Manuscript copyright
USENKO
Denis Valerievych
ACUTE ENTERIC INFECTIONS IN CHILDREN WITH ATOPIC DERMATITIS:
CLINICAL AND IMMUNOLOGICAL FEATURES, MANAGEMENT AND REHABILITATION
14.01.09 - Infectious Diseases
Thesis abstract
for a doctor’s degree
Doctor of Medicine
Moscow-2013
The work has been performed in the Federal Budget Scientific Institution "Central Research and
Development Institute of Epidemiology "of Federal service on customers’ rights protection and human
well-being surveillance.
Scientific adviser
MD, Professor Alexander Vasylievich Gorelov
Official opponents
Feklisova, Lyudmila Vladimirovna- MD, professor
State-financed health institution of Moscow region "Moscow Regional Research and
Development Clinical Institute named after M.F. Vladimirsky", head of the department of pediatric
infections
Bokovoy, Alexander Grigoryevich- MD, professor
Federal state budgetary educational institution of higher professional education "Moscow State
University named after M.V. Lomonosov", Fundamental Medicine faculty, Professor, Department of
multidisciplinary clinical training;
Federal State Budgetary Institution "Central Clinical Hospital and Polyclinic» Administrative
Department of the President of the Russian Federation, Head of the department of pediatric infectious
Kalyuzhin, Oleg Vitalyevich - MD, professor
Federal state budgetary educational institution of higher professional education « Moscow First
State Medical University named after I.M. Sechenov” of Ministry of Health of the Russian Federation,
Professor, Department of Clinical Immunology and allergy
Leading organization: Federal state budgetary educational institution of higher professional
education « Peoples’ Friendship University of Russia" Ministry of Education of the Russian Federation.
Thesis defense viva voce will be held on “____” _________2013, ___ h. ____ min. in a panel
session of Dissertation Council D 208.114.01 in the Federal Budget Institution of Science "Central
Research and Development Epidemiology Institute " of Federal service on customers’ rights protection
and human well-being surveillance situated at the address: Novogireevskaya Street 3a, 111 123
Moscow,.
Those who wish can acquaint themselves with the thesis in the library of Federal Budget
Institution of Science "Central Research and Development Epidemiology Institute " of Federal service on
customers’ rights protection and human well-being surveillance.
Author's thesis has been distributed on "____" ___________ 2013
Scientific Secretary of the Dissertation Council
MD, Professor Alexander Gorelov
General work characteristics
Rationale. Acute intestinal infections (AII) remain the most common infectious diseases.
According to World Health Organization (WHO), every year 2.5 billion cases of diarrheal disease is
detected in the world, up to 70% of the patients are children aged up to 14 years [WHO, 2008]. In 2008,
AII caused 15% of all deaths of children in the first five years of life on the planet, yielding the first place
only to acute pneumonia (18%) [WHO, 2011]. In the Russian Federation over the past few decades, a
stable tendency of increase of AII incidence rate was observed, with the mean annual rate of increase 67% [Onishchenko G.G., 2008; Mindlina A. Ya., 2010]. According to Federal service on customers’ rights
protection and human well-being surveillance, in 2011 782,000 AII cases were registered, both of
established and unknown etiology, of which 79.6% of age structure cases were children under 17 years
of age.
High frequency of severe and adverse AII course in children of different age groups as well as
long-term bacterioexretion and virus shedding still remains an urgent problem of practical health care
[Feklisova L.A., 2005; Mikhailova E.V. et al., 2009; Gorelov, B.C. et al., 2010; Fedotov N.N., 2009; Anokhin
V.A. et al., 2012; Grigorovich M.S., 2012; Lobzin Yu.V. et al., 2012]. The reasons of this problem include
violation of nutritional status, constitution anomalies, acute and chronic foci of infection (adenoiditis,
tonsillitis, bronchitis, SARS), anemia, organic lesions of the central nervous system, microbiocenosis
violation, minor forms of immunodeficiency diseases, functional disorders of the gastrointestinal tract
(GIT) and allergic diseases.
The role of allergic diseases in children has increased significantly over the recent decades
[ICCAD II, 2003; Holt P.G. et al., 2010; Balabolkin I.I., 2012].
According to the results of epidemiological studies carried out abroad, the most common
allergic disease in children is atopic dermatitis (AD), the frequency of which varies from 15 to 30%
[BieberT, 2008]. In the Russian Federation, AD frequency in different regions varies from 10 to 37% and
in infants – up to 38% [Khaitov R.M., 2001; Kondyurin E.G. et al., 2004; Revyakina V.A. et al., 2006].
Atopic dermatitis is a multifactorial disease with a basically a genetic predisposition,
complicated immunopathological development mechanism, with violations both in innate and in
adaptive immunity [Suvorov K.N., 1998; Fedenko E.S., 2005; Khaitov R.M., 2009; Kochergin N.G. et al.,
2010; Mar A., 2010] In children with AD, neuroendocrine abnormalities are detected as well as
metabolic disturbance and digestive organ dysfunction [Illek Ya.Yu. et al. 2003; Shutova O.V., 2006;
Balabolkin I.I., 2006; Galanin A.V., 2008], which maintains chronic disease. The problem of simultaneous
course of two common pathological states is acute, because immune disbalance and damage of GIT
microbiocenosis resulting from this combination may lead to a change of clinical symptoms, and the low
efficiency of conventional treatment [Kvetnoy AS et al., 2008].
So far, immunological aspects of AII development, with concurrent allergic diseases still have to
be examined, besides presence of immunity disorders inherent to the allergic process and variations of
immune homeostasis caused by bacterial and viral agents should be considered as well [Martynov G.P.,
2003, Maikova I.D., 2008]. Mechanisms of cytokine regulation under the influence of infectious antigens
have not been fully studied. Levels of the main pro- and anti-inflammatory cytokines were actively
studied in children with AII [Beniova S.N. et al. 2007; Gussoyeva I.G., 2008; Zheleznikova G.F., 2009],
whereas the effect of background allergic diseases on production of key immune mediators are almost
unexplored.
Among the questions that remain unexplored are Influence of morphological and functional as
well as microecological GIT disorders in patients with allergic diseases on AII course as well as possibility
of manifestation of allergic lesions of the digestive tract simulating acute infectious gastroenteritis /
gastroenterocolitis"
To date there are no coordinated approaches to the treatment of this category of patients in the
medical practice. Attempts have been made to implement probiotics and enterosorbents in complex
treatment, but there are only few works in this area. Tactics of antihistamine AII therapy in children with
atopic dermatitis requires further development. Rehabilitation of children with AD undergoing AII
requires separate consideration. Given the high frequency of postinfectious bowel dysfunction and
microflora disorders, use of biocenosis-correcting technologies, in particular modern probiotic foods is a
promising approach to the timely correction of such damages, improvement of the quality of life and
favorable disease outcomes [Burkin A.V., 2005; Elezova L.I., 2005; Loverdo R.G. et al., 2009].
Objectives: to optimize diagnosis and treatment of acute intestinal infections in children with
atopic dermatitis based on identification of clinical and pathogenic characteristics and study of the state
of intestinal microbiocenosis.
Research tasks:
1.
To determine the frequency of concomitant allergic diseases in children hospitalized
with acute intestinal infection.
2.
To study clinical and laboratory features of acute intestinal infections in children with
atopic dermatitis, to evaluate effect of various factors (age, etiopathogenic variant of intestinal
infection, type and severity of atopic dermatitis).
3.
To investigate performance of cellular, humoral and mucosal immunity, cytokine status
in children with acute intestinal infection suffering from atopic dermatitis according to etiology and
severity infectious process, genesis and severity of allergic disease.
4.
To examine intestinal microbiocenosis status in AAI children with AD considering their
age and disease severity.
5.
To assess clinical and laboratory efficiency of modern enterosorbents, probiotics and
antihistamines in AAI children suffering from atopic dermatitis, and to justify the differential use of
these drugs for treatment and rehabilitation.
Scientific novelty:
New data have been received on the role of allergic diseases in the structure of concomitant
somatic pathology of children with acute intestinal infections. A possibility appeared of manifestation of
allergic GIT disease simulating AII, and tactics of differential diagnostic search have been proposed.
The first studies have been conducted for AD effect on the clinical features, course and
outcomes of AII in children. A high frequency of wave-like and prolonged AII course has been
demonstrated, as well as prevalence of moderate to severe forms, high symptom load (intoxication
exsicosis, diarrheal syndrome) and duration of clinical manifestations, persistent gastrointestinal
disorders, secondary disaccharidase deficiency and dysbiosis in the convalescence period.
New data have been received on the state of cellular and humoral immunity, phagocytic system,
gastrointestinal mucosal immune system in children in various periods of acute intestinal infection with
various immunopathological AD variants. It has been detected that patterns of AII against the
background of atopic dermatitis are characterized by violations of immunoregulatory mechanisms
whose severity and direction depends on the type of pathogen and severity of the disease. It has been
established that immunopathogenic factors causing unfavorable clinical course in AD children with acute
intestinal infections is disbalance of quantitative parameters of cellular immunity, with increase in the
ratio of CD4 + - and CD8 + - cells; deficiency of serum IFN-γ; high IgE serum levels, reduction of factors of
local GIT protection, particularly free and secretory IgA.
For the first time differences have been revealed in the patterns of cytokine regulation immune
response in AII on the background of atopy and without concomitant allergic pathology. It has been
shown that in AII of viral etiology, Th2-type of immune response dominates in patients with atopic
dermatitis, manifested in significant increase in the levels of IL-4, with parallel IFN-γ deficiency, whereas
in patients without allergy pathologies a balanced Th1 / Th2-immune response is determined.
Based on the first evaluation of allergy indicators (total IgE and specific IgE antibodies to
opportunistic microorganisms) in AII dynamics, the data have been received showing their
multidirectional character: sensitization growth after undergoing AII of viral etiology and a downward
trend of IgE level in convalescence from bacterial AII.
For the first time negative impact of AD has been shown on the depth and durability of
microecological disorders in the GIT in pediatric intestinal infections.
It has been established that their expression is directly correlated with the severity of atopic
dermatitis. Note that frequency of self-relief of GIT microbiocenosis disorders arising from AII in children
with atopy has not suceeded 5,2%.
For the first time, pathogenic substantiation has been given, and comparative assessment of
efficiency of modern enterosorbents, probiotics and antihistamines in AII has been conducted in
children with atopic dermatitis. Therapy and rehabilitation tactics of these patients have been
developed.
Practical significance:
• Clinical and laboratory features of acute intestinal infections have been identified in children
with concomitant AD, allowing clinicians to predict the course of infection and adjust the therapy in
time.
• A set of clinical and laboratory parameters has been proposed for differential diagnosis of
acute intestinal infections and manifestation of gastrointestinal food allergy in infants.
• These features of the immune response in AII of various etiology on the background of AD
increase the possibility of assessing severity of the course and prognosis of the disease.
For this purposes, monitoring of proinflammatory (IFN-γ, IL-1β) and anti-inflammatory (IL-4)
cytokines, leukocyte index (IFN-γ / IL-4), serum levels of total IgE, levels of secretory IgA and free IgE in
the coprofiltrate is recommended.
• Based on the new data on efficiency of modern enterosorbents, probiotics and antihistamines,
recommendations have been developed to optimize their use for the treatment of AII children with
atopic dermatitis, which can improve the prognosis and outcome of acute intestinal infections in this
category of patients.
• A complex of rehabilitation measures, including use of antihistamines of II generation,
probiotics and products of functional foods has been proposed to correct postinfectious functional GIT
disorders and effects of dysbiosis, to reduce sensitization and AD progression.
Evaluation of the research results
Results of the study have been presented at the IX Congress of Pediatricians of Russia "Actual
problems of Pediatrics" (2004), Russian national scientific and practical conference "Treatment of
infectious diseases in children: modern conceptions and unsolved problems "(2005), Russian national
conference "Topical issues of Pediatrics" (2005); VII-IX Congress of Russian pediatric infectious diseases
(2008-2010); XIV Russian Gastroenterological Week (2008), I-IV Annual Russian Congress on Infectious
Diseases (2009-2012), XII -XIV Russian Congress of Dietitians and Nutritionists "Nutrition and Health"
(2010-2012), X and XI Russian Congress of Pediatricians specializing in infectious disease (2011, 2012), III
Interregional Scientific and Practical Conference "Infectious diseases: topical issues of diagnosis,
treatment and prevention "(2012).
The dissertation has been approved in a panel session of Dissertation Council D 208.114.01 in
the Federal Budget Institution of Science "Central Research and Development Epidemiology Institute "
of Federal service on customers’ rights protection and human well-being surveillance on November 26,
2012.
Publications
The main scientific results on the dissertation topic have been published in 47 printed works, of
them 24 are journals recommended by State Commission for Academic Degrees and Titles for
publication of major scientific results of dissertations.
Implementation of the research results
The results have been applied in the direct of specialized departments of National public
institution of health care Hospital for the infectious diseases of children №5, Moscow Department of
health, as well as included in the "Practice guidelines to diagnosis and comprehensive treatment of
acute intestinal infections in children "(Study guide for physicians. Moscow, 2003), "Clinical practice for
diagnosis and treatment of acute intestinal infections in children "(Study guide for physicians. Ministry
of Health and Social Development of the Russian Federation. Moscow, 2005), "Practice Guidelines for
antibiotic shigellosis therapy in children" (Study guide for physicians. Moscow, 2006).
Thesis structure
The work is presented on 331 pages of typescript text and consists of introduction, four chapters
and reference list. The work contains 47 figures and 75 tables. The source book contains 470 reference
links, including 197 of Russian and 253 of foreign authors.
