Showing papers in "Egyptian Journal of Pediatric Allergy and Immunology in 2012"
TL;DR: Serum calprotectin levels are significantly higher in full-term neonates with late onset neonatal sepsis than controls and its levels correlated well with other laboratory markers of sepsi and neonatal mortality.
Abstract: Background: Calprotectin, a complex of two calcium-binding proteins that belong to the S100 protein family, is abundant in the cytosolic fraction of neutrophils. A high level of calprotectin reportedly exists in extracellular fluid during various inflammatory conditions, but its role in neonatal sepsis was investigated only in one study as a marker of sepsis in very low birth weight neonates. Objective: This study aimed to measure the serum calprotectin level by ELISA in full-term neonates with late onset neonatal sepsis, its correlations with other laboratory markers of sepsis as interleukin-6, C-reactive protein (CRP), total leucocytic count and platelet count and its relation to the outcome of cases. Methods: This study comprised 48 full-term neonates with gestational ages of 37 to 42 weeks with manifestations of late onset neonatal sepsis admitted to the neonatal intensive care unit, Minia University Hospital during the period from February, 2011 to December, 2011 and 40 healthy neonates, age and sex matched as a control group. Serum levels of calprotectin, IL6 and CRP were measured for all neonates recruited in this study. Results: Serum calprotectin levels were significantly higher in term neonates with late onset neonatal sepsis than controls (3.77±1.85 μg/ml and 0.70±0.33 μg/ml respectively, P-value = 0.000). Cases with positive blood cultures and poor outcomes had the highest levels of calprotectin (5.8±0.61 μg/ml and 6.1±0.42 μg/ml respectively). Significant positive correlations were found between calprotectin levels and IL6 (P-value =0.000, r=0.92), C-reactive protein (p=0.000,r=0.95) and total leucocytic count (P-value =0.000, r=0.72), and negative correlations were found between its level and platelet count (P-value =0.000, r=-0.87), gestational age (P-value =0.014, r=-0.35) and body weight (P-value=0.018, r=-0.34). No significant differences were observed between males and females as regards calprotectin levels (3.96±2.10 μg/ml vs 3.55±1.52 μg/ml, P-value=0.444). Conclusions: Serum calprotectin levels are significantly higher in full-term neonates with late onset neonatal sepsis. Its levels correlated well with other laboratory markers of sepsis and neonatal mortality. It is a sensitive diagnostic marker for late onset neonatal sepsis. Keywords: Calprotectin, IL6, Full-term, Late-onset sepsis Egypt J Pediatr Allergy Immunol 2012;10(1):19-24
11 citations
TL;DR: Polymorphisms of ADRB2 at codon 16 may be a determinant of asthma severity and response to salbutamol in Egyptian asthmatic children.
Abstract: Background: Several polymorphisms of the β2-adrenergic receptor (ADRB2) gene have been identified. There is mounting evidence that these polymorphisms are associated with significant variability in response to bronchodilator therapy and thus in severity and duration of asthmatic symptoms. Objectives: to assess the frequency of ADRB2 polymorphisms at codon 16 in Egyptian asthmatic children and to study the association of these polymorphisms with asthma severity and response to inhaled salbutamol. Methods: This case-control study was conducted at pulmonology unit, Zagazig University children’s hospital during the period from December 2010 to December 2011. One hundred children (50 asthmatics and 50 controls) were enrolled into the study. For all study population, detailed history taking, systematic physical examination, chest x-ray, pulmonary function testing and ADRB2 genotyping were performed. Results: There was a significant increase in frequencies of Arg/Gly and Gly/Gly genotypes among asthmatic children in comparison with healthy controls (OR = 7.9; CI: 0.94-67.4, P0.05). Regarding bronchodilator responsiveness, Gly/Gly and Arg/Gly genotypes were associated with reduced response, while Arg/Arg genotype was associated with favorable response to nebulized salbutamol. Conclusion: Polymorphisms of ADRB2 at codon 16 may be a determinant of asthma severity and response to salbutamol in Egyptian asthmatic children. Further studies are needed to demonstrate effects of other polymorphisms of ADRB2 gene on these outcomes. Keywords: Polymorphism; β2-adrenergic receptor (ADRB2) gene; asthma; Egyptian children; bronchodilator therapy Egypt J Pediatr Allergy Immunol 2012;10(2):81-86
9 citations
Journal Article•
TL;DR: Inappropriate concentration of vitamin D decreases the ability of the immune system to defend against infection through lowering LL-37 and elevated Hs-CRP which leads to occurrence and precipitation of asthma.
