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Studies linking type of diet and juvenile idiopathic arthritis (JIA) have variable results and are inconsistent. This case shows an evolution which fulfilled the criteria of JIA, but was diagnosed as food allergy. Case: A seven-year old boy had fever, arthralgia, general malaise, headaches, abdominal pain and rashes. These symptoms were diagnosed as fever of unknown origin (FUO) and probable JIA. There was a stabbing pain in the right iliac fossa. An upper and lower endoscopy were performed and nodular ileocolitis was detected. A hypoallergenic diet was prescribed, in addition to mesalazine and oral corticosteroids. The patient was asymptomatic for 2.5 months and then relapsed with all symptoms after consuming dairy. This JIA case shows the diagnostic phases of food allergy: improvement and recurrence of symptoms with the reintroduction of the allergen (oral challenge=gold standard of food allergy). There is evidence that supports the existence of a gut-joint axis, where the luminal content triggers a series of immunologically mediated reactions that can cause systemic diseases such as J other connective tissue diseases. This case report adds reasonable evidence in support of food allergy as a cause of JIA.

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ABSTRACT Studies linking type of diet and juvenile idiopathic arthritis (JIA) have variable results and are inconsistent. This case shows an evolution which fulfilled the criteria of JIA, but was diagnosed as food allergy. Case: A seven-year old boy had fever, arthralgia, general malaise, headaches, abdominal pain and rashes. These symptoms were diagnosed as fever of unknown origin (FUO) and probable JIA. There was a stabbing pain in the right iliac fossa. An upper and lower endoscopy were performed and nodular ileocolitis was detected. A hypoallergenic diet was prescribed, in addition to mesalazine and oral corticosteroids. The patient was asymptomatic for 2.5 months and then relapsed with all symptoms after consuming dairy. This JIA case shows the diagnostic phases of food allergy: improvement and recurrence of symptoms with the reintroduction of the allergen (oral challenge=gold standard of food allergy). There is evidence that supports the existence of a gut-joint axis, where the luminal content triggers a series of immunologically mediated reactions that can cause systemic diseases such as JIA and other connective tissue diseases. This case report adds reasonable evidence in support of food allergy as a cause of JIA.

RESUMEN Los estudios que relacionan el tipo de dieta y la artritis idiopática juvenil (AIJ) tienen resultados variables y son inconsistentes. Este caso muestra una evolución que cumplió con los criterios de AIJ, pero fue diagnosticada como alergia alimentaria. Caso: Un niño de siete años tenía fiebre, artralgia, malestar general, dolores de cabeza, dolor abdominal y erupciones cutáneas. Estos síntomas fueron diagnosticados como fiebre de origen desconocido (FUO) y probable AIJ. Hubo un dolor punzante en la fosa ilíaca derecha. Se realizó una endoscopia superior e inferior y se detectó ileocolitis nodular. Se prescribió una dieta hipoalergénica, además de mesalazina y corticosteroides orales. El paciente estuvo asintomático durante 2,5 meses y luego recayó con todos los síntomas después de consumir lácteos. Este caso de AIJ muestra las fases diagnósticas de la alergia alimentaria: mejora y recurrencia de los síntomas con la reintroducción del alergeno (desafío oral = estándar de oro de alergia alimentaria). Existe evidencia que respalda la existencia de un eje de la articulación intestinal, donde el contenido luminal desencadena una serie de reacciones inmunológicamente mediadas que pueden causar enfermedades sistémicas como la AIJ y otras enfermedades del tejido conectivo. Este informe del caso agrega evidencia razonable en apoyo de la alergia a los alimentos como causa de AIJ.

