2020 Apr 8;21(7). Epub 2020 Apr 8.

Kidney Disease Center, Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo 193-0998, Japan.

It is widely known that glomerulonephritis (GN) often develops after the curing of an infection, a typical example of which is GN in children following streptococcal infections (poststreptococcal acute glomerulonephritis; PSAGN). On the other hand, the term "infection-related glomerulonephritis (IRGN)" has recently been proposed, because infections are usually ongoing at the time of GN onset in adult patients, particularly in older patients with comorbidities. However, there has been no specific diagnostic biomarker for IRGN, and diagnosis is based on the collection of several clinical and pathological findings and the exclusion of differential diagnoses. Read More

IDCases 2020 15;19:e00659. Epub 2019 Oct 15.

Department of Pediatrics, Thriasio General Hospital, Athens, Greece.

Influenza virus primarily affects the respiratory system. It rarely causes extrapulmonary complications, with otitis media and febrile seizures being the most common in children. Acute glomerulonephritis as a complication of H1N1 influenza virus infection has been described only sporadically. Read More

Dtsch Med Wochenschr 2020 Feb 18;145(4):240-247. Epub 2020 Feb 18.

Glomerulonephritis, secondary to bacterial, or, more rarely, viral or parasitic infections, is called infection-associated. The epidemiology of infection-associated glomerulonephritis has changed in recent decades. For a long time, the classic form has been acute poststreptococcal glomerulonephritis (APGN), but in developed countries its incidence has declined sharply. Read More

BMC Nephrol 2019 12 18;20(1):471. Epub 2019 Dec 18.

Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan.

Background: Poststreptococcal acute glomerulonephritis (PSAGN) in the elderly tends to have a severe clinical course and often presents with crescentic necrotizing glomerulonephritis in the renal biopsy. However, vasculitis lesions are unusual.

Case Presentation: We present a 71-year-old man who was admitted to our hospital for a recurrent gout attack with a rapid decline of renal function. Read More

Pediatr Infect Dis J 2019 12;38(12):1183-1188

Heart Institute, Cincinnati Children's Hospital Medical Center.

Background: Group A Streptococcus (GAS) skin infections can lead to invasive sepsis, poststreptococcal glomerulonephritis, and potentially rheumatic heart disease (RHD). Within a study to identify predisposing factors of RHD in Ugandan schoolchildren, we determined the prevalence of skin infections and assessed the clinical features and antibiotic susceptibility of GAS skin infection.

Methods: Cross-sectional study conducted at 3 urban primary schools in Western and Northern Uganda in March 2017. Read More

Clin Nephrol 2019 Nov;92(5):263-272

Infection-related glomerulonephritis (IRGN) was previously thought to be due mostly to species, but is now known to be caused by a variety of other pathogens. Nephritis-associated plasmin receptor (NAPlr) was originally isolated from group A streptococci as the protein responsible for acute poststreptococcal glomerulonephritis, and was shown to be identical to streptococcal glyceraldehyde-3-phosphate dehydrogenase (GAPDH). Here, we describe a 7-year-old boy diagnosed with IRGN presenting with acute nephritic syndrome. Read More

Curr Rheumatol Rev 2020 ;16(1):2-8

Department of Rheumatology, Queen's University, Kingston, ON, Canada.

Introduction: Post-Streptococcal Reactive Arthritis (PSRA) is defined as inflammatory arthritis of ≥1 joint associated with a recent group A streptococcal infection in a patient who does not fulfill the Jones criteria for the diagnosis of Acute Rheumatic Fever (ARF).

Methods: In this narrative review, we conducted a systematic search on MEDLINE, EMBASE, Cochrane Library and Google Scholar using the words poststreptococcal reactive arthritis. The search covered the time period between 1982 and 2016. Read More

Clin Rev Allergy Immunol 2019 Oct;57(2):294-302

Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.

