Hypoproteinemia in childhood: What should you look for?

Abstract

Introduction: Menetrier’s disease (MD) is a fundus and body gastritis frequently associated with hypoalbuminemia secondary to protein loss through the gastricmucosa. Clinical findings include vomiting, diarrhoea, abdominal pain, anorexia and peripheral oedema inmost cases. In one third of cases Cytomegalovirus (CMV) it is demonstrated having a central role in the pathogenesis and in childhood MD is usually a benign and self-limiting condition, lasting for a few weeks. Patients and methods: We present a 2 yrs old girl with important protein-loss admitted to our Unit; we describe diagnosis and management discussing the causative role of CMV in MD. Results: Two yrs-old girl with a few days history of diarrhoea, cough and fever especially during the night, important peripheral and periorbital oedemas presented at our Unit. Serological tests revealed anemia, iron deficiency, WBC elevated, hyponatremia, hypocalcemia, low level of thyroid hormones, hypoproteinemia, hypoalbuminemia and she was treated by human albumin. Antigliadin, antiendomysial and anti-tissue transglutaminase antibodies were negative. Urinary protein loss was excluded and her liver synthetic function was normal. Abdominal ultrasonography was negative for abdominal ascitic fluid. Nephrological cause was excluded and gastrointestinal causes were studied. Upper gastrointestinal endoscopy was performed and it showed mild multinodular duodenitis and a widely bleeding mucosa with large areas of erosions in the gastric body and fundus. Histologic examination confirmed a profound chronic active hypertrophic gastritis with intense regenerative epithelial hyperplasia. Tissue culture for Helicobacter Pylori and intranuclear CMV inclusion bodies were negative. Duodenal biopsy revealed normal mucosa and villous that excluded coeliac syndrome. An infectious cause is hypothised and serological tests for virus, bacteria and parasites revealed positive serum IgM antibodies against CMV; CMV DNAwas detected in blood through polymerase chain reaction (PCR). During her stay in hospital, shewas treatedwith PPI and another human albuminwas not necessary because of the improvement of her clinical condition. Next upper endoscopy after 20 days showed healing of duodenitis and an erythematous mucosa in the gastric body and fundus without erosions. She continued therapy with PPI and at clinical follow-up 4weeks later shewas free of symptomswith satisfactory weight gain and her haemoglobin, serum electrolytes and serum protein levels were normal, including IgA levels that exclude any Ig deficit. Conclusions: One of the major causes of MD in children is the CMV infection that should be suspected in every childwhopresents with protein-losing gastropathy. Upper endoscopy with histological examination and PCR level should be performed. Usually only supportive care is required, according to literature that describes MD in children as a transient and self-limiting condition. PO26