Abstract: Background: Vitamin D modulates a variety of processes and regulatory systems including host defense, inflammation, and immunity. A connection between Vitamin D status and asthma has been considered. Vitamin D mediates innate immunity, particularly through enhanced expression of the human cathelicidin antimicrobial peptide (LL-37). Increased levels of high sensitive-C reactive protein (Hs-CRP) were found to be significantly associated with respiratory function impairment. Objective: to evaluate the relation between serum vitamin D, Hs-CRP and LL-37 levels and asthma. Study design: Thirty children (15 males and 15 females) with proven diagnosis of asthma (ages ranged from 3-13 years) were studied; they attended the pediatric department of Zagazig University Hospital in the year 2011. In addition, 30 age and sex matched apparently healthy children served as a control group. All children were subjected to history taking, clinical examination, laboratory investigations (CBC, CRP, ESR), determination of serum level of 25-hydroxyvitamin D (25 OHD) and plasma LL-37. Results: The study revealed a highly significant decrease in 25 OHD, LL-37 and a highly significant increase in Hs-CRP in children with asthma than in control group. There were a highly significant positive correlation between vitamin D and LL37 in patients' and control groups and a significant negative correlation between both 25OHD and LL37 and Hs-CRP in patients' group. High WBC count (specially neutrophils and lymphocytes), Hs-CRP level and low levels of hemoglobin, 25OHD and LL 37 in patient group were considered risk factors of asthma. Conclusion: Inappropriate concentration of vitamin D decreases the ability of the immune system to defend against infection through lowering LL-37 and elevated Hs-CRP which leads to occurrence and precipitation of asthma. Keywords: Vitamin D- LL-37- asthma Egypt J Pediatr Allergy Immunol 2012;10(2):101-107
6 citations
Journal Article•
TL;DR: Real-time PCR proved superior to culture in early diagnosis of IFI in patients with immunodeficiency before the appearance of the characteristic clinical and imaging signs, as compared to those without infection.
Abstract: Background: Crucial to the diagnosis and effective therapy of invasive fungal infection (IFI) in the immunodeficient is the early identification of the causative agent especially in patients who lack clinical evidence of the disease. The standard methods for the detection of fungi in clinical specimens are direct microscopy and mycological culture. Microscopy often lacks a satisfactory sensitivity, whereas diagnosis by mycological culture often requires a long growth period. Studies have demonstrated the feasibility of detecting molds and yeast in a single reaction using the universal fungal primer. Objective: Evaluation of the role of real-time PCR in the early detection of fungal infection in immunodeficient patients with suspected IFI, who lack clinical evidence of the disease. Methods: This study included 30 immunodeficiency patients suspected of having IFI; 9 with primary and 21 with secondary immunodeficiency. All patients had at least one host factor, but no clinical criteria according to the EORTC-MSG definition of IFI. Twenty seven had fever and 3 had bronchopneumonia, both not responding to broad spectrum antibiotics for 96 hrs. or more. Blood samples were cultured for fungi and were analyzed with real-time PCR using universal fungal primers. For positive samples of fungal infection, aspergillus-specific primers were used for detection of aspergillus. Results: Seventeen patients (56.7%) proved to have IFI. Blood culture detected Candida in 2 patients only, while PCR detected Candida in another 9 and Aspergillus in 6, thus 15/17 patients with IFI (88%) were missed by blood culture. Blood culture for IFI diagnosis had a very low sensitivity (12%) but had a 100% specificity and positive predictive value. The results PCR did not vary with gender, degree of fever, immunodeficiency type, clinical presentation or current intake of antifungal treatment. Patients with proven IFI showed significantly increased CRP levels as compared to those without infection. Conclusion: Real-time PCR proved superior to culture in early diagnosis of IFI in patients with immunodeficiency before the appearance of the characteristic clinical and imaging signs. Reliance on blood culture alone at that stage would result in missing most of the positive cases with consequent delay in the initiation of specific treatment. Keywords: Invasive fungal infection, immunodeficiency, blood culture, real-time PCR, candida, aspergillus Egypt J Pediatr Allergy Immunol 2012;10(2):67-74
6 citations
TL;DR: Measurement of serum anti MCV antibody level holds promise as a diagnostic tool in juvenile rheumatoid arthritis, however, they failed to show a significant efficacy in determining disease activity.