Streptococcus A infections have been associated with immune-mediated sequelae including acute glomerulonephritis, acute rheumatic fever, thrombocytopenia, hemolytic anemia, Henoch-Schönlein purpura, arthritis, uveitis, guttate psoriasis, and erythema nodosum. Available reviews do not report the occurrence of acute poststreptococcal glomerulonephritis in association with one of the mentioned conditions. We performed a systematic review of the literature on extrarenal immune-mediated disorders associated with acute poststreptococcal glomerulonephritis. Read More

J Am Acad Dermatol 2020 Mar 13;82(3):533-548. Epub 2019 Jul 13.

Department of Dermatology, University of California, San Francisco, San Francisco, California; International Alliance for the Control of Scabies, Parkville, Australia. Electronic address:

Scabies is an ectoparasitic dermatosis caused by Sarcoptes scabiei var. hominis and is a public health issue in all countries regardless of socioeconomic status. In high-income countries, delays in diagnosis can lead to institutional outbreaks; in low- and middle-income countries, poor access to health care contributes to disease undertreatment and long-term systemic sequelae. Read More

Front Pediatr 2019 21;7:202. Epub 2019 May 21.

Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, South Korea.

Kawasaki disease (KD) may be associated with infection of unknown pathogen(s). For predicting of the etiology of KD, we evaluated epidemiological characteristics in KD, common infectious diseases and immune-mediated diseases in childhood. We respectively, reviewed the data of patients with KD, influenza, aseptic meningitis, exanthem subitum (ES), (MP) pneumonia, acute pyelonephritis (APN), Henoch-Schönlein purpura (HSP), acute poststreptococcal glomerulonephritis (APSGN), and childhood asthma. Read More

Open Forum Infect Dis 2019 Apr 26;6(4):ofz097. Epub 2019 Feb 26.

Menzies School of Health Research, Charles Darwin University.

Background: In high-burden settings, guidelines recommend antibiotic treatment for all suspected group A (GAS) infections to prevent rheumatic fever and poststreptococcal glomerulonephritis. Highly sensitive rapid GAS tests could reduce unnecessary antibiotic use in these settings.

Methods: This was a prospective study of the Xpert Xpress Strep A (Cepheid) molecular test compared with culture of throat swab samples collected at a referral hospital in northern Australia. Read More

Microbiol Spectr 2019 03;7(2)

University of Miami Miller School of Medicine and Miami Veterans Affairs Healthcare System, Miami, FL 33125.

Streptococci carrying serogroup C and G antigens, and in particular, subsp. (SDSE), are emerging human pathogens that are increasingly isolated from patients with a myriad of infections that range from mundane to life-threatening. SDSE is microbiologically similar to . Read More

Pol Merkur Lekarski 2019 Mar;46(273):115-121

Medical University of Warsaw: Department of Pediatrics and Nephrology.

Acute poststreptococcal glomerulonephritis (APSGN) is a complication of infection with group A beta-hemolytic streptococcus. The disease manifests as microscopic/gross hematuria, arterial hypertension, edema, and acute kidney injury and has most commonly self-limiting course.

Aim: The aim of study was the analysis of clinical course of APSGN in period of increased incidence in the first half of 2018. Read More

mSphere 2019 02 13;4(1). Epub 2019 Feb 13.

Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia

Group A (GAS) is a major cause of global infection-related morbidity and mortality. A modern controlled human infection model (CHIM) of GAS pharyngitis can accelerate vaccine development and pathogenesis research. A robust rationale for strain selection is central to meeting ethical, scientific, and regulatory requirements. Read More

Saudi J Kidney Dis Transpl 2018 Nov-Dec;29(6):1256-1266

Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman.

According to the best of our knowledge, there is no review compiling incidence of glomerular disease in all Arab countries. Most of the Arab countries do not have a national renal biopsy registry. In addition, there is scanty data available on the epidemiology of glomerular diseases in Arab countries. Read More

Pediatr Clin North Am 2019 02;66(1):59-72

Division of Nephrology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.