CONTENT OF THESIS
Materials and Methods
The thesis was written in the clinical department of infectious pathology Federal Budget
Institution of Science "Central Research and Development Epidemiology Institute" of Federal service on
customers’ rights protection and human well-being surveillance in the years 2002-2010. To achieve the
goals and solve the tasks, clinical and laboratory observations of 476 patients (boys - 60.4%, girls 39.6%) at the age from 3 months to 14 years hospitalized in the specialized departments of National
public institution of health care Hospital for the infectious diseases of children №5, Moscow
Department of health (Chief executive officer Vlasov EV.). have been performed. The main group
consisted of 231 children who had previously been diagnosed with atopic dermatitis (according to the
form 112 / u "Infant record", approved by the Order № 1030of USSR Ministry of Health from October 4,
1980). 245 patients who did not have any data on concomitant allergic pathology in the history and at
the time of admission were chosen by random sampling technique for the comparison group of 3409
children patients treated in the hospital during the period 2002-2010.
Among the patients surveyed, 33.3% were children of the first year of life, 26% - aged from 1
year to 3 years, 40.7% - older than 3 years. All the patients were diagnosed with acute intestinal
infection based on history, clinical and epidemiological data, results of bacteriological, serological,
molecular genetic studies considering the diagnostic criteria adopted in the hospital.
Mild AII course was observed in 21% of children, moderate to severe - in 60.4%, severe – in
18.6%. In 77.3% cases the patients were hospitalized within the first three days of illness
(day 1 - 31.4%, day 2 - 27.3%, day 3 – 18.6%). According to the disease topography of GIT, in the
patients observed gastroenteritis form prevailed (41.1%), more seldom the pathological process
involved distal segments of the intestine, with the development of enterocolitis (19.9%) and
gastroenterocolitis (22.5% patients).
Among the surveyed patients of the main group, mild AD course was observed in 48.5% (112
children) - 1-2 exacerbations per year, remission duration 6-8 months. Moderate course of the disease
(exacerbation frequency 3-4 times a year, remission duration 2-3 months) was established in 44.2% (102
patients), and severe course - in 7.3% (17 children) (not less than 5 exacerbations in the past year, with
brief remission in 1-2 months or persistent disease). In assessing AD severity, criteria of scientific and
practical program "Atopic dermatitis and skin infections in children: diagnosis, treatment and prevention
"(Union of pediatricians of Russia, 2004) were used as a guide.
Etiology of acute intestinal infections defined using a set of diagnostic methods (bacteriological,
serological, molecular-genetic), was determined in 75.6% children. rotaviruses were the leading cause of
the disease - 28.6%, other diarrheagenic viruses (Norwalk, astro-, adenoviruses) - 17.5%, and Salmonella
- 12.6%. Much rarer causes of AII included Shigella (5.2%), Escherichia (5.2%), opportunistic pathogenic
microorganisms (5%) and Campylobacter (1.5%). In every fourth patient, disease etiology was not
deciphered. All patients received combined therapy according to present clinical recommendations
including diet therapy, oral rehydration or infusion therapy for the main indication as well as
symptomatic therapy.
In accordance with the purpose and objectives of the present study, clinical and laboratory
evaluation of the efficiency of modern enterosorbents in AII was conducted in 99 children with
concomitant AD. Group 1 consisted of 53 patients receiving dioctahedral smectite (Smecta) from the
first days of the disease; group 2 consisted of 46 patients receiving polymethylsiloxane polyhydrate
(Enterosgel); group 3 (comparison group) included 26 children treated without using enterosorbents.
The preparations were prescribed based on standard dosages set forth in the instructions for use.
Clinical and laboratory evaluation of the effectiveness of modern probiotics in the complex
therapy of acute intestinal infections was conducted in 92 children with atopic dermatitis (main group).
Patients of the study group received monocomponent (Enterol - 15 patients, Probifor - 23 patients) or
multicomponent (Acipol - 34 children, Linex - 20 patients) probiotics. Simultaneously, observation of 63
patients receiving no probiotics (comparison group) was conducted. The dynamics of the relief of AAI
symptoms, severity of manifestations and AD course as well as intestinal microbiotic values were
assessed.
According to the task of identifying therapy and rehabilitation tactics in AAI children suffering
from AD, effectiveness of clinical and laboratory values of antihistamines (AHP) of the first (suprastin,
tavegil) and second generation (zyrtec) was assessed in complex AII therapy in children suffering from
atopic dermatitis (study group). The comparison group included 59 patients receiving AHP treatment at
prehospital and hospital stages. Symptom load and duration of the main symptoms of intestinal
infection as well as value dynamics of activity of cutaneous allergic process and frequency of AD
exacerbation was identified as effectiveness criteria.
In order to improve the rehabilitation program for AII convalescents suffering from atopic
dermatitis, efficiency was assessed for a set of measures including II generation AHP (course of up to 3
months.) Polycomponent probiotic (Linex) or probiotic products for functional nutrition containing
Lactobacillus casei DN-114001 or Bifidobacterium animalis DN-173010 (adjusted for age, character of
gastrointestinal disorders and the absence of allergy to cow milk protein). The efficiency of the proposed
complex has been studied in 72 children with atopic dermatitis.
Laboratory examination
A standard laboratory examination included: complete blood count and clinical urinalysis,
coprological examination, biochemical blood assay, determination of blood acid-base composition, feces
analysis and scraping for helminth eggs and protozoa in the clinical laboratory of National public
institution of health care Hospital for the infectious diseases of children №5, Moscow Department of
health (Chief of laboratory Schastnych L.A.). Determination of the level of free carbohydrates in the
feces was conducted in the clinical diagnostic Center of Federal Budget Institution of Science "Central
Research and Development Epidemiology Institute" of Research Center of Epidemiology and
Microbiology named after G.N. Gabrichevsky, Federal service on customers’ rights protection and
human well-being surveillance.
In order to establish AII etiology, the following procedures were conducted: single-step / threefaeces inoculation to determine pathogenic microorganisms, in case of indication - inoculation of gastric
lavage and faeces on the opportunistic flora (Chief of bacteriological laboratory of National public
institution of health care Hospital for the infectious diseases of children №5, Moscow Department of
health Gulid E.P.), detection of rotavirus antigen in the faeces by ELISA using Rota-analysis test system
of JSC "Bioimmunogen" (Moscow) (specialist - virologist Kosorotikova A.I.). On the first day of admission
(but not later than 3 days from the disease onset), initial testing of faeces of patients on the presence of
intestinal infection agents (Shigella and EIEC, Salmonella, Campylobacter, group A rotaviruses,
noroviruses of genotype 2, astro- and adenoviruses) was performed by polymerase chain reaction using
diagnostic test systems with electrophoretic amplification product detection of "AmpliSens" family
(performed in the Laboratory of Molecular diagnosis and epidemiology of intestinal infections, National
public institution of health care " Central Research and Development Epidemiology Institute of Federal
service on customers’ rights protection and human well-being surveillance ", Chief of the laboratory,
PhD Podkolzin A.T). In the second week of disease (according to indications), blood serological test was
carried out by passive hemagglutination test (PHA) method with Salmonella, Shigella and Yersinia
antigens (Chief of bacteriological laboratory of National public institution of health care Hospital for the
infectious diseases of children №5, Moscow Department of health Gulid E.P.)
Intestinal microbiocenosis investigation was conducted in the acute period (days 1-3 of the
disease) and in the recovery period (days 14-16 of the disease) by method of R.V. Epstein-Litvak and F.L.
Vilshanskaya in the National public institution of health care CNIIEP of Federal service on customers’
rights protection and human well-being surveillance (Chief of laboratory Bochkov I.A, MD) and FSBI
"Research and Development Nutrition Institute", RAMS (Chief of laboratory Sheveleva S.A., MD).
Evaluation of GIT metabolic activity was carried out by gas-liquid chromatography (GLC) in the
Department of Gastroenterology FSBI "Academic Methodological Center Presidential Management
Department of the Russian Federation"(MD, professor Ardatskaya M.D.) by method of Ikonnikov N.S.,
Ardatskaya M.D. et al. ("Method of separating a mixture of fatty acid, fraction C2 -C7, by GLC", Patent
RU 2145511, cl. B 01 D 15/08, 20.02.2000).
Immunological methods. Immunological studies were performed in the laboratory of
immunological study methods, FSBI "Research Institute of Vaccines and Sera named after
I.I.Mechnikov", RAMS (Chief of the Laboratory Ph.D., Professor Krasnoproshina L.I.). Lymphocyte CD3 +,
CD4 +, CD8 +, CD16 +, CD72 + level was determined by flow cytofluorometry on a cytometer FAC Scan
(BectonDickinson, USA) using monoclonal antibody of the same firm for differentiation and activation
markers. To determine concentration of immunoglobulins IgA, IgG, IgM, method of radial
immunodiffusion in the agarose gel sensu G. Manchini (1965) was used in the in the modification of E.V.
Chernohvostova and G.P. German. Neutrophil phagocytic rate was determined by their absorbing
capacity of suspension of killed Staphylococcus aureus.
To examine the status of mucosal immunity, determination of concentration of
immunoglobulins G, A and secretory A was determined in the saliva and coprofiltrates by
immunodiffusion reaction sensu . Manchini (1965) in the in the modification of E.V. Chernohvostova and
G.P. German using a commercial kit issued by Scientific and Production Center "Medical immunology".
Study of IgE in the coprofiltrates was performed by ELISA using diagnostic kits "Diaplus", Scientific
Production Association "Biotechnology" (Russia).
Assessment of cytokine status included determination of serum levels major proinflammatory
markers, IFN-γ and IL-1β, as well as anti-inflammatory IL-4 by ELISA assay using diagnostic test-systems
R&D DiagnosticsInc. (USA). For approximate estimation of Th1 / Th2 ratio we used IFN-γ / IL-4
[Mosmann T., Sad S., 1996].
Allergology methods. General IgE in blood serum was determined by ELISA using a commercial
test system released by LLC "TsKFF" (Stavropol). To determine the level of specific IgE antibodies to 5
groups of casually significant allergens, original techniques were used developed in the Laboratory of
allergic diagnostics, FSBI "Research Institute of Vaccines and Sera named after I.I. Mechnikov", RAMS
(Chief of the Laboratory Ph.D., Professor Gervaziyeva V.B.). Integral evaluation of sensitization was
carried out using allergization index [Kobets T.V. et al., 2002].
Instrumental studies. Status of the liver, pancreas, gall bladder and stomach was evaluated by
ultrasound method using diagnostic tool company «Aloca» (Japan) using convexion and linear array
probe with a frequency of 3.5 MHz (by method of I.V.Dvoryakovsky, V.V. Lukin, L.V. Kedik, 1993). The
study was carried out by Kozhevnikova E.N., MD and Ploskireva A.A., MD, specialists of ultrasound
diagnostics, National public institution of health care Hospital for the infectious diseases of children №5,
Moscow Department of health
Methods and scope of laboratory and instrumental investigations are presented in Table1.
Table 1.
Methods and scope of the studies performed
Study method
Material
Number of patients
Number of studies
Clinical methods
Complete blood count
Biochemical blood assay
Blood acid-base balance
Clinical urinalysis
Coprological feces
blood
476
634
blood
117
169
blood
81
152
urine
348
348
feces
81
143
feces
85
170
feces
476
476
scraping from anal
476
476
examination
Biochemical feces analysis
(microflora metabolites,
free carbohydrates)
Stool ova & parasites test
Scraping for enterobiasis
folds
Immunological methods
PHA (dysentery,
blood
113
162
feces
314
449
nasal discharge
96
96
кровь
161
240
blood
79
158
blood
161
376
blood
47
94
saliva
47
94
feces
70
140
salmonellosis and other)
Feces analysis for
rotavirus antigen
Nasopharyngeal swab for
viruses (flu, parainfluenza,
RS-viruses, adenoviruses)
(ELISA)
Immunological status,
including cell (CD3+,
CD4+, CD8+, CD16+,
CD72+), humoral (Ig A,
G, M) and natural (NKcells, neutrophil
phagocytic rate, ФИ)
immunity
Cytokine status (IFN-γ, IL1β, IL-4)
Allergological
status
General
IgE
Specific
IgE to 5
antigen
groups
Mucosal
immunity
Ig G, A,
secretory
Ig A
Secretory
Ig A and Ig
E
Microbiological methods
Feces bacterial
feces
476
639
examination
Washing bacteriological
washings
78
78
feces
45
45
feces
141
282
inoculation
Bacteriological
inoculation for
campylobacters
Feces for dysbacteriosis
by method of R.V.EpsteinF.l.Vilshanskaya
Instrumental methods
Abdominal ultrasound
ECG
93
109
27
35
Other methods
Molecular and genetic
feces
357
436
methods
Medical documentation
Disease stories (from 003/ u)
Inpatient cartograms
476
3640
Statistical analysis was performed using commercial software package Primer of
Biostatistics 4.03 and statistical module of Microsoft Excel 2010 on the PC. Determined were the
following values:
statistical series percentage (%), simple average (M), standard deviation (STD), average
error of the mean value (m).
Comparison of the frequency of occurrence of qualitative clinical signs was based on
comparison of empirical distributions using the χ2 criterion.
Differences were considered significant for p <0.05, highly significant for p <0.001,
insignificant for p> 0.05.
The significance of differences between mean values was determined using Student's ttest (t). Differences were considered significant for p <0.05, highly significant for p <0.001,
insignificant for p> 0.05.
Results and discussion
Structure of concomitant somatic pathology in children with acute enteric infections.
Structural analysis of the concomitant somatic pathology in AII children admitted to the
hospital, was conducted in 3640 patients in the period from 2002-2010. It has been established
that allergic diseases accompanied AII in 1228 children (33.7%), dominating in frequency of
occurrence in the major groups of somatic diseases of all age groups. In the second place were
disease of the central nervous system (20%). The third place was occupied by diseases of the
digestive system (14.4%) and ORT pathologies (13.1%). The smaller number of children
experienced iron deficiency anemia (5.7%) and pathology of the genitourinary system (2.0%).