Abstract: Background: JRA is currently diagnosed using the American College of Rheumatology (ACR) 1987 revised criteria that are primarily based on clinical parameters. The criteria may be insufficient for the diagnosis of early RA as they are based upon measurements of disease classification predominately featuring manifestations typical of later-stage disease. Measurement of serum anti-mutated citrullinated vimentin antibodies (MCV) has been shown to be a better marker for early adult RA, and it correlates well with the disease activity score (DAS). Objectives: The aim of this work is to evaluate the role of antimutated citrullinated vimentin antibodies (anti-MCV) in the diagnosis, and in monitoring disease activity in juvenile rheumatoid arthritis. Methods: The study included 40 children with JRA fulfilling the American College of Rheumatology criteria for diagnosis of JRA: 4 children with oligoarticular JRA, 12 with polyarticular JRA and 24 children with systemic onset JRA. Fifty healthy children, matching the patients in age and sex served as a control group. The studied children with JRA were subjected to laboratory tests including CBC, ESR, CRP, ANA and rheumatoid factor (RF). Serum samples from both patients and controls were assayed for anti-MCV levels using an ELISA technique. Results: The study showed high mean serum anti-MCV antibodies level in JRA patients when compared to controls (P= 0.00). In addition, there were no significant correlations between anti-MCV antibody levels and parameters of disease activity, namely, number of swollen joints, number of tender joints, ESR and CRP. The receiver operating characteristic (ROC) curve was drawn and it showed that the area under the curve (AUC) was (0.896). At a cutoff level > 17 u/mL, anti-MCV antibodies had diagnostic specificity of 88%, diagnostic sensitivity of 87.5%, negative and positive predictive values of 89.8% and 85.4%, respectively and diagnostic efficacy of 87.8%. We also reported 3/40 of JRA patients to be positive for RF and 2/40 of JRA patients to be positive for ANA. Conclusion: Measurement of serum anti MCV antibody level holds promise as a diagnostic tool in JRA. However, they failed to show a significant efficacy in determining disease activity. Keywords: Juvenile rheumatoid arthritis, MCV Egypt J Pediatr Allergy Immunol 2012;10(2):75-80
5 citations
TL;DR: In this article, a cross-sectional study was conducted among prep school students in Assiut city and two rural areas in Upper Egypt in order to determine the prevalence and risk factors of asthma among preparatory school children.
Abstract: Background: The prevalence of asthma and allergies is increasing in both Western and developing countries. Few studies evaluated asthma prevalence in Egypt . Objectives: Determination of the prevalence and risk factors of asthma among preparatory school children in Assiut district, in Upper Egypt. Methods: A cross sectional study was conducted among preparatory school students in Assiut city and two rural areas in Assiut district in Upper Egypt. Twelve schools were selected randomly from different regions in Assiut city and two rural areas one to the North and the other to the South of Assiut city. The total coverage of the students included was 1048 (482 boys and 566 girls). Data were collected by self-administered questionnaire (in Arabic Language) which was filled by the participants. Results: Of the 1048 positively responding subjects, 65 fitted the diagnosis of asthma with over all prevalence of 6.2%. No significant difference was found between urban and rural areas (P = 0.075). Using logistic regression analysis: a positive family history of allergy and the presence of other one or more allergic diseases were significantly associated risk factors for asthma. Exposure to dust, cigarette smoke, playing and physical activity, common cold attacks, and special food or drinks were the most common triggering factors for asthma exacerbations . Conclusion: Bronchial asthma is a significant health problem among children and adolescents in Assiut district and needs special medical care. Wider scale multi-center studies in upper Egypt and other localities of Egypt are needed to outline the profile of bronchial asthma among children and adolescents in the whole country. Keywords: prevalence of asthma, preparatory school children, Assiut district Egypt J Pediatr Allergy Immunol 2012;10(2):109-117
5 citations
TL;DR: Breathing training and aerobic training can be used as a safe complement to medical treatment in asthma and showed high statistical significant differences in the FVC, FEV1, PEF, FEF 25-75% and MVV within each group.