Acute postinfectious glomerulonephritis or infection-related glomerulonephritis has been associated with several viral or bacterial infections. Group A beta-hemolytic streptococcal infection is the prototypical cause of postinfectious glomerulonephritis and the main focus of this discussion. The clinical spectrum can vary widely, from asymptomatic microscopic hematuria incidentally detected on routine urinalysis to rapidly progressive glomerulonephritis with acute kidney injury requiring emergent dialysis. Read More

Clin Pediatr (Phila) 2019 01 10;58(1):10-12. Epub 2018 Aug 10.

2 West Virginia University, Morgantown, WV, USA.

J Clin Microbiol 2018 10 25;56(10). Epub 2018 Sep 25.

Laboratório de Toxina de Alimentos, Fundação Ezequiel Dias, Belo Horizonte, MG, Brazil.

is an emerging and opportunistic zoonotic pathogen which plays an important role in the development of severe and life-threatening diseases and is potentially capable of triggering large glomerulonephritis outbreaks. Between December 2012 and February 2013, 175 cases of glomerulonephritis were confirmed in the town of Monte Santo de Minas, MG, Brazil. During the outbreak, 19 isolates of were recovered, 1 from ice cream, 2 from the oropharynx of food handlers, and 16 from patients affected by acute poststreptococcal glomerulonephritis (APSGN). Read More

Perit Dial Int 2018 Nov-Dec;38(6):413-418. Epub 2018 Jul 31.

Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.

Background: In a resource-limited setting, acute peritoneal dialysis (APD) is the modality of choice as a form of renal replacement therapy in children with acute kidney injury (AKI). However, there is a high risk of peritonitis that causes significant morbidity and mortality. Data on PD and peritonitis in developing countries are scarce. Read More

BMJ Case Rep 2018 Jul 18;2018. Epub 2018 Jul 18.

Department of Pediatrics, NYU Winthrop Hospital, Mineola, New York, USA.

Infection-related glomerulonephritis results from glomerular immune complex deposition due to a variety of potential pathogens. Poststreptococcal glomerulonephritis is the best known example. We present a case of acute infection-related glomerulonephritis associated with disseminated gonococcal infection in a sexually active 13-year-old girl, the first report of such an association in the absence of endocarditis. Read More

Saudi J Kidney Dis Transpl 2018 May-Jun;29(3):728-731

Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.

A 14-year-old female presented with oliguric dialysis requiring kidney injury due to acute poststreptococcal glomerulonephritis (PSGN) with hypertension strongly suggestive of atypical hemolytic uremic syndrome (aHUS) with microangiopathic hemolytic anemia and elevated factor H antibody levels. Renal biopsy revealed crescentic glomerulonephritis with typical subepithelial, intramembranous and mesangial electron-dense deposits (humps) on electron microscopy. She was treated with glucocorticoids following which she recovered, remained dialysis free and her Factor H antibody levels and depressed complement 3 levels normalized. Read More

Case Rep Transplant 2018 31;2018:2695178. Epub 2018 May 31.

Division of Nephrology-Hypertension, University of California San Diego, San Diego, CA, USA.

Acute kidney injury is common among kidney transplant recipients. Postinfectious glomerulonephritis secondary to nephritogenic streptococci is one of the oldest known etiologies of acute kidney injury in native kidneys but rarely reported among kidney transplant recipients. This report is of a biopsy-proven case of acute kidney injury in a renal allograft recipient caused by de novo poststreptococcal glomerulonephritis. Read More

Am Fam Physician 2018 04;97(8):517-522

University of Tennessee Family Medicine Residency Program, Jackson, TN, USA.

