Symptomatic infantile helicobacter pylori gastritis infection in indigenous african infants: a case series

Helicobacter pylori gastritis infection rate increases with age. Higher rates have however been reported among young people in the developing countries of the world. The infection however has rarely been reported in infants, especially in Africa. This case series describes three cases of Helicobacter pylori gastritis infection as diagnosed in three infants. The goal is to raise the suspicion index of medical practitioners about the possibility of this this infection among infants who present with suggestive symptoms. On three separate occasions in 2012 and 2013, three ill, indigenous, black African female infants aged 4, 6 and 7 months, were brought to hospital with symptoms ranging from fever, refusal to feed, diarrhoea, restlessness, vomiting and irritability. In each case, systemic examination findings were unremarkable. After several laboratory investigations, each infant was found to have Helicobacter pylori infection following positive blood antibody (using Tell Me Fast H. Pylori antibody serum and Plasma test manufactured by Biocan Diagnostics Canada) and fecal HpSA ImmunoCardSTAT antigen tests. Repeat stool antigen test was negative in each case after completion of the recommended triple therapy. Helicobacter pylori infection has been rarely reported among infants. This case series highlights the need for health care providers to have a high index of suspicion so that infants with suggestive symptoms, especially in settings with high Helicobacter pylori colonization prevalence can be evaluated for Helicobacter pylori gastritis infection.


Introduction
Helicobacter pylori is a bacteria that causes gastritis in humans [1].
Though the rate of infection increases with age, higher rates have been reported among young people in the developing countries of the world, where poor sanitation is thought to contribute to an overall high prevalence of Helicobacter pylori infection [1][2][3]. The infection however has rarely been reported in infants, especially in Africa. In this case series, we describe three cases of Helicobacter pylori gastritis infection as diagnosed and treated in indigenous female black African infants from Uganda. We intend to highlight the need for attending medical practitioners to think about and indeed look out for possibility of Helicobacter pylori infection in infants. These infants often , present with symptomatology that may suggest other different childhood infections. Our concern mainly involves , developing low income settings where Helicobacter pylori colonization has previously been described generally among children, but rarely in infancy. Affected patients from these poor settings would therefore would therefore benefit from; a more focused and targeted approach to diagnosis that quickens the treatment of this disorder while reducing the overall costs of investigations and treatment for a patient population that often cannot afford the usual high costs of health care.

Methods
The first case was a four month old indigenous black African female infant, with a two week history of low grade fever, two days of diarrhea, vomiting and refusal to breastfeed. There was no cough, difficulty in breathing, painful micturition, convulsions or abdominal distension. The mother had introduced the child to complementary feeding with both cow milk and infant formula three weeks to the onset of symptoms.

Results
Each of these three indigenous Ugandan infants improved on a combination of IV/oral omeprazole, oral clarithromycin and IV/oral metronidazole, with complete resolution of symptoms after completing a fourteen day course. Dehydration was managed as per World Health Organization guidelines [5]. Repeat Helicobacter pylori stool antigen test after treatment was negative in each of the cases.
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Discussion
The prevalence of Helicobacter pylori as a common cause of infection has been previously described [1][2][3][4] However, the diagnosis of these cases is correct, especially considering that we used confirmatory monoclonal antigen fecal HpSA ImmunoCardSTAT test, which has a high sensitivity, specificity, accuracy and reproducibility [1,3,[5][6][7], and is easily affordable for the poor and low income settings especially in Africa.
Studies show that most children colonized with Helicobacter pylori are asymptomatic [3][4][5], and this could contribute to a low index of suspicion by attending health care providers. Most of these studies also focus on general paediatric population with little emphasis on infants.
Presentation of Helicobacter pylori gastritis in infants is nonspecific at best, with abdominal pain in children being a non-specific symptom [8]. While studies show improvement in abdominal pain in children with Helicobacter pylori gastritis after triple therapy, a recent double-blind controlled trial did not confirm this finding [8], while a meta-analysis found conflicting evidence for association between Helicobacter pylori and epigastric pain [9]. Whereas a positional statement of the North American Society of Pediatric