Abstract: Background: There is worldwide public interest in physical therapies for asthma Objective: To compare the effects of a program of breathing training and aerobic training on ventilatory functions in children with bronchial asthma Methods: Forty asthmatic children from both genders (22 boys and 18 girls) were recruited to participate with age range 6-13 years The children were divided into two groups of equal number, group A received a program of breathing training and group B received a program of aerobic training on cycle ergometer three times per week for three months Ventilatory functions were measured before beginning and after finishing the training Results: The results showed high statistical significant differences in the FVC, FEV1, PEF, FEF 25-75% and MVV within each group while on comparing the two groups, the ventilatory functions were comparable Conclusion: Breathing training and aerobic training can be used as a safe complement to medical treatment in asthma Keywords: Asthmatic children; ventilatory functions, breathing training; aerobic training Egypt J Pediatr Allergy Immunol 2012;10(1):33-37
4 citations
Journal Article•
TL;DR: Sublingual immunotherapy for foods was described in 1969 by David Morris and reintroduced in 1970 for inhalant allergens, and although some patients treated for food, pollen, pet dander and mold allergy by SLIT appeared to improve, the ideal dose, degree of expected improvement, and the mechanism of action were not established, and few studies were published in peer reviewed journals until the 1990s.
Abstract: HISTORICAL TIPS The science of “Immunology” originated in the 19th century and grass pollens were identified for the first time as the likely trigger of seasonal hay fever in the 1870s. Skin allergy testing became an accepted assessment technique around 1910. Immunoglobulin E (IgE) was identified in the 1960s. The first scholarly report of immunotherapy for allergy appeared by Noon and Freeman in 1911 in the medical journal, The Lancet. Clinical attempts to determine the best dose and route for allergy therapy increased dramatically in the 1920s and 1930s. The oral route of immunotherapy was suggested earlier in 1900 by Curtis but, the clinical use of sublingual immunotherapy (SLIT) for foods was described in 1969 by David Morris. SLIT was reintroduced in 1970 for inhalant allergens. Although some patients treated for food, pollen, pet dander and mold allergy by SLIT appeared to improve, the ideal dose, degree of expected improvement, and the mechanism of action were not established, and few studies were published in peer reviewed journals until the 1990s. Generally, sufficient research evidence on the effectiveness and mechanism of immunotherapy began to accumulate in the last 15 years of the 20th century.
4 citations
Journal Article•
TL;DR: Asthmatics have increased expression of FOXP3, and corticosteroid therapy –whether oral or inhaled - enhances FoxP3 expression.
Abstract: Background: T cells are considered the main cells responsible for production of suppressive cytokines, and play a key role in balancing the immune responses to maintain the peripheral tolerance against allergens Objective: The present study investigates T regulatory (Treg) forkheadwinged helix protein 3 FOXP3 expression in childhood asthma and its relation to corticosteroid therapy Methods: In this case control study, Treg FOXP3 was measured in blood of 60 children using real time polymerase chain reaction (RT-PCR) technique Two asthmatic groups were included, one on corticosteroid therapy (20 patients) and the other not on corticosteroid treatment (20 patients) They were compared to 20 healthy children as controls Results: FOXP3 concentration was significantly elevated in asthmatic patients (90 ± 774) compared to healthy children (12844 ± 106) (p= 0000) FOXP3 was significantly more elevated in asthmatics on corticosteroids (161158 ± 639) than steroid naive asthmatics (36038 ± 234) (p=0000) Levels of Treg FOXP3 in asthmatics with inhaled corticosteroids (mean 15116 ± 5379) were almost similar to FOXP3 in asthmatics with systemic corticosteroids (16149±725) (p>005) FOXP3 levels did not differ with smoking, asthma severity or disease control and did not correlate with age, FEV1, blood lymphocytes percentage or eosinophils percentage Conclusion: Asthmatics have increased expression of FOXP3, and corticosteroid therapy –whether oral or inhaled - enhances FOXP3 expression Keywords: FOXP3, Treg, Corticosteroids, Bronchial asthma, Transcription factors, Cytokines Egypt J Pediatr Allergy Immunol 2012;10(1):39-43
2 citations
TL;DR: Children with autism have significantly reduced levels of serum IgG, IgA and IgM compared to the control children, suggesting an underlying defect in the immune function, and the cell-mediated immunity is impaired as evidenced by low numbers of CD4+ cells and increased CD8+ T cell subpopulations and decreased CD4/CD8+ ratio.