The most frequent cases were AD (in 19.8% of patients with acute intestinal infections)
and gastrointestinal food allergy (11.2%). The frequency of these diseases was highest in infants
(25.2 and 11.8%, respectively) and tender age groups (18.2 and 11.7%, respectively). Allergic
airway diseases were recorded in children of preschool and increased age (7.2 and 16.7%).
In the structure of patients allergic diseases in the examined, food allergy and AD were
determined in 58.7%, drug allergy - in 14.8%, airway diseases – in 7.1% (including bronchial
asthma- 4.3%, allergic rhinitis- 3.4%).
Thus, allergic diseases are the most common comorbidity in children with acute
intestinal infections of, especially in infancy and tender age. These data confirm the results of
studies conducted by Elezova L.I., (2006), Bitiyeva R.L. (2007), Gurieva O.A. (2010) on high
incidence of concomitant allergic pathology in this category of patients.
Clinical and laboratory features of acute intestinal infections in children with
concomitant atopic dermatitis.
To assess AD impact on the course and outcome of acute intestinal infections in children
considering age, etiopathogenic variant of intestinal infection, type and severity of atopic
dermatitis, comparison of clinical data and laboratory examination was conducted in
comparable groups of 231 patients (study group) and 245 patients without allergic diseases
(control group).
It was established that in patients with atopic dermatitis acute intestinal infections are
characterized by more frequent acute onset, with the development of basic clinical symptoms
on the first day of the disease (in 85.3% of patients versus 72.7% in the comparison group (p
<0.05), high frequency of moderate (67.1 vs. 53.9%, p <0.05) to severe forms (22.9 vs. 14.3%, p
<0.01). Significantly more frequent in these patients was undulation (26.8 vs. 15.1%, p <0.001)
and chronic (13.0 versus 4.5%, p <0.001) AII course, compared with children without allergic
diseases for which a smooth course of the disease was typical (80.4 vs 60.2%, p <0.001).
AII in the two comparison groups was often presented by gastroenteritis (41.1 and
46.1%, p> 0.01) and gastroenterocolitis (22.5 and 21.2%, p> 0.01). At the same time, children
with AD experienced enterocolitis form of the disease significantly more frequent than those in
the comparison group - 22.9 vs 13.9% (p <0.001). In our opinion, a significantly higher frequency
of infectious diseases of the colon in the study group was due to the background allergic disease
and was not associated with the disease etiology which can be confirmed by the results of
scoring etiological causes of AII (see Fig. 1).
Data presented in Figure 1. show no statistically significant differences in the etiological
AII structure between the groups: rotaviruses and other diarrheal viruses (total percentage 61.4
and 60% in the main group and the reference groups, respectively) dominated, among the
bacterial pathogens (total percentage - 21.9 and 25.9%, respectively) the most often was
salmonella (9.8 and 11.9%, respectively), and AII frequency of combined etiology was 17 and
14.8% of which coincides with previously published data [Kozina G.A., 2009; Grigorovich M.S.,
2011].
Fig. 1 Etiological structure of AII scored in the two groups (%)
Figure captions:
<
Children with atopic dermatitis
Rotaviruses 38.0
Other viruses 23.4
Salmonella 9.8
Shigella 4.3
Campylobacters 3.3
Children without atopic dermatitis
Rotaviruses 40.0
Other viruses 19.6
Salmonella 11.9
Shigella 3.8
Campylobacters 4.3
Combined infections 17.0
Colibacillosis 4.5
Combined infections 14.8
Colibacillosis 5.1
Clinical performance of acute intestinal infections in the two groups was characterized
by combination of intoxication symptoms (fever, apathy, loss of appetite) and dyspeptic
manifestations (vomiting, diarrhea). At the same time, the children with concomitant AD
experienced some differences. For example, statistically more significant was accidence of
decreased appetite (67.5 vs 56.7, p <0.05), anxiety (50.6 vs 36.7%, p <0.05), and excitation (29.4
vs. 9.4%, p <0.05) in comparison with the control group. Fever was present in the majority of
patients, and in 47.6-49 % of cases, it was pronounced. Presence of background allergy
contributed to lengthening of febrile period (see Fig. 2) and increase in the number of patients
who experienced persistent fever for more than 6 days (13 vs 3.3%, respectively, p <0.05).
Fig. 2 The average duration of the main AII symptoms in the two groups of patients
(* - Statistically significant differences in p <0.05).
Figure captions:
Comparison group
Study group
Diarrhea
Vomiting
Fever
Loss of appetite
Apathy
Among dyspeptic symptoms of the disease the greatest differences were observed in
the character, nature and duration of diarrhea syndrome. Up to 75.8% of the study group (p
<0.05) experienced pronounced diarrheal syndrome (stool frequency higher than 6 times a day),
and every third child – loose stool more than 10 times per day. In the comparison group, in
contrast, 43.7% experienced moderate diarrhea (up to 5 times a day), and only 19.6% children
(p <0.05) – multiple diarrhea. The mean duration of diarrhea syndrome in patients with
concomitant AD was 1.8 days higher than in the control group (p <0.05) (Fig. 2). In the main
group of patients diarrhea was significantly more seldom in comparison with the patients
without AD, it was stopped during the first five days of the disease (28.1 vs 40.8%, p <0.05), and
in 22.9% patients it persisted 8 days or more (comparison group – in 12.2%, p <0.05). it is
noticeable that high frequency of blood admixture in stool (20.3 vs 11.4%, p <0.05), as well as
watery diarrhea (30.7 vs. 14.7%, p <0.05) was determined in children with concomitant AD.
Intensity and duration of vomiting had no significant difference between the patient groups.
Significantly more frequent in the study group were symptoms of water and electrolyte
imbalance (27.7 vs 16.3%, p <0.05), however the ratio of patients with second degree exsicosis
did not differ significantly in the two groups (11.3 vs 9%, p> 0.05).
It was established that scatological signs of exocrine pancreas insufficiency syndrome
and dysbiosis in the acute AII period in children with concomitant AD was recorded significantly
more often (67 and 82%) than in the comparison group (41 and 61%, p <0.05). In the late
convalescence period (day 21-24 from the onset of the disease), 59% children with AD (p <0.01)
still experienced signs of scatological syndrome, dysbiosis, 48% (p <0.01) - exocrine pancreas
insufficiency, 37% - inflammatory changes, which can suggest about the negative impact of AD
on the dynamics of normalization of scatological disorders. In the comparison group in these
period scatological violations stopped in 57% children.
Age features of acute intestinal infections in children with comorbid AD were studied
in 3 groups of children. Children in the age under 1 year (n = 77) were in the group 1, 1 - 3 years
(n = 60) – group 2, older than 3 years (n = 94) – group 3. The groups were comparable in
admission terms and preclinical background. In comparative evaluation of infectious process
features (see Fig. 3), there was no difference in the nature of the disease onset (in the vast
majority of patients it was acute) and its course.
Fig. 3 Infection process characteristics (%).
Figure captions:
Onset
Under 1 year – 1 to 3
years – Older than 3
years
Acute - subacute
Course
Disease topology
Severity
Under 1 year – 1 to 3
Under 1 year – 1 to 3
Under 1 year – 1 to 3
years – Older than 3
years – Older than 3
years – Older than 3
years
years
years
Acute – ondulation -
Gastroenteritis –
Mild – moderate -
chronic
gastroenterocolitis -
severe
enterocolitis
Gastroenteritis / enteritis prevailed among gastrointestinal lesions of all age groups. In
this case, the frequency of enterocolitis in children aged 1-3 years was significantly higher than
in the other groups (p <0.05), and gastroenterocolitis was recorded significantly more often in
children of 1-3 years of age and older than in infants (p <0.05).
On analyzing severity, a significantly greater frequency of severe AII can be noted in
infants (24.7 - 30%). Comparative clinical characteristics of acute intestinal infections in children
with AD in different age groups is shown on the Figure 4.
Figure 4. Comparative clinical characteristics of acute intestinal infections in children
with atopic dermatitis considering the age.
Figure captions:
< Under 1 year – 1 to 3 years – Older than 3 years
Apathy – Loss of appetite – Anxiety – t 37-38°C – t 38.1 - 39°C – t=> 39.1°C – first degree exsicosis –
second degree exsicosis – vomiting 1-2 times – vomiting 3-4 times – stool up to 5 times – stool 6-9 times
– stool >10 times – hepatomegalia – megalosplenia>
Manifestations of infection process common for all age groups of patients included loss of appetite,
single vomiting, pronounced diarrheal syndrome (stool frequency in 27.7 - 36.4% patients was >10 times
a day). At the same time a number of age-related features have been identified. Compared with other
age groups, infants more often experienced anxiety, subfebrile fever, vomiting 3-4 times a day and
hepatomegaly. In the patients of 1-3 years of age, AII clinical performance often included apathy, febrile
fever, splenomegaly and symptoms of exsicosis (first and second degree).
Comprehensive analysis of clinical data, anamnesis, results of standard and optional
allergen-immunological surveys allowed to detect gastrointestinal forms of food allergy (GIFA) in
11.3% infants initially hospitalized with preliminary diagnosis of acute infectious enteritis /
enterocolitis. In all the cases infectious etiology of the disease has been denied according to
results of bacteriological, immunological, molecular genetic methods of activator identification.
In the clinical performance, exacerbation of cutaneous manifestations of allergy was
conspicuous, preceding onset of intestinal dysfunction, in particular liquid stool, loss of appetite,
one third of the patients experienced low-grade fever without vomiting. GIFA diagnosis was
confirmed by laboratory parameters, including high level of eosinophils in the peripheral blood
(> 300μ / l) and in the feces, total IgE, detection of specific IgE and IgG4 antibodies to cow milk,
goat milk and soya proteins. Standard basic therapy had no effect. An allergist performed
further follow-up and treatment.
One of the key factors determining the course and outcome of intestinal infection was a
pathogenic disease variant depending on the pathogen type and pathogenicity factors. We have
studied AD impact on clinical manifestations and course of the “watery” (n = 126) and "invasive"
AII (n = 105).
Course of "watery" AII type with AD background was characterized by higher frequency
of acute onset (81 vs 64.3%, p <0.05), severity (moderate – 73 vs 61.1%, p <0.05) as well as
undulating course in 26.2% (in the comparison group – 9.5%, p <0.05).
Higher frequency and severity of intoxication symptoms (loss of appetite - 62.7 vs. 46%,
p <0.05), general anxiety in every fourth child (in the comparison group – 10.3%, p <0.05), as
well as anxiety (54 vs 38.1%, p <0.05) were main clinical symptoms in children with atopic
dermatitis. Febrile fever was significantly more frequent in the comparison group (36.5 vs 23%,
p <0.05), while its average duration had no significant differences (3.2 days in the main group
compared to 3.7 in the comparison group, p = 0.08). Water and electrolyte imbalance was
significantly more frequent in children with concomitant AD (44.5 vs 27.8%, p <0.05), which was
due to pronounced diarrhea syndrome (stool >10 times a day in 32.5% vs 16.7% in the
comparison group, "watery" type in 52.3% patients - (in comparison group - 27%, p <0.001).
Diarrhea in AD patients resisted 1.5 days longer than in the comparison group (6.8 vs 5.3 days, p
<0.001).
When monitoring the dynamics of free carbohydrates in the feces, a phenomenon of
lactase deficiency (LD) in the first days of the disease in the main group patients with recorded
significantly more frequently than in the control group (86.5 vs 63%, p <0.05). At the same time,
pronounced LD (level of carbohydrates in the feces higher than 1.1%) occurred 3.6 times more
frequently in the study group than in the comparison group (13.5 vs 3.7%, p <0.05), and
moderate LD – 1.3 times (43.2 vs 33.3%, p> 0.05). In the recovery period (days 21-24 of the
disease,) moderate and high levels of carbohydrates in feces were determined in 27% patients
of the main group (absent in the comparison group), in 43.3% minimum LD degree was recorded
(37.5 in the comparison group). The data received show a slow recovery of enterocytes
disaccharidase activity in children with concomitant AD, as well as possibility of hidden lactose
intolerance.
AII of "invasive" type in children with atopic dermatitis was characterized by more
severe concomitant infection process (every third patient experiences a severe disease course,
60% patients - moderate (in comparison group – in 19% and 44.8%, respectively, p <0.05)), while
there was an undulation in 27.6% (vs 21.6%) or a chronic disease (18.1 vs 6.7%, p <0.05).
According to modern concepts, bacterial pathogens are primarily etiologic factors of invasive
diarrhea. According to our data (see Fig. 5), in children without concomitant allergic diseases in
78% cases were allocated bacterial pathogens (Salmonella, Shigella, enteroinvasive Escherichia,
Campylobacter, opportunistic microorganisms) and only in 22% - bacterial and viral association.
In atopic children with clinical invasive diarrhea, frequency of mixed infections was significantly
higher (36.5%, p <0.05), which may be caused by defects of mucosal immunity as well as deeper
and communication of gastrointestinal lesions on account of concomitant allergic process in
acute intestinal infection.
Figure 5. Etiological structure of scored "invasive" type AII
(* - Statistically significant differences for p <0.05).
Figure captions:
<Main group
Comparison group
Viral and bacterial mixt – Salmonella – Shigella – enteroinvasive – Opportunistic
pathologic microorganisms - Campylobacter
Comparative analysis of clinical symptoms in the acute period if invasive AII in children
with and without AD allowed to establish significant differences in general anxiety frequency
(35.2 vs 8.6%, p <0.05), timing of fever relief (4.8 ± 2.1 vs 3.9 ± 1.5 days, p = 0.002) and diarrhea
(9.4 ± 1.8 ± 1.7 vs 7.6 days, p <0.001), as well as severity of diarrheal syndrome (loose stools
more than 6 times a day, significantly more frequent than in the comparison group - 68.6 and
52.3%, respectively (p <0.01).