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OBJECTIVE: To present two cases of food allergy of uncommon presentation and discuss the diagnostic approach to give in these cases: Case N° 1: 11-year-old girl, afflicting pain in the right iliac fossa 3 months ago. BACKGROUND: Prematurity, atopy (dermatitis, rhinitis, cramping). Sister and mother are atopic too. The physical exam show exquisite pain on right iliac fossa at palpation. Laboratory: Urine normal, parasitological serial negative. EDN (neurotoxin derived from eosinophils) fecal >3210 ng/ml (V. N. < 360 ng/ml). Colonoscopy: lymphoid hyperplasia of ileum. Case N° 2: Child of 9 years of age. Right fossa iliac painful three months ago, predominantly nocturnal and with irradiation to right thigh. A child psychiatrist may prescribe antidepressants. Personal History: Breastfeeding and formula since newborn. Atopy: asthma, atopic dermatitis, infant colic. Family history: Mother allergic to food, father presents rhinitis. The physical examination: Pain on palpation in the right iliac fossa. Laboratory: Immunoglobulin E 160.5 IU/ml (V. N. < 90) Colonoscopy: lymphoid hyperplasia in the distal ileum. Both cases relieved by hypoallergenic diet. CONCLUSION: When both, ileal nodular lymphoid hyperplasia and atopy personal or familiar are present, we must be think in food allergy therapeutic.

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Objetivo: Presentar dos casos de alergia alimentaria de presentación poco común y discutir el enfoque diagnóstico de DAR en niños Casos: Caso N° 1: Niña de 11 años, aqueja dolor en fosa iliaca derecha hace 3 meses. Antecedentes: Prematuridad, atopía (dermatitis, rinitis, cólicos). Hermana y madre atópicas. Al examen físico: Dolor exquisito a la palpación de fosa iliaca derecha, cuerda cólica bilateral. Piel seca. Laboratorio: Hematobiometría sin alteraciones. Examen de orina normal, parasitológico seriado (-). EDN (neurotoxina derivada de eosinófilos) fecal >3210 ng/ml (V.N. <360 ng/ml). Colonoscopía: hiperplasia linfoidea de íleon. Caso N° 2: Niño de 9 años. Dolor en fosa iliaca derecha hace tres meses dolor abdominal localizado en fosa iliaca derecha, a predominio nocturno y con irradiación a muslo derecho. Un psiquiatra infantil le prescribe antidepresivos. Antecedentes personales: Lactancia mixta. Atopía: Asma, dermatitis atópica, cólicos de lactante. Antecedentes familiares: Madre alérgica a alimentos, padre presenta rinitis. Al examen físico: Cuerda cólica bilateral. Dolor a la palpación en fosa iliaca derecha. Laboratorio: Inmunoglobulina E 160,5 UI/ml (V.N. < 90). Colonoscopía: Hiperplasia linfoidea en íleon distal. Ambos casos mejoraron con dieta hipoalergénica. Conclusión: En presencia de hiperplasia nodular linfoide de íleon y antecedentes familiares y/o personales de atopía, debemos considerar en el diagnóstico diferencial de dolor abdominal recurrente de fosa iliaca derecha a la alergia alimentaria. La dieta de eliminación es diagnóstica y terapéutica a su vez.

Objective: To present two cases of food allergy of uncommon presentation and discuss the diagnostic approach to give in these cases: Case N° 1: 11-year-old girl, afflicting pain in the right iliac fossa 3 months ago. Background: Prematurity, atopy (dermatitis, rhinitis, cramping). Sister and mother are atopic too. The physical exam show exquisite pain on right iliac fossa at palpation. Laboratory: Urine normal, parasitological serial negative. EDN (neurotoxin derived from eosinophils) fecal >3210 ng/ml (V. N. < 360 ng/ml). Colonoscopy: lymphoid hyperplasia of ileum. Case N° 2: Child of 9 years of age. Right fossa iliac painful three months ago, predominantly nocturnal and with irradiation to right thigh. A child psychiatrist may prescribe antidepressants. Personal History: Breastfeeding and formula since newborn. Atopy: asthma, atopic dermatitis, infant colic. Family history: Mother allergic to food, father presents rhinitis. The physical examination: Pain on palpation in the right iliac fossa. Laboratory: Immunoglobulin E 160.5 IU/ml (V. N. < 90) Colonoscopy: lymphoid hyperplasia in the distal ileum. Both cases relieved by hypoallergenic diet. Conclusion: When both, ileal nodular lymphoid hyperplasia and atopy personal or familiar are present, we must be think in food allergy as differential diagnosis of recurrent abdominal pain of right iliac fosse in children. The elimination diet is diagnostic and therapeutic.