Group A beta-hemolytic streptococcus can cause several postinfectious, nonsuppurative immune- mediated diseases including acute rheumatic fever, poststreptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders, and poststreptococcal glomerulonephritis. Except for sporadic outbreaks, poststreptococcal autoimmune syndromes occur most commonly in sub-Saharan Africa, India, Australia, and New Zealand. Children younger than three years are rarely affected by group A streptococcus pharyngitis or rheumatic fever, and usually do not require testing. Read More

J Clin Rheumatol 2019 09;25(6):e87-e89

Department of Rheumatology, University Hospital Basel, Basel, Switzerland Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland Department of Pathology, University Hospital Basel, Basel, Switzerland Department of Radiology, University Hospital Basel Basel, Switzerland Department of Nephrology and Transplantation Medicine, University Hospital Basel, Basel, Switzerland Department of Rheumatology, University Hospital Basel, Basel, Switzerland.

Arch Argent Pediatr 2018 Apr;116(2):e288-e291

Department of Pedi-Nephrology, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China.

We present a case of acute post-streptococcal glomerulonephritis (APSGN) with autoimmune hemolytic anemia (AIHA). Along with the classic findings of APSGN, the patient had a positive direct antiglobulin test and an anticardiolipin antibody without any typical clinical manifestations of antiphospholipid syndrome (APS). This case raises questions of the relationship between Streptococcus and the development of autoimmune hemolytic anemia in children. Read More

Case Rep Crit Care 2017 20;2017:1050284. Epub 2017 Dec 20.

Division of Pediatric Respirology, University of Saskatchewan, Saskatoon, SK, Canada.

This report summarizes a case of a 4-year-old girl with poststreptococcal glomerulonephritis and diffuse alveolar hemorrhage, an atypical presentation in this age group and type of vasculitic disease. We propose that her rapid improvement in clinical status was due to her treatment, continuous renal replacement therapy (CRRT). This mechanism would have impacted recovery by removing factors such as endothelial microparticles, superantigens, and immune complexes that have been postulated as the pulmonary-renal link. Read More

BMC Pediatr 2018 02 5;18(1):28. Epub 2018 Feb 5.

American International Medical University, Gros Islet, Saint Lucia.

Background: Earthquakes impact child health in many ways. Diseases occurring immediately following an earthquake have been studied in field based hospitals but studies on the inpatient disease pattern among children without trauma in a permanent hospital setup is lacking.

Methods: We examined the diagnoses of all children without trauma, admitted to Kanti Children's Hospital, Kathmandu for fifteen-week duration (from 4th week to end of the 18th week) following the 7. Read More

J Med Case Rep 2018 Feb 1;12(1):24. Epub 2018 Feb 1.

Prince Sultan Oncology Center, King Salman Armed Forces Hospital, Tabuk, 100, Kingdom of Saudi Arabia.

Background: Posterior reversible encephalopathy syndrome is a neurotoxic condition that occurs as a result of the failure of posterior circulatory autoregulation in response to acute changes in blood pressure. Overperfusion with resultant disruption of the blood-brain barrier results in vasogenic edema, but not infarction. Posterior reversible encephalopathy syndrome can be the presenting feature of postinfectious glomerulonephritis, which has been reported in approximately 5% of hospitalized children, and it has been reported in very few cases of adult patients with sickle cell anemia. Read More

J Coll Physicians Surg Pak 2018 Jan;28(1):80-81

Department of Pediatric Medicine Unit-1, Nishtar Hospital, Multan.

Saudi J Kidney Dis Transpl 2017 Nov-Dec;28(6):1421-1426

Department of Nephrology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India.

Infection-related glomerulonephritis (IRGN) is an immune-mediated glomerulo-nephritis, most commonly caused by bacterial infections. Although there is an increased incidence of infectious episodes in renal transplant recipients, IRGN as a cause of de novo glomerulonephritis is rarely seen probably due to impaired immunity. We hereby report a 28-year-old male renal transplant recipient, who developed IRGN following impetigenous skin lesions after six years of transplant. Read More

Korean J Pediatr 2017 Aug 14;60(8):266-271. Epub 2017 Aug 14.

Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea.

Purpose: The aim of this study was to assess the clinical characteristics of hypertensive encephalopathy according to the underlying etiologies in children.

Methods: We retrospectively evaluated 33 pediatric patients who were diagnosed as having hypertensive encephalopathy in Chonbuk National University Children's Hospital. Among the patients, 18 were excluded because of incomplete data or because brain magnetic resonance imaging (MRI) was not performed. Read More

J Leukoc Biol 2018 02 29;103(2):193-213. Epub 2017 Dec 29.

School of Chemistry and Molecular Biosciences, Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Australia.

Streptococcus pyogenes, the Group A Streptococcus (GAS), is the most common cause of bacterial pharyngitis in children and adults. Innate and adaptive host immune responses are fundamental for defense against streptococcal pharyngitis and are central to the clinical manifestation of disease. Host immune responses also contribute to the severe poststreptococcal immune diseases that constitute the major disease burden for this organism. Read More

J Clin Diagn Res 2017 Jul 1;11(7):SD13-SD14. Epub 2017 Jul 1.

Professor, Department of Radiodiagnosis, Pt B D Sharma PGIMS, Rohtak, Haryana, India.

Postinfectious Glomerulonephritis (PIGN) usually follows 1-2 weeks after respiratory tract infection and 4-6 weeks after skin infection. Acute Glomerulonephritis (AGN) is uncommon with simultaneous severe throat infections. We describe a 10-year-old boy who was presented with high grade fever, dysphagia and tender swelling over left side of neck. Read More

Saudi J Kidney Dis Transpl 2017 Jul-Aug;28(4):830-835

Department of Pediatrics, Division of Pediatric Nephrology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India.

Acute poststreptococcal glomerulonephritis (PSGN) is the most common type of glomerulonephritis seen in children. It can affect multiple organs with heart being frequently involved. Yet, there are very few studies on cardiac status in children with PSGN and hence this study was conducted. Read More

CEN Case Rep 2017 May 27;6(1):118-123. Epub 2017 Mar 27.

Division of Nephrology, Department of Internal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, Saga, 849-8501, Japan.

Retropharyngeal abscess is an infection involving the retropharyngeal space which is posterior to the pharynx and oesophagus, and it results as a complication of a primary infection elsewhere in the head and neck including the nasopharynx, paranasal sinuses, or middle ear, which drain lymph to the retropharyngeal lymph nodes. Their lymph nodes are prominent in children and atrophy with age. Therefore, retropharyngeal abscess is most frequently encountered in children, with 75% of cases occurring before the age of 5 years, and often in the first year of life. Read More

BMJ Case Rep 2017 Apr 17;2017. Epub 2017 Apr 17.

Department of Medicine, Metropolitan Hospital Center, New York, New York, USA.

Med Princ Pract 2017 7;26(3):292-295. Epub 2017 Mar 7.

Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Serbia.

Objective: To present a case with 4 different potential causes of hyponatremia.

Clinical Presentation And Intervention: The patient presented with the following symptoms: nausea, vomiting, diarrhea, and dark urine after drinking large amounts of fluids that included alcohol and caffeine. Laboratory, microbiological, and morphological examinations revealed the existence of severe hyponatremia and acute poststreptococcal glomerulonephritis. Read More

Turk Pediatri Ars 2016 Dec 1;51(4):217-220. Epub 2016 Dec 1.

Division of Pediatric Hematology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey.

Posterior reversible encephalopathy syndrome is characterized by hypertension, seizure, headache, clouding of consciousness, and visual disturbance, and is diagnosed in the presence of typical lesions on magnetic resonance imaging. We retrospectively evaluated five patients who were diagnosed as having posterior reversible encephalopathy syndrome and followed up in Meram Medical Faculty, Pediatric Intensive Care and Hematology wards, between January 2010 and January 2014. We reviewed the demographic and clinical data, and neuroimaging findings. Read More

Case Rep Pediatr 2016 27;2016:7192359. Epub 2016 Oct 27.