Figure 6. Dynamics of scatological signs of inflammation in invasive AII
Figure captions:
<Mucus – Leukocytes: single – up to 20 per field – 20-50 per field – Eosinophils –
Erythrocytes: single – up to 20 per field
Main group: acute period – days 7-10 of the disease – days 21-24 of the disease
Comparison group: acute period – days 7-10 of the disease – days 21-24 of the disease >
To assess the relief of inflammatory process in the gastrointestinal tract, analysis of the
main scatological values in "invasive" AII type was conducted in two groups. As seen on Figure 6,
in AD children inflammatory changes were more persistent. Thus, by the period of early
recovery macroscopic mucus persisted in 47.8% (comparison group – 22.2%, p <0.001), in all the
patients, white blood cells were present in the feces, in 91.3% - in a significant amount (in the
comparison group - only in 44.5%, p <0.05). In the period of late convalescence, scatological
signs of inflammation persisited in 34.8% of patients of the main group (mucus, white blood
cells), which was significantly more frequent than in the comparison group – 11.1% (p = 0.072).
Status of the immune system in AII children with concomitant atopic dermatitis
depending on AII etiology and immunopathogenic variant of allergic disease
As a result of the studies, data were obtained indicating that AII in children is
accompanied by changes of cellular, humoral and innate immunity whose direction and severity
was directly dependent on the presence of concomitant allergic pathology. Thus, in patients
with concomitant AD, during the acute phase of AII an increase in quantitative helper-inductorlevel of immune response was observed, that was demonstrated by a relative increase in the
mean CD3+ and CD+-lymphocyte levels as well as immunoregulatory index (IRI) on background
of CD8+ cells reduction (see Fig. 7). In comparison group, statistically significant violations were
detected only in the pool of CD8 + lymphocytes whose average absolute and relative amounts
were significantly reduced in comparison with healthy children. Frequency analysis revealed
deviations of immunological parameters in all patients of the main group and in 77.8% in the
comparison group (p> 0.05). Significantly more frequent than in the control group, deviation of
absolute lymphocyte count was determined in children with AD (70.7% vs 46.7, p = 0.006) and
CD8 +-cells (77.6 versus 40%, p = 0.023). In the control group the most often detected was
deviation of IRI (in 71.1% patients, significantly more frequent than in the main group (p = 0.05)
and the relative amount of CD16 +-cells (in 64.4%, no significant differences with the main
group).
Figure 7. Parameters of systemic immunity in children with acute intestinal infections
considering allergic status (converted value of healthy children is equal to 1).
Figure captions:
Children with AD
Children without AD
Lymphocytes, % - Lymphocytes, abs. – CD3, %
- CD3, abs. – CD4, % - CD4, abs. – CD8, % CD8, abs. – IPI – CD72, % - CD72, abs. – CD16,
% - CD16, abs. – NPR (neutrophil phagocytic
rate) – PI (phagocytic index)
Lymphocytes, % - Lymphocytes, abs. – CD3,
% - CD3, abs. – CD4, % - CD4, abs. – CD8, % CD8, abs. – IPI – CD72, % - CD72, abs. – CD16,
% - CD16, abs. – NPR (neutrophil phagocytic
rate) – PI (phagocytic index)
The study of humoral immunity showed significant reduction in the number of Blymphocytes in patients with concomitant AD (p <0.001), but levels of major immunoglobulin
classes had no significant differences with the comparison group (except IgE).
In the innate immune system during the acute AII phase patients with AD experienced
significantly more severe disorders (deficiency of NK-cells (p = 0.01), reduced phagocytic activity
of neutrophils and phagocytic index).
Figure 8. Correlations of immunological parameters in AII children with atopic dermatitis
(A) and without AD (B).
Note: The solid line indicates strong correlations (r = 0.7-1, for p <0.01), stipple correlation of medium strength (r = 0.3-0.7, p <0.01).
Figure captions:
A) Leukocytes – lymphocytes, % - lymphocytes, 109 – CD3, % - CD4, 109 – CD8, % - CD8,
109 – CD72, % - CD72, 109 – CD16, % - CD16, 109 – phagocytosis – completeness –
IgG – IgA – IgM – IgE total
B) Leukocytes – lymphocytes, % - lymphocytes, 109 – CD3, % - CD4, 109 – CD8, % - CD8,
109 – CD72, % - CD72, 109 – CD16, % - CD16, 109 – phagocytosis – completeness –
IgG – IgA – IgM – IgE total
Correlation analysis of the immune status revealed both general and specific correlation
(defined in only one of the groups) (see Fig. 8). In both groups of patients a direct correlation of
leukocyte level with absolute level of population and subpopulation of lymphocytes (in the main
group strong ties were determined (r = 0.783 - 0.886, p <0.01), in the comparison group – vice
versa: medium strength (r = 0.383 - 0.685, p <0.01) as well as with total number of lymphocytes
with CD3 +-cells and absolute level of CD4 + and CD8 + lymphocytes. At the same time, in the
main group general relationship was detected between relative number of lymphocytes and the
absolute number CD72 + - (r = 0.444, p <0.01), between absolute number of lymphocytes and
NK cells (r = 0.316, p <0.01). In the comparison group, relationship data were missing. At the
same time, IRI value in the study group, as was expected, had a strong direct relationship with
CD4 + rate (r = 0.758, p <0.01), and negative - with level of CD8 +-cells (r = -0.781; -0.398, p
<0.01). In the comparison group, IRI level correlated only with the percentage of CD8 +
lymphocytes (r = -0.492, p <0.01). Correlations were identified between AII severity and level of
CD4 + - (r = 0.725, p = 0.0021), CD8 + - (r = -0.813, p = 0.0043), CD16 + (NK)-cells (r = -0.459, p =
0.0054). Diarrhea duration directly correlated with the level of CD8 + - (r = -0.781, p = 0.007) and
NK cells (r = -0.623, p = 0.0082).
In the analysis relationship between humoral and cellular immunity, features observed
only in AD children were detected. In particular, IgG concentration in the serum, in addition to
relationship with level of B-lymphocytes, correlated with the rate of CD8 +-cells (r = 0.402, p
<0.01) and IPI (r = -0.424, p <0.01). According to numerous studies, reduction of the rate of CD8
+- cells in children suffering from atopic dermatitis is observed mainly in the period of acute
disease and is accompanied by reduction of the main immunoglobulin classes. Considering the
above said, is possible to speak about immunological causes of AD exacerbation on the
background of intestinal infection. Increase in IgA and IgM serum levels in the comparison group
correlated with the percentage of CD72 +-cells (r = 0.425; 0.378, p <0.01), which fully
corresponds to the modern concept of humoral response in infectious diseases. However,
noteworthy is inverse relationship of IgA level and phagocytic activity of neutrophils (r = -0.391,
p <0.01) in children with atopic dermatitis. Considering literature data on IgA insufficiency in AD
children and data obtained on the reduced level of phagocytic activity of neutrophils in the
initial AII period, it can be assumed that the upward trend in IgA levels in the first days of the
disease is a compensatory response to the lack of phagocytic immunity in children with atopic
dermatitis.
During the study, patterns of immune response were evaluated in AII children with
allergic and non-allergic form of atopic dermatitis. Among the patients examined 61 children
(52.5%) had allergic AD form and 55 (47.5%) - non-allergic form. Results of comparison of
immunological values with the data of AII patients without concomitant allergic diseases are
present in the Table 2.
Table 2
Mean values of immunity system in AII children with allergic and non-allergic AD
Immunologic values
Children with allergic
Children with non-
Children without AD
AD (n=61)
allergic AD (n=55)
(n=45)
Lymphocytes
35,56 ± 0,97#
37,98 ± 0,75*
CD 3+, %
70,29 ± 0,88*#
64,35 ± 1,15*
CD 4+, %
47,87 ± 1,03*#
42,10 ± 0,80*
CD 8+, %
23,94 ± 0,83*#
23,35 ± 0,65
IPI
2,32 ± 0,14#
1,95 ± 0,07
CD 72+, %
12,97 ± 0,79*#
17,95 ± 1,02*
CD 16+, %
12,47 ± 0,65*#
14,32 ± 0,64*
67,58 ± 1,82
67,82 ± 1,59
64,7 ± 1,75
5,1 ± 0,25*
5,9 ± 0,47*
8,79 ± 0,26
IgG, g/l
6,29 ± 0,46#
7,88 ± 0,39
IgA, g/l
0,58 ± 0,02#
0,81 ± 0,06
1,30 ± 0,07
1,51 ± 0,09
383 ± 73,61*#
71 ± 2,07
NPR
PI
IgM, g/l
IgE total, IU/l
39,1 ± 1,9
55,9 ± 1,8
31,7 ± 1,1
25,1 ± 0,8
1,80 ± 0,8
21,2 ± 0,82
18,4 ± 0,91
8,2 ± 0,42
0,74 ± 0,04
1,28 ± 0,09
89 ± 11,6
Statistically significant differences, p <0.05: * - between groups of AD patients, # - with
comparison group.
As a result of the studies, it was found that immunological disorders developed in both
groups of AD patients. In acute phase of infection there was a significant increase in rate of CD3
+ - and CD4 + lymphocytes (p = 0.021, p = 0.008) and IPI (p = 0.083), with a significantly lower
rate of CD8 + - (p = 0.002), CD72 + - (p = 0.027) and CD16 +-cells (p = 0.017) in patients with IgEmediated AD form, in comparison with the second subgroup. The levels of IgG, IgA and IgM
serum antibodies were significantly reduced. Changes revealed coincide with data of I.O.
Shestakova (2010) for a group of patients with allergic AD. Increase in number of CD4 +
lymphocytes and, consequently, IPI and reduction of CD8 + - (Tc1) cells on the background of IgE
significantly increased in this form of AD compared with the other group, shows an important
role of type I hypersensitivity in the pathogenesis of intestinal infection.
Compared with patients without concomitant AD, patients of the first subgroup
experienced a significantly lower rate of lymphocytes (p = 0.015) and B cells (p = 0,002),
absolute number of CD8 + - (p = 0.01) and CD16 +-cells (p = 0.019); simultaneously a significantly
higher rate of CD3 +- and CD4 +-cells (p <0.001, <0.001), and IPI (p <0.05) was recorded.
Parameters of humoral immunity in this subgroup were characterized by a moderate IgG and
IgA deficiency, against the background of overproduction of class E reaginic antibodies, on
retention of IgM level comparable with that of children without AD.
In patients with non-IgE AD form, significant differences of immunological parameters
from those in patients without concomitant allergic diseases included a significant increase in
white blood cell count (p = 0.016), rate of CD3 + - (p <0.001) and CD4 +-cells (p <0.001), due to
decrease in total rate of lymphocytes (p = 0.048).
Thus, it is possible to state that the most pronounced immunological disorders in AII
develop in children with IgE-mediated form of atopic dermatitis.
Given the immunopathogenesis differences, data for immune system status in AII of
viral and bacterial etiology were analyzed, with a background of atopic dermatitis. The results
are shown in Table 3 and Table 4. It was established that during the acute phase of AII of viral
etiology in children with atopic dermatitis helper-inductor version of the immune response is
mainly formed, as evidenced by elevated levels of CD4 + lymphocytes and IPI. In constrast, in
the comparison group shifts immune suppressor mechanism was observed that was manifested
through decreased levels of CD3 + - (p <0.001), CD4 + lymphocytes (p <0.01) and CD4 / CD8
index (p <0.05).
Table 3.
Mean values of the immune system in AII of viral etiology in children of the
comparison group
Immunologic Children with AD (n=32)
Children without AD (n=13)
Healthy
values
Acute
patients
Acute period
Recovery
Recovery
(n=20)
period
CD 3+, %
CD 4+, %
CD 8+, %
IPI
54,86±1,43**
52±1,6*,**
41,03±1,43*,** 39,4±1,3*,**
47,10±0,94* 44,6±1,2*
27,40±1,10* 25,6±1,39*,#
22,16±1,32
19,1±1*,**
21,30±1,20
1,97±0,16**
2,06±0,21**
1,29±0,09*
59,2±1,6
34,1±1,3
23,9±1,49
24,7±1,12
1,07±0,1*
1,6±0,1
CD 72+, %
20,19±2,60
22,3±1,3
19,20±1,10
24,90±1,70*,# 20,5±0,64
19,34±1,42
16,7±0,9**
18,50±0,90
20,70±1,23
17,5±1, 1
63,70±3,10*
59,4±2,7*,**
61,20±2,70* 70,2±1,80#
71,3±1,4
6,90±0,42*,**
7,80±0,74*,**
8,90±0,31*
8,74±1,64
6,3±1,3
0,70±0,16
0,96±0,19
(B-lymph.)
CD 16+, %
(NK-cells)
NPR, %
PI
IgG, g/l
IgA, g/l
IgM, g/l
10,10±0,92
11,3±0,34
8,55±1,74
7,1±0,9
7,4±0,5
0,5±0,17
0,53±0,21
0,62±0,13
0,65±0,07
0,71±0,4
1,3±0,34
1,1±0,27
0,86±0,15
Note: Here and in Table 3 statistically significant are the following differences (for p <0.05,
<0.001): * - with values for healthy children ** - with values of the comparison group, # - with
values for the acute period.
Parameters of humoral immunity in the two groups had no significant differences from
those of healthy children. In the acute phase of viral diarrhea signs of failure of the innate
immunity were determined, which manifested itself through a decrease in the neutrophil
phagocytic activity and phagocytic index (mostly in children with concomitant AD) .On this
background there was a compensatory increase in average level of NK cells in the two groups.