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UNLABELLED: We present the first Peruvian pediatric case of induction of remission and maintenance of Crohn's disease with infliximab. CASE: 9-year old female who presented with perianal fistulas, intermittent diarrhea and poor weight gain since 8 months of age. Due to lack of improvement with medical therapy she had a colostomy at 4 years of age. A surgical biopsy showed chronic colitis with inflammation extending to the muscularis mucosae, with areas of glandular atrophy. A diagnosis of Crohn's disease was made. She received prednisone, sulfasalazine and antibiotics without significant improvement. She became undernourished, stunted, and anemic. Consequently, at 8 years of age we started infliximab, 100 mg per doses (5.5 mg/kg/doses). After 4 infusions her perianal fistulas closed. However, after 8 months of treatment she had a disease exacerbation with abdominal pain and diarrhea. Therefore, we added azathioprine (2 mg/kg/d PO) and shortened maintenance infliximab infusions from every 8 to every 4 weeks. Gastrointestinal symptoms resolved. So far the patient has had no adverse events secondary to therapy. CONCLUSION: This patient has a rare early onset and aggressive form of Crohn's disease that responded to infliximab, who needed the addition of azathioprine to maintain remission.

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Presentamos el primer caso pediátrico peruano de uso de infliximab para inducir remisión en enfermedad de Crohn. Caso: niña de 9 años, con presencia de fístulas perianales desde los 8 meses de edad, además de diarreas recurrentes y pobre ganancia ponderal. Se le realizó una colostomía a los 4 años de edad, sin variación. A esa edad, una biopsia mostró colitis crónica severa superficial y profunda extensiva a la muscularis mucosae con áreas de fibrosis y atrofia glandular, planteándose enfermedad de Crohn. Recibió manejo con corticoides, sulfasalazina y antibióticos sin mejoría. A los 8 años de edad presentaba desnutrición crónica reagudizada, además de anemia moderada. Se decidió iniciar terapia con infliximab, 100 mg por dosis aplicada (5,5 mg/kg/dosis). A la cuarta infusión todas las fístulas perianales estaban inactivas, sin embargo, presentó exacerbación de la enfermedad a los 8 meses de tratamiento. Se decidió agregar azatriopina a 2 mg/kg/d VO y se acortaron las infusiones de mantenimiento a cada 4 semanas. Toda la sintomatología gastrointestinal se resolvió. Hasta el momento la niña no presenta eventos adversos a la administración de la terapia médica. Conclusión: El caso presentado corresponde a una presentación temprana, rara y agresiva de enfermedad de Crohn. El infliximab se constituye en herramienta clave para alcanzar la remisión.

We present the first Peruvian pediatric case of induction of remission and maintenance of Crohn’s disease with infliximab. Case: 9-year old female who presented with perianal fistulas, intermittent diarrhea and poor weight gain since 8 months of age. Due to lack of improvement with medical therapy she had a colostomy at 4 years of age. A surgical biopsy showed chronic colitis with inflammation extending to the muscularis mucosae, with areas of glandular atrophy. A diagnosis of Crohn’s disease was made. She received prednisone, sulfasalazine and antibiotics without significant improvement. She became undernourished, stunted, and anemic. Consequently, at 8 years of age we started infliximab, 100 mg per doses (5.5 mg/kg/doses). After 4 infusions her perianal fistulas closed. However, after 8 months of treatment she had a disease exacerbation with abdominal pain and diarrhea. Therefore, we added azathioprine (2 mg/kg/d PO) and shortened maintenance infliximab infusions from every 8 to every 4 weeks. Gastrointestinal symptoms resolved. So far the patient has had no adverse events secondary to therapy. Conclusion: This patient has a rare early onset and aggressive form of Crohn’s disease that responded to infliximab, who needed the addition of azathioprine to maintain remission.