Abstract: Background: Autism spectrum disorder (ASD) is a spectrum of behavioral anomalies characterized by impaired social interaction and communication, often accompanied by repetitive and stereotyped behavior. The condition manifests within the first 3 years of life and persists into adulthood. There are numerous hypotheses regarding the etiology and pathology of ASD, including a suggested role for immune dysfunction. While immune system abnormalities have been reported in children with autistic disorder, there is little consensus regarding the nature of these differences which include both enhanced autoimmunity and reduced immune function. It has long been known that extensive interactions occur between the immune system and neuronal system/brain, and that normal neurodevelopment is contingent upon an appropriate interaction with the immune system. Objectives: the aim of the present study was to evaluate the cell mediated and humoral immunity of children with autism through evaluation of the serum antibody levels of immunoglobulin (IgG, IgM, IgA), also we evaluated the T helper and T suppressor cells (CD4 and CD8 T cell subpopulations) and CD4/CD8 ratio in children with autism and compared with the healthy control children. Methods: This study was carried out in the Psychiatry Unit, Department of Pediatrics, Tanta University Hospital. Thirty children with autism (24 males, 6 females) newly diagnosed were included in the study, their age range was (3-9 years) with the mean age of 51.8 years. Childhood Autism Rating Scale (CARS) was used for the diagnosis of autism. Diagnosis of autism was based also, on the criteria for the diagnosis of autism that are set out in the Diagnostic and Statistical Manual of Mental Disorders DSM-IVTR (Fourth Edition, Text Revision). The intial Childhood Autism Rating Scale (CARS) score for these children was ≥30, as children with a CARS score ≥30 were considered to have autism. Intial CARS score range for children with autism was (31-60). The control group consisted of thirty healthy children (10 females, 20 males). Their age range was (2-10 years) and the mean age was 5.3 ± 2.4 years. Results: Children with autism had significantly lower serum levels of IgG, IgA and IgM compared to the control children p < 0.001. Also children with autism had significantly lower numbers of CD4 cells with increased CD8+ T cell subpopulations and decreased CD4+/CD8+ ratio. Conclusion: Children with autism have significantly reduced levels of serum IgG, IgA and IgM compared to the control children, suggesting an underlying defect in the immune function, also the cell-mediated immunity is impaired as evidenced by low numbers of CD4+ cells and increased CD8+ T cell subpopulations and decreased CD4+/CD8+ ratio. Keywords: autism spectrum disorder (ASD), neurodevelopment, immunity Egypt J Pediatr Allergy Immunol 2012;10(1):25-32.
2 citations
TL;DR: This review will highlight the characteristics of H1 antihistamines and their indications in pediatric allergic disorders.
Abstract: Histamine is a key mediator in allergic diseases, where it exerts most of its effects through the H1 receptor and to a less extent the H2 receptor. H1-antihistamines provide rapid relief of many of the allergic symptoms and are considered the main stay of treatment of allergic rhinoconjunctivitis and urticaria. H1 antihistamines comprise first generation (old) and second generation (new) H 1 antihistamines with different pharmacological aspects, efficacy and safety profile. Few studies dealt with H1 antihistamines in pediatric population. This review will highlight the characteristics of H1 antihistamines and their indications in pediatric allergic disorders. Egypt J Pediatr Allergy Immunol 2012; 10(1):3-12
Journal Article•
TL;DR: ABPA occurs in 1/3 of atopic asthmatic children and is related to the duration and severity of asthma.