In the convalescence period, a further increase of identified immune disorders was
observed in AD children: in the dynamics - decreased levels of CD3 + (p <0.05), CD4 + - and CD8
+ lymphocytes in the blood (p <0.01, p <0.01), as well as number of NK-cells (p <0.001), FAN (p
<0.01). In the comparison group, a decrease the relative level of CD4 + lymphocytes (p <0.01)
was detected, with no significant dynamics of the content of CD3 + - and CD8 +-cells, with
simultaneous regeneration of functional activity of phagocytic immunity (NPR and PI values had
no significant difference from physiological norm). The differences found in the dynamics of the
immunological parameters allow to suggest about more persistent immunological disorders in
intestinal viral infections, with the background of atopic dermatitis.
Study of the state of the immune system in bacterial intestinal infections, given the
presence of concomitant allergic diseases allowed to identify significant differences in the
patterns of immune response between the groups compared (Table 4).
Table4.
Mean values of the immune system in AII of bacterial etiology in children of the
groups compared
Immunologic
Children with AD (n=32)
Children without AD (n=13)
Healthy
values
Acute period
Acute
patients
Recovery
Recovery
(n=20)
period
71,83±1,38*,**
53,60±0,98*,#
56,20±1,50
54,70±1,12*
CD 4+, %
46,73±1,67*,**
36,80±1,18**,#
30,10±1,35*
29,70±1,54*
34,1±1,3
CD 8+, %
21,58±1,20,**
22,70±1,60
27,90±1,40
21,50±1,20#
24,7±1,12
IPI
2,41±0,21*,**
1,62±0,15#
1,10±0,13*
1,38±0,23
1,6±0,1
25,70±1,67*
20,5±0,64
18,70±0,92
17,5±1, 1
CD 3+, %
CD 72+, % (B- 14,66±1,16*,**
18,20±1,60**
59,2±1,6
22,70±1,50
lymph.)
CD 16+, %
12,21±0,82*,**
15,90±1,11#
21,40±1,20*
64,20±3,40
63,50±2,40*
67,50±2,90
71,3±1,4
5,60±0,41*,**
7,80±0,57*,**,#
7,40±0,38*
9,80±0,67#
11.3±0.34
7,02±0,47**
9,80±0,74*,**,#
10,40±0,53*
12,40±0,50*,#
7,4±0,5
0,84±0,08*
0,67±0,12
0,86±0,04*
0,58±0,06#
0,65±0,07
1,54±0,16*
1,10±0,29
1,20±0,09
1,37±0,17*
0,86±0,15
(NK-cells)
66,16±3,99
NPR, %
PI
IgG, g/l
IgA, g/l
IgM, g/l
Note: Statistically significant are the following differences (for p <0.05, <0.001): * - with values
for healthy children ** - with values of the comparison group, # - with values for the acute
period.
Against AD background, a significant increase in CD3 + lymphocytes (p <0.001), CD4 +-cells (p <0.001),
IPI (p <0.001) has been detected in acute period of bacterial AII as well as deficiency of NK-cells (p <0.05)
and disorder of the functional activity of phagocytes (PI value of was significantly lower than in the
comparison group and healthy children). In the humoral defense system in children with atopic
dermatitis, concomitant pronounced deficiency of B-lymphocytes and IgG titer was observed that was
compensated by high IgM levels in the first days of the disease. It was only during convalescence (days
10-14 of the disease) that IgG level increased, with level of B cells significantly lower than in the control
group.
In the comparison group, by contrast, reduction of cell immunity was observed which was primarily
demonstrated by low CD4 + lymphocytes (p <0.01) levels and IPI (both in comparison with AD patients
and reference physiological values). Reaction of the innate immunity system to the introduction of the
infectious agent was also opposite: compensatory increase in the level of natural killer cells, on the
background of oppression of neutrophil functional activity (reduction of NPR and PI, the latter remaining
significantly higher than in the main group).
In the infectious process dynamics on AD background, suppression of cell component of immune system
took place, as evidenced by reduction of CD3 + lymphocytes, CD4 +-cells and IPI to the physiological
norm level.
In children with allergy-burdened analysis, only reduction of CD8 + lymphocytes was observed, with
trends towards increase of initially reduced immunoregulatory index. Levels of T-lymphocytes and CD4
+-cells remained unaltered. Preserved were the symptoms of phagocytic immunity deficiency (CD16 +cells deficiency, reduction of PI value).
In order to study cytokine regulation of the immune response in AII pathogenesis of viral and bacterial
etiology, occurring on AD background, serum levels of pro-inflammatory (IFN-γ, IL-1β) and antiinflammatory (IL-4) cytokines (K) were investigated.
It was found that in the acute phase of viral intestinal infection in children without concomitant atopia,
serum IFN-γ and IL-1β was 4.2 - 6 times significantly higher than in healthy children (Table. 5).
Simultaneously hyper-IL-4-cytokinemia was recorded, which plays a key role in the regulation of
antibody response; it shows simultaneous activation of both Th1 and Th2-types of immune response
whose function is to ensure adequate immune response aimed at pathogen elimination. On days 7-10 of
the disease the level of IL-1β significantly decreased, indicating a decrease in the inflammatory process,
as well as IL-4 concentration. Serum levels of IFN-γ had no significant dynamics, significantly exceeding
values of healthy children in the period of clinical recovery, proving the intensity of anti-infectious
immunity and providing effective body sanitation against the pathogen as well as smooth flow of the
disease [Zheleznikova G.V., 2007]. Dynamic growth of index values IFN-γ / IL-4 showed a shift of
functional Th1 / Th2 balance towards Th1-type of immune response.
Table 5.
Mean values of serum interleukins in AII of viral etiology in the patients of the groups compared
(M±m)
Immunologic
Children with AD (n=32)
Children without AD (n=15)
Reference
values
Acute period
Acute
values
Recovery
Recovery
period
IFN-γ, pcg/ml
IL-1β, pcg/ml
39,2±4,9*,**
13,7±3,9**#
106,5±10,4*
98,5±8,1*
78,4±64,7
463,7±34,2**,#
276,2±41,7*
113,9±25,1#
0-25
<50
IL-4, pcg/ml
IFN-γ/ IL-4, U
97,2±7,5*,**
83,7±9,3*,**,
63,7±6,2*
29±9,6#
0,71±0,06*,**
0,52±0,07*,**
1,67±0,13
3,4±0,7*
6-24
1-1.5
Note: Statistically significant are the following differences (for p <0.05, <0.001): * - with values
for healthy children ** - with values of the comparison group, # - with values for the acute
period.
In patients with concomitant AD, cytokine profile values of acute phase had significant
differences. Concentration of IL-4 produced by Th2-lymphocytes was significantly greater
control values and the values in the comparison group for all disease periods, which also means
an imbalance of immunoregulatory mechanisms in Th2 terms. Th1 K-IFN-γ and IL-1β- was
significantly (p <0.05) lower than in patients without atopy in the first days of the disease.
Convalescence period was marked by increase in IFN-γ deficiency, which shows
deterioration of antiviral defense mechanisms. Considering the data of R.M. Haitov (2009), a 6fold increase in IL-1β concentration revealed in patients with atopy is a marker of increase in the
severity of allergic inflammation on the background of viral infection. A significant decrease in
the index of IFN-γ / IL-4 reflected further increase in priority of Th2-type immune response.
Thus, the results show significant differences in phase regulation of antiviral response
on the background of persistent allergic inflammation and in its absence.
As a result of the study of CK levels in patients with AII of bacterial etiology regardless
of allergic status (p> 0,05), IL-1β and IL-4 overproduction was detected in the acute stage of the
disease (Table. 6). Taking into account different IFN-γ baseline, it is possible to talk about
domination of Th2-type immune response in children with atopy in the early days of the disease,
and vice versa, balance maintenance of Th1 / Th2-immunocytes in the comparison group.
However, in the convalescence period in patients with concomitant AD immune response shift
towards Th1-dominance type was observed, which was primarily confirmed by the increase in
IFN-γ and reduction of IL-4concentration. In the comparison group, levels of the above said CK
decreased simultaneously, reflecting persistence of the balanced Th1/Th2-immune response.
Table 6.
Mean values of serum interleukins in AII of bacterial etiology in the patients of the groups compared
(M±m)
Immunologic
Children with AD (n=32)
Children without AD (n=15)
Reference
values
Acute period
Recovery
Acute
Recovery
values
period
IFN-γ, pcg/ml
IL-1β, pcg/ml
IL-4, pcg/ml
IFN-γ/ IL-4, U
34,2 ± 4,4**
75,6 ± 5,7*
49,1 ± 3,4*,#
386,3 ±
24,2*,#
52,1 ± 3,8*,#
0,94±0,07
237,1 ± 21,8*
93,7 ±
3,4*,**,#
321,4 ± 18,5*,#
112,7 ± 13,4*
43,5 ± 5,7*,#
284,4 ±
26,7*
87,6 ± 6,5*
,30±0,05*,**
2,14±0,11*,**,#
0,86±0,08*
0-25
<50
6-24
1-1.5
Note: Statistically significant are the following differences (for p <0.05, <0.001): * - with values
for healthy children ** - with values of the comparison group, # - with values for the acute
period.
During the study, state of system mucosal immunity has been studied in 70 children
with AII background, considering concomitant allergic pathology. The results are shown in Table
7.
Table 7.
Mean values of GIT mucosal immunity in AII patients of the comparison groups (M ±
m)
Patien
Coprofiltrate
Parotid fluid
t
sIgA, µg/ml
IgE, IU/ml
sIgA, µg/ml
IgA, µg/ml
IgG, µg/ml
group
Acute
Convale
Acute
Convale
Acute
Convale
Acut
Convale
Acut
Convale
s
period
scence
perio
scence
period
scence
e
scence
e
scence
d
perio
perio
d
d
Main
119±8, 148±10,
53±3,
41±2,7*
223,4+
242,5+3
22,1+ 35,4+6,
13,3+ 12,6+1,
group
7*,**
7*,**,#
1*,**
,
**
35,2**
2,4*
3,6*
2,5*
Comp
325±1
461,5±1
13±1,
6,2±0,7
437,6±
324,4±3
43,1± 51,1±10
18,74 16,4±3,
arison
6*
2*,#
4*
42,2*
6,4*,#
7,4*
±3,6
4*
4*
(n=45)
*
group
y
2*
,
(n=25)
Health
,4
#
62±2,4
0,421
154,4±24
63,4±3,1
21,8±2,3
childr
en
Note: Statistically significant are the following differences (for p <0.05, <0.001): * - with values
for healthy children ** - with values of the comparison group, # - with values for the acute
period.
(1 - Partsalis Е.М., Revyakina В.А. State of local immunity of digestive tract//Pediatrics.
1983; 12: 19-21).
Functional state of the gastrointestinal mucosal immunity in AD children in AII acute
period was characterized by low production of the AII protective factors. Despite the levels of
secretory IgA (sIgA) in feces and saliva increased in comparison with reference values (p <0.001),
they were significantly lower (p <0,05) with regard to comparison group (n = 25) in all disease
periods, which may indicate the reaction retardation of the local immunity with inoculation of
the pathogen as well as inhibitory effect of hyper-IL-4-cytokinemia characteristic of AD [Khaitov
R.M., 2009] on switching immunoglobulin synthesis from IgE to IgA and its subsequent
secretion.
The study was conducted of IgE level in the feces of AII children, which showed its
significant increase regardless of the background of allergic patients (Table. 7, Figure 9).
Figure 9. Dynamics of IgE level in feces of AII children (IU / ml)
Figure captions:
<IU/ml
Acute period:
Children with AD allergic forms (n=26) - mild AII form (n=13) - AII severe form (n=8) Moderate to severe AII without AD (n=12)
Convalescence:
Children with non-AD allergic (n=19) - Moderate to severe AII (n=24) - mild AII form
without AD (n=13)>
The data obtained coincide with the results of I.G. Gussoeva (2008) and allow to suggest
participation of an allergic component in the pathogenesis of GIT inflammation, as well as
possible protective role IgE as a barrier to the pathogen penetration in the intestine mucous
membrane following sIgA [Zheleznikova G.V., 2011].
IgE exceeded reference values to the fullest extent in patients with concomitant AD and
first of all in IgE-mediated form (see Fig. 9). In both groups of patients, IgE content in feces was
highest in the moderate form, with a tendency to decrease with the recovery. However, by
convalescence no IgE normalization in feces occurred in any of the groups examined.
Evaluation of allergic disposition values (total IgE serum level and sensitization index) on
AII background was conducted considering the disease etiology, severity and nature of the
disease. These results obtained are shown on Figure 10.
Figure 10. Dynamics of total IgE serum level and allergization index in AII children.
Note: “” - values of healthy children.
Figure captions:
<IU/ml
Total IgE level:
Children with AD – Children withour AD
Acute period – convalescence – after three months
Allergization index:
U
Children with AD – Children withour AD
Acute period – convalescence – after three months>
During AII height and convalescence, general IgE level raised in patients with
concomitant AD (p <0.001) and in the comparison group (p <0.05), which may indicate
involvement of allergic reactivity in AII pathogenesis. Data obtained allow to explain the high
rate of allergic diseases in the outcome of an intestinal infection, which was indicated by M.S.
Grigorovich (2011) in her study. Subsequent examination of children 3 months after the onset of
the disease showed normalization of total IgE level in patients without concomitant allergic
diseases, while maintaining significantly high titers in AD children. High IA values in all
observation periods were marked in patients with concomitant AD and only during the early
convalescence in the comparison group.
Dynamics of total IgE in AII of viral and bacterial etiology in children suffering from AD
had significant differences (see Fig. 11). High titers of total IgE in AII of bacterial etiology
determined in the first days of the disease, significantly decreased by the period of early
recovery (p <0,01) and remained on the similar level up to 3 months of follow-up.