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GOAL: Milk-based formulas can induce cow's milk protein allergy (CMPA) in infants. This article discusses two cases of severe CMPA in infants exposed to casein-based formulas. CASES: Case N°1: A 7 day old boy developed diarrhea with no improvement despite several courses of antibiotic and switching to formula without lactose. At 2 months of age he had a hemoglobin 8.6 mg/dL, IgE = 17.8 IU/ml (normal <1.5 UI/ml) and a CD4/CD8 ratio = 0.16 (normal 1.5 ­ 2.5). Upper endoscopy biopsies showed duodenal atrophy. He received a casein hydrolysate formula with decreased fecal flow but continued diarrhea. At 3 months of life he was changed to an amino acid formula with cessation of diarrhea in < 48 hours, resumption of normal growth and normalization of duodenal histology. Case N°2: A 10 month old boy had a 6-day history of vomiting, diarrhea and edema. His albumin was 2.35 mg/dL. An upper endoscopy biopsy showed severe duodenal atrophy. He received a casein hydrolysate with good tolerance and resolution of the edema. At 26 months of age, and endoscopic duodenal biopsy showed regeneration of the mucosa. CONCLUSION: The CMPA is a frequent diagnosis in young infants that can be confused with infection. An early diagnosis is key to a positive outcome.

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OBJETIVO: El uso de fórmulas maternizadas puede causar alergia a la proteína de leche de vaca (ALPLV). Se discuten dos casos de ALPLV en infantes. CASOS: Caso N°1: Niño que presentó diarreas desde los 7 días de vida, sin mejoría a pesar de varios cursos de antibióticos y uso de fórmula sin lactosa. A los dos meses tenía anemia (8.6mg/dL), además de IgE de 17.8 UI/ml (normal <1.5 UI/ml) y una relación CD4/CD8 = 0.16, (normal 1.5 û 2.5). Endoscopía mostró atrofia duodenal. Recibió una fórmula a base de hidrolizado extenso de caseína, con mejoría parcial. A los tres meses de vida se le cambió a fórmula a base de aminoácidos cesando la diarrea en < 48 horas, retomando crecimiento normal y normalizando la histología duodenal. Caso Nº2: Niño que debutó a los 10 meses de edad con un cuadro de 6 días caracterizado por vómitos, diarreas, y anasarca. Presentó hipoalbuminemia (2.35mg/dL). Una endoscopía mostró atrofia duodenal severa. Recibió hidrolizado extenso de proteínas con resolución de los edemas. Biopsia duodenal control a los 2 años y dos meses de vida evidenció regeneración de la mucosa. CONCLUSION: La ALPLV es un diagnóstico que se debe plantear precozmente para un manejo exitoso.

GOAL: Milk-based formulas can induce cowÆs milk protein allergy (CMPA) in infants. This article discusses two cases of severe CMPA in infants exposed to casein-based formulas. Cases: Case N°1: A 7 day old boy developed diarrhea with no improvement despite several courses of antibiotic and switching to formula without lactose. At 2 months of age he had a hemoglobin 8.6 mg/dL, IgE = 17.8 IU/ml (normal <1.5 UI/ml) and a CD4/CD8 ratio = 0.16 (normal 1.5 û 2.5). Upper endoscopy biopsies showed duodenal atrophy. He received a casein hydrolysate formula with decreased fecal flow but continued diarrhea. At 3 months of life he was changed to an amino acid formula with cessation of diarrhea in < 48 hours, resumption of normal growth and normalization of duodenal histology. Case N°2: A 10 month old boy had a 6-day history of vomiting, diarrhea and edema. His albumin was 2.35 mg/dL. An upper endoscopy biopsy showed severe duodenal atrophy. He received a casein hydrolysate with good tolerance and resolution of the edema. At 26 months of age, and endoscopic duodenal biopsy showed regeneration of the mucosa. Conclusion: The CMPA is a frequent diagnosis in young infants that can be confused with infection. An early diagnosis is key to a positive outcome.