Abstract: Background: Allergic bronchopulmonary aspergillosis (ABPA) occurs in patients with asthma and cystic fibrosis. When aspergillus fumigatus spores are inhaled they grow in bronchial mucous as hyphae. It occurs in non immunocompromised patients and belongs to the hypersensitivity disorders induced by Aspergillus. Objective: To diagnose cases of allergic bronchopulmonary aspergillosis among asthmatic children and define the association between the clinical and laboratory findings of aspergillus fumigatus (AF) and bronchial asthma. Methods: Eighty asthmatic children were recruited in this study and divided into 50 atopic and 30 non-atopic children. The following were done: skin prick test for aspergillus fumigatus and other allergens, measurement of serum total IgE, specific serum aspergillus fumigatus antibody titer IgG and IgE (AF specific IgG and IgE) and absolute eosinophilic count. Results: ABPA occurred only in atopic asthmatics, it was more prevalent with decreased forced expiratory volume at the first second (FEV1). Prolonged duration of asthma and steroid dependency were associated with ABPA. AF specific IgE and IgG were higher in the atopic group, they were higher in Aspergillus fumigatus skin prick test positive children than negative ones .Wheal diameter of skin prick test had a significant relation to the level of AF IgE titer. Skin prick test positive cases for aspergillus fumigatus was observed in 32% of atopic asthmatic children. Conclusion: ABPA occurs in 1/3 of atopic asthmatic children and is related to the duration and severity of asthma. Keywords: Aspergillosis, bronchial asthma, children Egypt J Pediatr Allergy Immunol 2012;10(2):95-100
Journal Article•
TL;DR: A female adolescent with SLE and lupus nephritis class III who presented as well with moderate dyspnea, tachycardia in absence of heart failure and hypertension gradually improved with complete resolution of her cardiopulmonary disease and significant reduction of her proteinuria is described.
Abstract: Cardiopulmonary involvement is one of the important manifestations of systemic lupus erythematosus (SLE) that tends to be more common in adults than children with SLE. SLE-related cardiopulmonary affection ranges from subclinical to life threatening condition. Although increased left ventricular mass and interstitial lung disease have been reported in association with SLE, the reversibility of such conditions with treatment of SLE was not sufficiently reported. Herein, we describe a female adolescent with SLE and lupus nephritis class III who presented as well with moderate dyspnea, tachycardia in absence of heart failure and hypertension. She had also productive cough of whitish sputum, no fever and both sputum and blood cultures were negative. Her echocardiography revealed left ventricular wall hypertrophy with preserved systolic function, electrocardiogram showed sinus tachycardia. Her pulmonary function tests revealed mild restrictive pattern and high resolution computed tomography revealed veiling of both lungs with increased attenuation and interstitial nodules with bilateral mild pleural effusion. She received full dose prednisone and intravenous monthly cyclophosphamide in addition to intravenous pulsed methylprednislone. She gradually improved with complete resolution of her cardiopulmonary disease and significant reduction of her proteinuria. In conclusion, cardiopulmonary involvement in relation to SLE could be reversible with adequate treatment leaving no residual damage.
TL;DR: Higher serum levels of the proinflammatory cytokines PAF and MCP-1 in children with refractory epilepsy suggest that both, PAf and M CP-1, may play a role in the pathogenesis of refractor epilepsy.
Abstract: Background: Epilepsy is an important common and diverse group of symptom complexes characterized by recurrent spontaneous seizures. It is estimated that about 5-10% of all cases of epilepsy eventually become refractory. It has been suggested that inflammation plays a role in epilepsy. In refractory epilepsy, an inflammatory response is produced that leads to rapid release of pro-inflammatory cytokines as platelet activating factor (PAF) and monocyte chemoattractant protein-1 (MCP-1). Objective: The aim of the present study was to evaluate the plasma levels of the monocyte chemoattractant protein-1 (MCP-1) and platelet activating factor (PAF) in children with refractory epilepsy to explore their role in the pathogenesis of refractory epilepsy. Methods: The present study was carried out in Tanta University Hospital, Pediatric Department, Neurology unit. Forty (40) children with idiopathic refractory epilepsy (25 males and 15 females) their age ranging between 4-15 years were included in the study. The control group consisted of thirty healthy children, 20 males and 10 females aged 5 years to 13 years. The serum levels of MCP-1 and PAF were measured for children with refractory epilepsy and the control children. Results: Children with refractory epilepsy had significantly higher serum levels of PAF (P < value 0.001) and significantly higher serum level of MCP-1 (P < value 0.001) in comparison to the control children. Also there was a significant correlation between the duration of refractory epilepsy and the serum levels of PAF and MCP-1. Conclusion: Higher serum levels of the proinflammatory cytokines PAF and MCP-1 in children with refractory epilepsy suggest that both, PAF and MCP-1, may play a role in the pathogenesis of refractory epilepsy. Keywords: Platelet activating factor, Monocyte chemoattractant protein-1, Neuroinflammation, Refractory epilepsy Egypt J Pediatr Allergy Immunol 2012;10(1):13-18