Figure 11. Dynamics of total IgE in AII of viral and bacterial diseases in children suffering
from atopic dermatitis.
Figure captions:
<IU/ml
Acute period – Convalescence – After 3 months
AII of viral etiology – AII of bacterial etiology – healthy patients>
Figure 11. Dynamics of total IgE in AII of various severity in children suffering from atopic
dermatitis.
Figure captions:
<IU/ml
Mild – severe – moderate – healthy>
On the background of AII of viral etiology, vice versa, increase in total IgE titers was
marked by days 7-10 of the disease (p <0.01), as well as up to 3 months of follow-up (p <0.05).
The differences defined in the dynamics of reaginic antibodies are determined by cytokine
regulation of the immune response, first of all by persistence of hyper-IL-4-cytokinemia during
the convalescence period of viral diarrhea.
Level of the body allergic disposition correlated with course severity of intestinal
infection (see Fig. 12). The highest concentration of reaginic antibodies in the early days of the
disease was recorded in severe AII (r = 0.834, p = 0.0013), exceeding the values of moderate and
mild forms 3.2 and 5 times, respectively (p <0.001). By the convalescence period, total serum IgE
in severe AII significantly decreased, but remained well above the reference values as well as
those for mild and moderate forms (p <0.01). Later on, IgE levels preserved their downward
trend, reaching values of patients with moderate AII form.
Comparative analysis of total IgE levels depending on AII course showed that a
significantly higher level in the early days of the disease directly correlated with the further
protracted intestinal infection (r = 0.782, p = 0.0075) (Fig. 13).
Figure 13. Dynamics of total IgE serum considering AII course in children on AD
background. (* - p <0.05)
Figure captions: <IU/ml
Acute period – severe acute disease – protracted disease – convalescence>
Thus, high levels of serum IgE in the acute period intestinal infection may serve as a
predictor of prolonged course of infectious process.
GIT microflora state in AII children with concomitant atopic dermatitis
Numerous literature data indicate formation of dysbiotic GIT disorders in AII
pathogenesis in children, negatively effecting the course and outcome of the disease. At the
same time, microflora GIT disorders are consistently recorded in children with atopic dermatitis
and other allergic diseases, while their course correlates with the severity [Maximov A., 1997].
Regularities of GIT microbiocenosis response to AII in children with comorbid AD are not yet
fully studied.
A study of composition and metabolic activity of intestinal microflora was conducted in
141 AII patients, including 96 children with concomitant AD. Apart from allergic burden,
disorders of GIT microflora were detected in 100% patients in the acute infection period. Serious
(III degree) microecological disorders were significantly more frequently detected in children
with atopic dermatitis (35.4 vs. 17.8% in the control group, p <0.05), and first of all affected
obligate microflora microorganisms involved in formation of colonization resistance. In AII
patients with AD background, deficiency of lactobacilli (<106 CFU / g) (p <0.01, χ2 criterion) and
bifidobacteria (<108 CFU / g) (p <0.01) was significantly more frequent than in the comparison
group (Fig. 14). Deficiency of typical Escherichia coli was recorded 1.8 times more frequently in
the study group (p <0.01) and was accompanied by formation of strains with altered enzymatic
activity. In 2/3 of all the AD patients, hemolyzing E.coli were detected (differences with the
comparison group significant, p <0.01, criterion χ2 ). At the same time, frequency of detection of
lactose-negative E.coli in acute AII had no significant differences in the comparison groups.
Deficiency or excessive growth of enterococci was 1.5 times more frequent among patients with
AD.
Fig. 14 Astrogramm of deviation frequency of basic representatives of the intestinal
microflora from the reference values (%).
Figure captions: <Children with AD (n=96) – Children with AD (n=45)>
It should be noted that the most frequent changes of lacto- and bifidobacteria pool have
been observed in infants with atopic dermatitis (in 78.3 and 69.6% patients their titers were
below 106 log IU/g), somewhat less in older age groups, however, in any case they were
recorded significantly more often than in the patients without concomitant allergic diseases.
In 57.2% patients with concomitant atopic dermatitis in AII acute period, the following
disorders of facultative microflora were detected: excessive growth of staphylococci in 38.5% of
patients (average 5,65 ± 0,76 logCFU/g), clostridia- in 48.9% (average 6.35 ± 1.09 logCFU /g) and
Candida fungi - in 35.4% (average 5.7 ± 1.4 logCFU / g). Frequency of detection of these
microorganisms in children of the comparison group was 20, 24.4 and 15.6%, with titers being
significantly lower – 5.12 ± 0.41 logCFU/g (p <0.05), 5.67 ± 0.61 logCFU /g (p <0.05) and 4.8 ± 1.2
logCFU /g (p <0.05), respectively.
In the convalescence period, obligate microflora imbalance was still detected in children
with AD. In 38.5% patients the number of lactic acid bacteria did not exceed 105 CFU/g, and the
average level in this group was significantly lower than in the comparison group (p <0.01) (Fig.
15). The frequency of lactobacilli deficiency was highest in infants - 60.9%, being significantly
lower in children older than 3 years (26.8%, p <0.05).
In the convalescence period of AII, in 29.2% of patients with AD
Bifidobacteria deficiency remained, including 52.2% infants (in 30.4%, the level of
bifidobacteria was 102 -105 CFU/g). The data obtained indicate the low regeneration potential of
bifidobacteria and lactoflora in infants suffering from AD, which proves absolute necessity of
biocenosis-corrective therapy in this age group.
Fig. 15. Dynamics of the main elements of obligate microflora.
Figure captions: <Ig CFU/g
AD+ - AD- - AD+ - AD- - AD+ - ADAcute period – ocnvalescence – reference value>
In AD children in the period of convalescence, in 42.7% cases hemolyzing E.coli was
identified repeatedly, including 60.9% infants and 50% children at the age of 1-3 years. These
changes were detected significantly more frequently than in the comparison group (p <0.01, χ2
criterion). In children suffering from atopic dermatitis, overgrowth of staphylococci (in 1/3 of all
thepatients, mean value 6.1 ± 1.13 logCFU/g), bacteria of Clostridium genus (in 34.4%), fungi of
Candida genus (in 27.1% of patients, mean value 4.7 ± 1.5 logCFU/g) was registered repeatedly.
At the same time, level of other opportunistic pathogens was significantly decreased (Fig. 14). In
the comparison group, detection frequency of the most widespread elements of facultative
microflora in our work reduced during the convalescence period, except Candida genus fungi.
When comparing the severity of AII and depth of microecological disorders considering
concomitant allergic diseases, significant differences were detected only in moderate forms of
the disease: in children with AD, III degree dysbacteriosis was registered significantly more
frequently (39.6% vs. 16%, p <0.05), significantly less frequent was I degree dysbacteriosis
(22.6% versus 48% in the comparison group, p <0.01).
Relationship of degree of microecological disorders with the AD severity was observed
in AD patients. It has been established that patients with mild AD (II degree), dysbiotic disorders
of moderate severity (52%) prevailed, AD of moderate severity correlate with degrees II and III
(32.4 and 44.1%, respectively), severe course with III degree (66.7%). In the observation
dynamics, dysbiotic disorders progressed mainly on the background of moderate and severe AD.
There is an ongoing study of the role of opportunistic pathogens in AD pathogenesis.
Given the findings on their frequent detection in all periods of intestinal infection on the
background of atopic dermatitis, sensitization to antigens of Staphylococcus aureus, Escherichia
coli, Candida albicans and Proteus was studied in 35 children with AD and 12 patients without
allergic pathology. In the acute phase of acute intestinal infection IgE antibodies of class 2 and 3
(moderate and severe sensitization) to S.aureus (48.6 vs. 16.7% in the control group, p <0.05,
criterion χ2) and C. albicans fungi (31.4 against 16.7%, p <0.05) were significantly more frequent
in AD children. In the disease dynamics a trend towards increase in sensitization to S.aureus and
C.albicans in children suffering from atopic dermatitis as well as in the comparison group.
Efficiency of modern enterosorbents, probiotics and antihistamines in the treatment of
intestinal infections and AII reabilitation in AD children.
One of the main methods of etiopathogenic therapy of intestinal infections is
enterosorption, the effectiveness of which has been repeatedly confirmed. At the same time a
comprehensive evaluation of the efficiency of natural and synthetic enterosorbents AII
occurring on the background of atopic dermatitis has not yet been conducted in children.
Considering this, we have examined 99 children with atopic dermatitis treated with diosmectit
(smectit, n = 53) or polymethylsiloxane polyhydrate (enterosgel, n = 46) in moderate to heavy
AII as well as 26 patients who were not treated with enterosorbents (comparison group).
It has been found that the use of enterosorbents in AII initial treatment in children
suffering from atopic dermatitis significantly reduced duration of intoxication symptoms, fever
(by 0.9 day in diosmectit group, p <0.05) (Table. 8), as well as leukocyte intoxication index (LII)
(from 3.1 ± 0.2 to 0.82 ± 0.1 U in diosmectit group (p <0.05); from 2.7± 0.1 to 0.6 ± 0.1 U- in
Enterosgel group (p <0.05)).
Table 8.
Mean duration of AII clinical manifestations depending on the therapy conducted
Symptoms
Intoxication, days
Fever, days
Vomiting, from the
Main group, n=99
Comparison group
Smecta (n=53)
Enterosgel (n=46)
(n=26)
3,1±0,4*
3,4±0,3*
4,1±0,4
2,8±0,4*
2,9±0,4
3,7±0,2
1,4±0,2
1,9±0,2
1,6±0,1
initiation of
treatment
Exsicosis I-II degree,
2,3±0,2
1,6±0,1*#
2,5±0,2
days from initiation of
treatment
3,1±0,2*
2,8±0,1*
4,1±0,3
Total days 5,6±0,6*
5,6±0,5*
7,2±0,5
Days from 3,2±0,5*
3,4±0,4*
4,8±0,3
Bloating, days from
initiation of
treatment
Diarrhea
initiation
of
treatment
Note: significant differences, p<0.05: * - with comparison group; # - with diosmectit
group
Duration of gastrointestinal disorders (diarrhea syndrome and bloating) on the
background of treatment with natural or synthetic sorbents was significantly lower than in the
comparison group. Smooth disease course, with reduction of most of the symptoms by day 5 of
the treatment, was more frequently observed in the study group (in 78.5% and 79.3%, against
57.9% in the comparison group, 0.05 <p <0.01, Fisher's ratio test). After 5-7 days of treatment,
complete clinical recovery was achieved in 73.6% of patients taking diosmectit, and 76.1% taking
Enterosgel. In the remaining patients stool was unformed, from 3 to 6 times a day, with
pathologic impurities, bloating was observed as well as loss of appetite. In the comparison
group, the proportion of such patients was significantly higher - 43.4% versus 26.4 and 23.9% (p
<0.05, Fisher's ratiop test). Duration of exsicosis symptoms significantly decreased in the
subgroup of patients receiving synthetic enterosorbent (Enterosgel) (p <0.05, Student's t test).
Analysis of the results of occasional bacterioexcretion / viral shedding after the
treatment course showed that clearing efficiency of enterosorbents was comparable with their
clinical efficiency and was 73.4% for bacterial AII pathogens and 80.6% - for viral pathogens.
Clearing efficiency of standard therapy did not exceed 57.2% and 40%, respectively, but the
differences between the groups were not statistically significant.
Uncludind enterosorbents in AII treatment schedule was accompanied by statistically
significant reduction (58-63%) in the frequency of AD exacerbation. Upon that, date of initiation
of enterosorption treatment was of crucial importance: the early (days 1-2 of the disease)
administration enterosorbents reduced exacerbation of atopic dermatitis till only 18.9 - 23.9% in
the study group; when administrating enterosorbents on days 3-4 of the disease, frequency of
AD exacerbation was significantly higher-32.1 - 32.6% and had no significant differences with
the comparison group (38.5%).
The treatment conducted was effective in 88.7 - 89.7%, among them, 60.8-67.9%
showed complete clinical efficacy, which was characterized by reduction of the majority of
pathological symptoms by the end of day 3 of hospital treatment. Treatment efficiency of
patients in the comparison group did not exceed 81%, the full being 57.6%.
At the moment another promising direction of AII therapy optimization is the use of
probiotics, whose mechanisms of achieving therapeutic effect are not limited to regeneration of
the balance of the normal microflora, but also include immunomodulatory effects on mucosal
immunity, anti-inflammatory and anti-allergic activity.
To determine the tactics of probiotics use in AD children with intestinal infections,
clinical and laboratory evaluation of the effectiveness of monocomponent (Enterol - 15 patients,
Probifor - 23 patients) and multicomponent probiotics (Acipol - 34 children, Linex - 20 patients).
Comparison group consisted of 63 patients receiving standard treatment.
The study revealed no significant differences in the duration of vomiting and exsicosis
(Table. 9). Relief of intoxication symptoms (including apathy, restlessness or loss of appetite) in
the shortest possible time was observed in subgroups treated with Probifor and Linex. Fever
duration significantly decreased in patients treated with Linex, in comparison with basic therapy
and Acipol therapy (p <0.05). Relief duration of diarrhea decreased by 1.3 - 2.2 days when
applying Probifor, Linex and Enterol (differences with the comparison group and Acipol- p <0.05,
Student's t test). Full normalization of stool by the time of discharge from the hospital was
significantly different between Linex and Probifor subgroups and the comparison group (91.3%
vs 71.5 and 85%, p <0.05, Fisher's test). In the other groups, rate of patients with unstable or
mushy stool had no significant differences with the comparison group after the treatment.
Table 9.