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INTRODUCCION: La prevalencia de la infección por Helicobacter pylori (HP) y su caracterización histopatológica en niños en el Perú es insuficientemente conocida. OBJETIVOS: Reportar las características clínicas e istopatológicas de la infección porHP en niños del Hospital Nacional Cayetano Heredia (HNCH) en Lima, Perú. METODOS: Se obtuvo información sobre endoscopías y biopsias realizadas en niños en el periodo de julio 2003 a noviembre 2006. RESULTADOS: De 210 endoscopías se obtuvo biopsias gástricas en 111. La prevalenciade HP fue de 45.9% (51 de 111 pacientes). Los niños HP positivos tuvieron mayor edad que los HP negativos (11 versus 8.9 años, p = 0.009). En los HP positivos la presenciaendoscópica de ôgastritis nodularõ (GN) fue significativamente mayor (p=0.001), mientras que la "esofagitis" fue más frecuente entre los HP negativos (p = 0.001). 8/11 (72.7%)de úlceras pépticas tuvieron HP positivo. Biopsias HP positivas comparadas a las HP negativas tuvieron mayor presencia de: Actividad inflamatoria - polimorfonucleares (PMNs) en la lámina propia -, Gastritis crónica - linfomononucleares (LMNs) en la lámina propia -, Folículos linfoides. Ninguna de las biopsias presentó displasia, atrofia o metaplasiaintestinal. CONCLUSION: Se encontró alta prevalencia de infección por HP en niños sometidos a endoscopía alta. Estuvieron ausentes la metaplasia, atrofia o displasia intestinal. La presencia en la endoscopía de "GN", en la biopsia de gastritis crónica, actividad inflamatoria y folículos linfoides estuvieron independientemente asociados a infección por HP.

INTRODUCTION: There is a lack of awareness of the prevalence of infection by Helicobacterpylori (HP) and its histopathological characterization in children in Peru. OBJECTIVES: To report the clinical and histopathological characteristics of infection byHP in children in Cayetano Heredia Public Hospital (HNCH) in Lima, Peru. METHODS: Information was obtained on endoscopies and biopsies done on children between July 2003 and November 2006. RESULTS: Biopsies were done in 111 of 210 endoscopies. HP prevalence was 45.9% (51 out of 111 patients). HP positive patients were older than HP negative (11 versus 8.9 years, p = 0.009). Endoscopic "nodular gastritis" (NG) was HP status dependent(p = 0.001), "oesophagitis" was most frequent among HP negative (p<0.05). 8 out 11 ulcers were HP positive. Histopathological findings in HP positive included more: Inflammationactivity - polymorphonuclears (PMNs) in the proper lamina-, Chronic gastritis- lymphomononuclears (LMNs) in the proper lamina-, and Lymphoid follicles. Dysplasia,atrophy or intestinal metaplasia were absent in our biopsies. CONCLUSION: A high prevalence of infection by HP was found in children who underwent anupper endoscopy. Metaplasia, atrophy and intestinal dysplasia were absent. The presence of "NG" in the endoscopy, and chronic gastritis, inflammatory activity and lymphoid follicles inthe biopsy were independently associated to infection by HP.

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La paracoccidioidomicosis es la micosis más prevalente en Sudamérica. La forma aguda afecta el sistema fagocítico mononuclear de niños y personas inmunocomprometidas. El compromiso gastrointestinal es frecuente y su patogenia implica diseminación hematógena y linfática. La linfadenomegalia abdominal causa obstrucción intestinal y abdomen agudo. En este artículo damos a conocer el caso de un niño con compromiso gastrointestinal por apendicitis. Este es el primer caso reportado de apendicitis por esta patología.

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