Department of Pediatric Endocrinology and Diabetes and Department of Pediatric Nephrology, The Children's Hospital at Montefiore, 3415 Bainbridge Ave., Bronx, NY 10467, USA.

Thyroid storm has a high mortality rate and is often associated with a precipitating factor such as intercurrent illness or infection. It is rare in pediatric patients. Cardiac disease in hyperthyroidism mostly manifests itself as tachycardia but more serious cardiac findings have also been described. Read More

Methodist Debakey Cardiovasc J 2016 Sep;12(3):175-176

Virginia Commonwealth University Health System, Richmond, Virginia; Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.

Pericarditis in conjunction with nephritis is an uncommon clinical scenario with a broad differential diagnosis. We present the case of a 58-year-old male who developed nephritis and pericardial effusion with tamponade physiology. In the following, we discuss the differential diagnosis for concomitant nephritis and pericarditis and discuss the work-up performed on our patient. Read More

Clin J Am Soc Nephrol 2017 01 7;12(1):39-49. Epub 2016 Nov 7.

Department of Pathology, and.

Background And Objectives: Staphylococcus infection-associated GN (SAGN) is a well recognized disease entity, particularly because of the frequent IgA-dominant glomerular immunoglobulin staining on kidney biopsy. Biopsy features can resemble two other disease entities - primary IgA nephropathy and Henoch-Schönlein purpura nephritis - posing a diagnostic pitfall. This is clinically relevant because of the crucial difference in the therapeutic approach. Read More

Pediatr Int 2016 Oct 26;58(10):998-1002. Epub 2016 Apr 26.

Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan.

Background: Myeloid-related protein 8/14 (MRP8/14) forms stable heterodimers and is the major calcium-binding protein secreted by activated granulocytes and monocytes. We evaluated whether serum MRP8/14 level is a useful indicator for a differential diagnosis of glomerulonephritis (GN)- and minimal change disease (MC)- related nephrotic syndrome (NS).

Methods: Serum MRP8/14 complex was evaluated in 37 NS patients with MC or GN. Read More

Int J Nephrol 2016 23;2016:5163065. Epub 2016 Aug 23.

Division of Nephrology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.

The most common acute glomerulonephritis in children is poststreptococcal glomerulonephritis (PSGN) usually occurring between 3 and 12 years old. Hypertension and gross hematuria are common presenting symptoms. Most PSGN patients do not experience complications, but rapidly progressive glomerulonephritis and hypertensive encephalopathy have been reported. Read More

Ann Pediatr Cardiol 2016 Sep-Dec;9(3):268-9

Center of Pediatrics, Children's Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania; Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania E-mail:

Clin Kidney J 2016 Feb 26;9(1):90-6. Epub 2015 Nov 26.

Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

A 7-year-old male with poststreptococcal glomerulonephritis (PSGN) developed hemolytic uremic syndrome (HUS) and achieved remission. He was treated with eculizumab for 1 year. The eculizumab was discontinued and the patient remained in remission. Read More

Croat Med J 2015 Dec;56(6):567-72

Rina R. Rus, Division of Nephrology, University Children's Hospital, Bohoričeva 20, 1000 Ljubljana, Slovenia,

There are only a few reports of the co-occurrence of acute poststreptococcal glomerulonephritis (APGN) and acute rheumatic fever. We report an unusual case of a 3-year-old boy with nephrotic syndrome and acute renal failure with the transitional need for peritoneal dialysis, biopsy-proven atypical IgA-dominant APGN, and concomitant acute rheumatic fever, successfully treated by steroids. Aggressive treatment with pulses of methylprednisolone proved to be successful and we recommend its use in this type of cases. Read More

Minerva Pediatr 2015 Dec;67(6):531-3

Department of Pediatrics, S. Chiara University Hospital, Pisa, Italy -