Mean duration of AII clinical manifestations depending on the therapy conducted and
clinical efiiciency
Symptoms
Main group, n=92
Acipol
Probifor
Linex
(n=34)
(n=23)
(n=20)
1
2
3
Comparison
Enterol (n=15)
group
(n=63)
4
Intoxication, days
3,5±0,4*,1 3,3±0,2*,1,4 4,2±0,3*
4,9±0,4
Fever, days
Vomiting,
5,1±0,4*
4,8±0,4
2,9±0,4
3,7±0,2
Total days
3,1±0,2
2,6±0,3
1,4±0,2
1,7±0,2
1,3±0,3
Days from
1,6±0,2
1,7±0,1
2,3±0,2
2,1±0,2
2,5±0,3
2,7±0,3
2,3±0,2
2,1±0,2
2,5±0,3
from the
initiation
of
treatment
initiation
of
treatment
Exsicosis
Days from
2,7±0,2
initiation
I-II
of
degree,
days from
treatment
initiation
of
treatment
Diarrhea
Total days
6,9±0,4
6,0±0,3*1
5,6±0,5*1
5,9±0,4*1
7,6±0,5
Days from
5,2±0,3
4,5±0,4*
3,7±0,3*1
4,1±0,3*1
5,8±0,4
59
69,6#
80#
73,3#
54
Incomplete 29,4
21,8
15
20
23,8
Absent
8,7#
5#
6,7#
22.2
initiation
of
treatment
Complete
Clinical
efficiency
11.6
Here and in Table 10: statistically significant differences, p<0.05: * - with pretreatment
level; 1 - with comparison group; 2 – taking Probifor; 3 – taking Linex; 4 – taking Enterol.
On analyzing effectiveness of the studied biocenosis-corrective probiotics (Table. 10), a
statistically significant increase and normalization of bifidobacteria levels in the feces was
detected after treatment in Probifor or Linex subgroups, lactoflora- in Acipol, Probifor and Linex
subgroups. Contents of a typical E. coli significantly increased in all subgroups of patients
receiving probiotics, to the greatest extent - in Enterol and Linex subgroups, while it almost did
not change in the comparison group.
Table 10.
Dynamics of microorganisms of obligate intestinal microflora in AII patients in the two
groups (lgCFU/g)
Microflora
Examinatio
Main group, n=71
forms
n terms
Acipol
Probifor
Linex
Enterol
n group,
(n=21)
(n=17)
(n=20)
(n=13)
n=25
7,1±0,32
8,0±0,46
7,5±0,36
7,9±0,41
7,4±0,45
8,1±0,522,
9,6±0,37*,1
9,17±0,41*,
8,6±0,37
Bifidobacteri
Before
treatment
a
After
Lactobacteri
a
7,9±0,43
treatment
3
Before
5,4±0,38
6,03±0,52
6,2±0,42
5,7±0,32
5,2±0,6
6,7±0,5*,3
7,07±0,38*,
7,61±0,3*,1
6,5±0,413
6,1±0,38
1
treatment
After
treatment
E. coli
Compariso
Before
1
7,1±0,5*
6,1±0,39
6,6±0,28
6,1±0,52
6,3±0,41
7,7±0,371
7,36±0,47*,
7,93±0,37*,
8,08±0,62*,
6,7±0,31
1, 4
1
1
treatment
After
treatment
The positive dynamics of facultative intestinal microflora was marked for use of Linex
and Enterol in AII treatment in patients with AD. In the subgroup treated with Linex, frequency
of detection of elevated titers of hemolyzing and lactose-negative E. coli, Staphylococcus, yestlike fungi and enterococci in feces significantly (2-3 times) decreased after treatment, and in
only 10% of patients elevated levels opportunistic pathogens level persisited (Table. 11). On the
background of Enterol therapy, 1.8-fold decrease was noted in the frequency of E. coli with
modified enzyme activity, 2.3 times- of clostridia, 2.5 times – of elevated enterococci titers and
3 times – of staphylococci.
However, despite the above-mentioned positive results of probiotic therapy, more than
20% children with AD, AII convalescents, continued to identify high concentrations of E.coli with
altered enzymatic activity, yeast-like Candida fungi, Clostridia. Combined therapy of these
patients should include, along with the probiotics studied, other biocenosis-corrective agents
(prebiotics, enteral immunoglobulins etc.).
Table 11.
Frequency of compositional disorder of facultative intestinal microflora on the
background of probiotic therapy in AII patients (%)
Microflora
Examination Main group, n=71
forms
terms
Acipol
Comparison
Probifor Linex (n=20)
(n=21) (n=17)
E. coli with
changed
enzyme
activity, >105
Before
Enterol
group,
(n=13)
n=25
72
52,4
64.7
55
69,2
33,3
29.4
25
38,5
28,6
41.2
40
20,8
36
23,8
23.5
10
28.5
28
47,6
35.3
6,6±0,28
6,1±0,52
6,3±0,41
23,8
29.4
7,93±0,37*,1 8,08±0,62*,1 6,7±0,31
66.7
47,1
55
46,2
52
38,1
35.3
20
30.8
28
28,6
41.2
30
38.5
28
19
17,6
10
15.4
20
treatment
After
52
treatment
(↑)
Staphylococcus, Before
>103 (↑)
treatment
After
treatment
Сlostridium,
Before
>105 (↑)
treatment
After
treatment
Enterococcus,
Before
>25%
treatment
After
treatment
Opportunistic
Before
pathogens
treatment
(Proteus,
After
Citrobaсter,
treatment
Enterobaсter
идр.), >104 (↑)
Thus, in the complex initial AII treatment on the background of AD the most rational was
the use of polycomponent probiotic Linex and drug Saccharomyces boulardii, which enhances
clinical efficacy and normalization of the intestinal microflora in 60.5% patients.
Given the evidence of a non-smooth AII course on the background of AD, including high
frequency of acute allergic process in acute and convalescence period, a comparative evaluation
was carried out on AHP efficiency in AII treatment on the background of moderate severity AD
according to two schemes:
I (n = 50) - basic therapy with I generation AHP (suprastin, tavegil, average course
duration – 6.3 ± 1.7 days.) with subsequent transition to III generation AHP (zyrtec, average
course – 12.7 ± 1.4 days);
2 (n = 37) - basic therapy with the inclusion of II generation AHP (zyrtec, average course
duration – 17.8 ± 2.9 days.). Comparison group consisted of 47 patients not receiving AHP.
Compared groups were matched in terms of hospitalization (76, 81.8, 80.6% - on days 1-3 of the
disease), clinical variant (gastritis/gastroenteritis/enteritis - 62, 56.8, 61.7%, gastroenterocolitis /
enterocolitis -38, 38.3, 43.2%), etiology (viral - 42.4, 40.5 and 44.7%, bacterial - 33, 35.1, 25.5%),
as well as AD severity (mild - 34, 40.5 and 44.7%, average - 52, 45.9 and 51.1%; severe- 14, 13.5
and 8.5%, respectively).
During the study, no significant difference in the duration of intoxication, vomiting and
diarrhea syndrome was found (Table. 12). At the same time, abdominal pain was reduced in the
shortest possible time on the background of II generation AHP, and the average rate of vomiting
in patients receiving I generation AHP was significantly less than in the comparison group (2.4 vs
4.3 times/day, p <0.05).
Table 12.
Clinical values of AHP efficiency in the complex AII therapy on the background of
atopic dermatitis.
Value
Intoxication duration,
Standard therapy + AHP
Standard therapy
Schedule I (n=50)
Schedule II (n=37)
(n=47)
4,5±0,5
4,1±0,6
4,6±0,5
3,9±0,4
4,6±0,3
4,3±0,6
2,1±0,7
1,9±0,5
2,8±0,7
6,7±0,9
5,2±0,6
6,3±0,7
days
Fever duration, days
Vomiting duration,
days
Diarrhea duration,
days
Abdominal pains,
3,1±0,5
2,7±0,4#
4,3±0,5
14.5%
11.3%
26,3%
54*
48,6*
78.7
40,7*
50*
13,5
(n=27)
(n=18)
(n=37)
51,9*
38,9
22,9
(n=27)
(n=18)
(n=37)
days
Non-smooth AII
course, %
Increase in AD clinical
manifestations in AII
acute period, %
AD clinical remission
by the end of AHP
course, %
Decrease in AD
clinical
manifestations by the
end of AHP course, %
Notes: statistically significant differences with the comparison group, p<0.05: * Fischer’s test, # - Student’s t-test.
Earlier AHP administration significantly reduced the frequency of AD exacerbations in
acute phase of an intestinal infection. After treatment, the positive dynamics of AD course
presented by clinical remission was recorded in half of the children treated with zyrtec (p
<0.001), as well as in 40.7% receiving I generation AHP, with subsequent transition to II
generation AHP.
Thus, efficiency analysis of desensitizing drugs in the treatment of acute intestinal
infections in AD children demonstrates the benefits of II generation AHP (zyrtec) from the
perspective of ensuring a favorable course allergic process (reduction in the frequency of AD
exacerbation in AII acute and convalescence period, decrease in severity of skin allergy and
terms of its relief). Antihistamines do not have significant impact on the dynamics of AII
gastrointestinal manifestations.
Follow-up of 52 AD patients convalescent from AII without receiving no special
rehabilitation remedies within 1-3 months, showed presence of persistent intestinal dysfunction
in 32.7% of patients in the form of episodes of unstable stool, a tendency towards stool
retention/ constipation (in 28.8%), loss of appetite (in 46.5%), complaints of abdominal pain
(36.5%), pathological impurities in the stool. At the same time, increase in AD clinical
manifestations was recorded in 48.1% children. Study of intestinal microbial homeostasis in 21
children has revealed presence of major dysbiotic violations (second degree – in 57.1%, third
degree- in 33.3%), due to low level of obligate microflora (average number of bifidobacteria-7.8
± 0.7 lgCFU/g, lactobacilli-6.3 ± 0.8 lgCFU/g), high titers of staphilococcus aureus (in 38.1%),
Candida fungi (in 23.8%) and Clostridium bacteria (33.3%).
Taking into account the results obtained as well as literature data, a rehabilitation
complex was proposed for AII children on AD background, which included long-term (up to 3
months) course of II generation AHP, polycomponent probiotic (Linex) or probiotic products for
functional nutrition (based on age, nature of gastrointestinal disorders and absence of allergy to
cow milk protein). Efficiency qualification of the proposed complex was verified in the group of
72 children with AD suffering from AII. As a result of the complex, positive dynamics of GIT
disorders was demonstrated in 70.8%, cutaneous manifestations in atopy – in 31.9%, frequency
of expressed dysbiotic violations also decreased (by 41.7%), exacerbation of atopic dermatitis in
the late convalescence period was observed in 26.4% (significantly less than in the comparison
group – 48.1% (p <0.001)).
CONCLUSIONS
1. In every third child hospitalized due to acute intestinal infection, a concomitant
allergic pathology is recorded, at the top of which were atopic dermatitis and
gastrointestinal food allergy (58.7%). Most commonly allergic diseases accompany
acute intestinal infections in young children.
2.
Manifestation of GIT form of food allergy in 11.3% children of first year of life is
accompanied by clinical signs of acute intestinal infection that determines the need
for additional allergen immunoassay for timely diagnosis and rational therapy.
3. Acute intestinal infections in children with concomitant atopic dermatitis are
characterized by higher severity, manifestation and duration of the main clinical
manifestations as well as undulating course in every fourth child. In the recovery
period, scatological disorders, functional dyspepsia, lactase deficiency and changes
in the microflora composition of metabolite status intestine more often identified
and longer persisted in these patients.
4. Factors determining severity and course of acute adverse intestinal
infections occurring on the background of atopy as well as slow body detoxification
from the pathogen, are early age of the patients, IgE-mediated atopic dermatitis and
its severe course.
5. Development of acute intestinal infections on the background of atopic
dermatitis in children is accompanied by disturbances of the immune homeostasis.
The deepest change in the parameters of cellular and humoral immunity is observed
in IgE-mediated, severe variant of atopic dermatitis: in 77.5% patients, imbalance of
T-cell immunity formed, with a significant increase in CD4 + lymphocytes and IRI,
CD8 + lymphocytes and NK cells insufficiency. A correlation is determined between
immunological disorders, AII severity and terms of relief of diarrheal syndrome.
6. In children with acute intestinal infection of viral etiology on the
background of atopic dermatitis, predominance of Th2-immune response is marked,
both in the acute period of infection and in convalescence. Increase in
concentrations of IL-4 serum on the background of IFN-γ deficiency in the onset of
the disease correlates with high frequency of its undulating and protracted course,
as well as increase of sensitization level during the convalescence period. In the
group of patients without concomitant allergic diseases, a balanced Th1/Th2immune response is observed in the acute period with a shift towards Th1-variant
during convalescence.
7. In the acute phase of intestinal infections of bacterial etiology in
children regardless of allergic pathologies, a shift in cytokine balance is observed
towards Th1-immune response mediated by IFN-γ and IL-1β, on the background of
constitutional hyper-IL-4-cytokinemia. In the convalescence period, a further
increase is marked in the levels of pro-inflammatory mediators IL-1β and IFN-γ,
along with reduction of IL-4.
8. In the convalescence period of viral intestinal infection in children with
concomitant AD, an increase in the level of total IgE and specific IgE-antibodies to
opportunistic pathogens is marked that is caused by persistence of dysbiotic
disorders of intestinal microflora, lack of local immunity factors (sIgA) and
prevalence of Th2-cytokine profile in the blood serum. In acute intestinal infection
of bacterial etiology, level of Class E reaginic antibodies significantly decreased by
the period of early convalescence and remained stable in the period of late
convalescence.
9. Functional state of GIT mucosal immunity in children with atopic
dermatitis in the acute phase of intestinal infection is characterized by low
production of free and secretory IgA (2-2.5 times lower than in the absence of
atopy) as well as a high level of IgE in coprofiltrate.
10. In all children with AII and AD, major violations of the intestinal
microflora were revealed which correlated with age, etiology and severity of the
underlying disease. On the background of atopic dermatitis, the most often was
sensitization to some kinds of conditionally pathogenic microflora (specific IgEantibodies to St.aureus, C.albicans, E.coli, with altered enzymatic properties).
11. Initiation AII treatment in children with concomitant atopic dermatitis
based on a graded administration of enterosorbents, probiotics and antihistamines,
accelerates the recovery, improves disease prognosis and outcome, reduces
exacerbation risk and duration of the background allergic disease as well as reduces
severity of microecological intestinal disturbances.
12. The developed complex of rehabilitation measures allows to reduce the
risk of post-infectious gastrointestinal disorders (by 70.8%) and AD exacerbation (by
41.7%) in the period of late convalescence.
PRACTICE RECOMMENDATIONS
1. For the purpose of differential diagnostics of acute intestinal infections
and manifestations of GIT food allergy in infants, it is advisable to take into account:
• medical history - exacerbation of cutaneous allergy manifestations preceding
appearance of dyspeptic symptoms;
• clinical data - gradual onset of the disease, prevalence of enteritic and enterocolitic
types of diarrheal syndrome, moderately severe intoxication symptoms (loss of appetite,
subfebrile fever);
• laboratory data - results of bacteriological, immunological, molecular genetic methods
to identify pathogens, the level of eosinophils in peripheral blood and in the feces, total IgE,
specific IgE and IgG-antibodies to cow milk proteins, gluten, goat milk and soy.
2. To monitor the course and outcomes of acute intestinal infections in
children with concomitant atopic dermatitis in the early stages of the disease, it is
recommended to use the following immunological parameters: total IgE of the
blood serum (basal value > 300 IU/mL is a predictor criterion of protracted course),
secretory IgA in coprofiltrate (basal value <50 mg/ml a predictor of non-smooth and
heavy course of infection), IgE in coprofiltrates (baseline> 80 IU/mL is a predictor of
common gastrointestinal lesions and severe disease).
3. For children with atopic dermatitis with acute intestinal infections
receiving complex initial therapy, earlier administration of the following drugs is
recommended:
a) antihistamines – in children up to 6 months, in repeated vomiting - suprastin, tavegil
(in age-related dosage), the rest of the patients - zyrtec (in age-related dosage);
b) enterosorbents - in domination of diarrheal syndrome, presumably of viral etiology e
– dioctahedral smectit (in age-related dosage), in case of expressed intoxication syndrome –
polymethylsiloxane polyhydrate (in age dosage) in the course up to 10 days;
c) probiotics - in advanced GIT lesions as well as in expected viral etiology of the disease
(excluding presence of AD exacerbation) - Linex (course not less than 2 weeks); in expressed
diarrheal syndrome and without AD exacerbation - Enterol (course not less than 7-10 days).
4. In the convalescence period of acute intestinal infections in children with concomitant
atopic dermatitis, it is recommended:
a) To continue desensitizing treatment with II generation AHP (Zyrtec) within three
months;
b) to correct microecological intestinal disturbances:
• in the presence of allergy to cow milk protein as well as in children of early age repeated courses of polycomponent probiotics (up to 10 -14 days within 3 months);
• in children older than 3 years -daily intake of probiotic products for functional
nutrition with Lactobacillus casei DN-114001 (in persistent intestinal dysfunction) or
Bifidobacterium animalis DN-173010 (with a prevalence of hypokinetic motor disorders).
SCIENTIFIC PUBLICATIONS
1. Gorelov A.V., Milutin L.N., Usenko D.V. Tactics of the complex therapy of
acute intestinal infections in children. Problems of Modern Pediatrics, 2003. № 2. S.
82-3.*
2. Usenko D.V., Matanina N.V., Milovanova S.V. Use of Saccharomyces
boulardii in the treatment of intestinal infections in young children. Russian Medical
Journal, 2003 Vol. 3. № 175. S. 218.
3. Usenko D.V. Acute enteric infections in children with atopy. Materials of
XI Congress of Russian pediatric gastroenterologists "Actual problems of abdominal
pathology in children ", Moscow, 2004, S.325-326.
4. Usenko D.V. Course of acute intestinal infections in children with atopic
dermatitis. Materials of IX Congress of Russian pediatricians "Actual Problems of
Pediatrics ". Moscow, 2004, S.425
5. Usenko D.V., Gorelov A.V. Use of elidel in treatment of atopic dermatitis
in children. Materials of IX Congress of Russian pediatricians "Actual Problems of
pediatrics", Moscow, 2004. P.426.
6. Elezova L.I., Usenko D.V., Gorelov A.V., Karasev E.A. New approaches to
treatment of intestinal infections in children. Materials of scientific conference of
Russian pediatricians "Pharmacotherapy in Pediatrics". Moscow, 2004, P.36.
7. Elezova L.I., Usenko D.V., Gorelov A.V. New approaches to correcting
disturbances of intestinal microflora in acute diarrhea in children. Materials of
scientific and practical Conference of Russian Pediatricians "Pharmacotherapy in
Pediatrics". Moscow, 2004. P.37.
8. Usenko D.V., Elezova L.I., Gorelov A.V. Influence of probiotic Lactobacillus Casei DN 114001 on state of mucosal immunity in acute intestinal infections. Materials of
scientific conference of Russian pediatricians "Pharmacotherapy in Pediatrics". M.,
2004 - P.94.
9. Semenov B.F., Gorelov A.V., Usenko D.V., Elezova L.I. et al. Evaluation of
probiotic foods in the complex treatment of acute intestinal infections in children.
Infectious diseases, 2004. Volume 2, № 4. Pp.52-58. *
10. Usenko D.V., Elezova L.I., Gorelov A.V. Study of the effect of probiotic
Lactobacillus casei DN-114001 on indicators of mucosal immunity in acute intestinal
infections in children. Materials of Russian scientific and practical conference "Key
problems of infection control". St. Petersburg, 2005, S.
11. Usenko D.V., Kadzhaeva E.P., Gorelov A.V. Clinical efficiency of
nifuroxazide in the treatment of acute intestinal infections in children. Materials of
Russian scientific and practical conference "Treatment of infectious diseases in
children: modern conceptions and unsolved problems ", St. Petersburg, October 1113, 2005. S. 127.
12. Gorelov A.V., Usenko D.V., Elezova L.I., Ardatskaya M.D., Burkin A.V.
Qualification of efficiency of probiotic product correction in microecological
disorders in acute intestinal infections in children. Epidemiology and infectious
diseases, 2005. №6. pp. 58-61. *
13. Usenko D.V., Burkin A.V., Elezova L.I., Gorelov A.V. et al. Evaluation of a
new approach to dietary correction in acute intestinal infections in children.
Epidemiology and infectious diseases, 2005. №5. pp. 41-43. *
14. Gorelov A.V., Usenko D.V., Elezova L.I., Ardatskaya M.D., Ivanchatenko
G.G. Efficiency of probiotic product in correction of intestinal microflora disorders in
children with acute intestinal infections. Problems of pediatric dietology, 2005 Vol.
3. №5. pp. 42-46.*
15. Elezova L.I., Kadzhaeva E.P., Gorelov A.V., Usenko D.V., Burkin A.V.
Clinical and laboratory evaluation of the efficiency of traditional fermented diary
products in dietary management of acute intestinal infections in children. Materials
of Russian conference "Actual problems of pediatrics" - Oryol, March 30-31, 2005. P.54.
16. Usenko D.V., Gorelov A.V., Shabalin S.V. Use of probiotic products
containing Lactobacillus casei defensis in treating intestinal infections in children
with altered allergic reactivity. Infectious diseases, 2005 Vol. 3. № 3. pp. 51-55.*
17. Gorelov A.V., Usenko D.V., Ardatskaya M.D. Use of probiotic products for
correcting microflora disturbances in acute intestinal infections in children. The
attending physician, 2006. №7. p. 89.
18. Kadzhaeva E.P., Gorelov A.V., Usenko D.V., Bitiyeva R.L. et al. Etiologic
structure of acute intestinal infections in children hospitalized in a large Moscow
hospital. Infectious diseases, 2006 Vol. 4. № 2. pp. 34-36. *
19. Gorelov A.V., Usenko D.V., Kadzhaeva E.P., Ardatskaya M.D. Evaluation of clinical
efficiency of enterofuril in complex therapy of acute intestinal infections in children
and its effect on intestinal microbiocenosis. Infectious diseases, 2006 Vol. 4. №3. pp.
47-50. *
20. Gorelov A.V., Usenko D.V. Probiotics: mechanisms of action and efficacy
in infections of the gastrointestinal tract. Epidemiology and Infectious Diseases,
2006. №4. pp. 53-57. *
21. Usenko D.V., Gorelov A.V., Pogorelov O.A. New horizons of probiotics
application. Infectious diseases, 2006 Vol. 4. № 4. pp. 57-61. *
22. Gorelov A.V., Usenko D.V., Ardatskaya M.D. Biocenosis-saving efficiency
of nifuroxaside with acute intestinal infections in children. Problems of modern
pediatrics, 2007 Vol. 6. №2. pp. 110-114. *
23. Kadzhieva E.N., Usenko D.V., Gorelov A.V., Ardatskaya M.D. Modern
nitrofurans in the treatment of intestinal infections in children. Farmatheca, 2007.
№ 13. pp. 79-82.
24. Gorelov A.V., Usenko D.V. Rotavirus infection in children. Problems of
modern pediatrics, 2008. Vol. 7. № 6. pp. 78-84. *
25. Ukraintsev S.E., Gorelov A.V., Ardatskaya M.D., Usenko D.V. The
dynamics of short-chain fatty acids spectrum in the feces of children with viral
diarrhea on the background of application of probiotic mixture. Pediatrics. Journal
named after G.N. Speransky, 2008 Vol. 87. №6. pp. 82-86. *
26. Gorelov A.V., Usenko D.V. The role of microflora in the gastrointestinal
tract and principles of correctuion of disturbances of its composition. Russian
Medical Journal, 2008 Vol. 16. №19. pp. 1-5.
27. Gorelov A.V., Usenko D.V., Elezova L.I. Combined therapy of acute
intestinal infections in children. The attending physician, 2008. №4. p. 94-95.
28. Usenko D.V., Gorelov A.V., Shabalin S.V. Experience of using fermented
milk probiotic product in the treatment of acute intestinal infections in children with
atopic dermatitis. Pediatrics. Journal named after G.N. Speransky, 2008 Vol. 87. №
4. pp. 85-90. *
29. Gorelov A.V., Usenko D.V., Ardatskaya M.D., Zaguzova L.I., Trefilova I.Sh.
Clinical and laboratory evaluation of the effectiveness of lactulose in the treatment
of rotavirus infections in children. Infectious diseases, 2008 Vol. 6. №2. pp. 24-28. *
30. Usenko D.V., Gorelov A.V., Elezova L.I., Zaguzova L.I. et al. Comparative
evaluation of efficiency of probiotic food and monostrain probiotic in AII children
older than 3 years. Proceedings of the Conference dedicated to 50th anniversary of
Department pediatric infectious disease of Moscow Regiobnal Research and Clinical
Institut,. 2008. pp 51-54.
31. Gorelov A.V., Milutin L.N., Reyzis A.R., Usenko D.V., Nikitin T.S., Drondina
A.K., Ploskireva A.A., Ruzhentsova T.A. Results and prospects of studying the
problem of acute intestinal and respiratory infections and hepatitis in children.
Epidemiology and infectious diseases, 2009. №2. pp. 51-57. *
32. Usenko D.V., Gorelov A.V. Lactase deficiency in children. Consilium
medicum. Pediatrics, 2009. №1. pp. 33-36.
33. Barmina O.S., Gorelov A.V., Usenko D.V., Ardatskaya M.D. Clinical and
laboratory efficiency of multiprobiotic drug Acipol in adjuvant therapy of "Invasive"
AII in children. Infectious diseases, 2009 Vol. 7. № 1. pp. 76-79. *
34. Usenko D.V. Dietary correction of colon dysmotility. Attending physician,
2009. №7. pp. 82-84.
35. Parfenov A.I., Usenko D.V., Prilepskaya S.I. Use of probiotic products in
the correction of mild digestive disorders. Pharmatheca. 2009. №2. pp. 76-79. *
36. Ploskireva A.A., Usenko D.V. Role of probiotics and probiotic products in
treatment and prevention of infectious diseases. Infectious diseases, 2010 Vol. 8.
№3. pp. 58-64. *
37. Usenko D.V., Shabalin S.V., Gorelova E.A. Infections and allergies.
Infectious diseases, 2010 Vol. 8. № 2. pp. 68-74. *
38. Gorelov A.V., Ploskireva A.A., Usenko D.V., Tkhakushinov N.H. The
modern approach to correction of exocrine pancreatic insufficiency syndrome and
malabsorption in children with acute intestinal infections of viral etiology. Infectious
diseases, 2010 Vol. 8. №2. pp. 89-92. *
39. Usenko D.V., Gorelov A.V., Shabalin S.V. Features of the cytokine profile
in acute intestinal infections of viral etiology in children with atopic dermatitis.
Materials of the III Annual Russian Congress on Infectious diseases. Moscow, March
27-29, 2011. - Infectious diseases, 2011 Vol.9, application 1, p.371
40. Usenko D.V., Gorelov A.V., Shabalin S.V., Gervazieva V.B. Dynamics of
allergic reactivity values in children with acute intestinal infections. Materials of III
Annual Russian Congress on Infectious Diseases. Moscow, March 27-29 2011. Infectious diseases, Vol.9. 2011, Annex 1, p.371-2.
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