The Role of Vitamin D in

Children with Recurrent

Tonsillopharyngitis
Ismail Yildiz
Emin Unuvar
Umit Zeybek
Bahar Toptas

Canan

Cacina
Sadk Toprak
Ayse Kilic
Salih Aydin

Frisca Finlania Agan - 07120090019

Pembimbing: dr. M. Agus, Sp.THT, M.Kes
Yildiz et al. Italian Journal of Pediatrics 2012, 38:25
http://www.ijponline.net/content/38/1/25

INTRODUCTION

TONSILOPHARYNGITIS
Tonsillopharyngitis : acute infection of
tonsil and pharynx, characterized by
erythema, exudation, ulceration or
membrane.
Etiology : Virus and Group A Betahaemolytic streptococci

 Recurrent tonsillopharyngitis :
7 episodes of tonsillopharyngitis in
a year OR
5 episodes of acute tonsillitis in a
year for two consequetive years OR
3 episodes of acute tonsillitis in a
year for three consequetive years

 Risk factors : The environmental

conditions, the childs immune system,
mucosal characteristics effecting the
bacterial biofilm formation on tonsillar
tissue and the respond to the infections
Antibiotics are not effective if bacterial
biofilm occurred.

Pathophysiology

VITAMIN D
Vitamin D has a preventive role for inhibition
of bacterial biofilm
Role of vitamin D : maintaining of innate
immunity dendritic cells, B lymphocytes, T
lymphocytes, NK cells
Vitamin D receptors (VDR) in many tissues
Fok I, Bsm, Apa and Taq polymorphisms
described regarding VDR gene affected by
vitamin D.

Vitamin D Metabolism

PURPOSE
to determine the role of the
polymorphism
characteristics
of
vitamin D and VDR receptors in
children diagnosed with recurrent
tonsillopharyngitis.

MATERIAL AND METHODS

Study design
Metode : retrospective study
242 children between 2 and 10 years
of age
Performed in Istanbul University,
Istanbul Medical Faculty, Department
of Pediatrics, Outpatient Clinic of
General Pediatrics
Between April 2008 and April 2009.

 the total number of access to the

outpatient clinic was 58933
4,7% (2780) acute tonsillopharygitis
115/2780 (4,1%) met the eligilbility
criteria
127 control group

 Conducted mostly in autumn and winter

seasons because of the increased frequency
of tonsillopharyngitis during those seasons
and seasonal variability of the vitamin D levels
Blood samples were collected from both
groups and were studied in the same season.
Serum 25(OH) vitamin D and 1,25-(OH)2
vitamin D levels were measured by ELISA
method

Figure 1 Flow chart of the study.

April 1st, 2008 April 1st , 2009
Number of visits to the outpatient clinic
(58933)
Number of cases diagnosed with acute tonsillopharyngitis
(2780)
Number of cases included to the study
(155)
DNA could not isolated from 15
12 of 96 ELISA kit were
samples in Taq and Apa
used during the preparation
polymorphisms and 14 samples
phase
in Fok 1 polymorphism
Number of cases
with measured
Serum 25(OH)
vitamin D level
84 (73%)

Number of cases
with measured
Serum 1,25(OH)2
vitamin D level
84 (73%)

Number of cases with studied

VDR gene polymorphism;
Taq polymorphism 100 (%86,9)
Apa polymorphism 100 (%86,9)
Fok 1 polymorphism 101 (%87,8)

The Eligibility Criteria For Participants

Inclusion criteria for the study group:
a) Having tonsillopharyngitis >7 times a year,
b) Having symptoms of tonsillopharyngitis
developed within last 7 days,
c) No conditions requiring to be hospitalized,
d) Given parental consent,
e) No known chronic diseases,
f ) Not having any supplementation of vitamin
D during the last 3 month.

Tonsillopharyngitis
Diagnosed : physical examination performed by a
physician and subjects included to the the study
regardless of the etiology
The subjects : diagnosed as tonsillopharyngitis
more than 7 times in a year are considered as
frequent tonsillopharyngitis. The frequency :
investigated by reviewing the hospital records and
by referring the feedback of parents if the patient
is diagnosed with tonsillopharyngitis in a different
institution or a prescription for tonsillopharyngitis
was given by another physician previously.

Measurement of serum vitamin D level and

determination of vitamin D receptor (VDR) gene
polymorphism

Study serum 25(OH) and 1,25-(OH) vitamin D

levels were measured by sandwich Enzyme
Linked Immunosorbent Assay (ELISA)
method
DNA of the subjects was isolated from the
blood samples obtained and VDRs Apa, Taq ,
Fok I polymorphisms were determined
through primer series

Interpretation of serum vitamin D levels

Serum 25(OH) vitamin D level was interpreted :
Insufficient : 5080 nmol/L
Sufficient
:80250 nmol/L
Excess :250325 nmol/L
Intoxication : > 325 nmol
Serum 25(OH) vitamin D level
Apperent deficiency : < 50 nmol/L

Factors affecting serum vitamin D level

Daily exposure to sunlight

Gender
Age
Weight
The amount of time spent with outdoor
activities and at seaside

Ethical committee approval and support

Istanbul University, Istanbul School of
Medicine ethical committee approval was
taken in January 2008 with the file
numbered 2008/35 before the study was
performed.
This study was supported by Istanbul
University Scientific Research Projects
(Project No: 2006).

Statistical analysis

Students t-test
Chi-Square
Fishers exact chi-square
Pearson correlation analysis and logistic
regression tests

RESULTS

DISCUSSION
The existence of VDRs in immune system cells a
The best parameter for the evaluation of vitamin D :
- Body vitamin D storage : serum 25 (OH) vitamin D
levels (half life : 20 days)
- Biologically active form : 1,25-(OH)2 vitamin D (half
life : 3 to 6 hours), circulating blood level is very low
Serum 25(OH) vitamin D and 1,25-(OH)2 vitamin D
levels were measured by ELISA method

 VDR gene polymorphisms : predisposition to some

diseases
t allele of the TaqI VDR receptor polymorphism is
associated with increased anti-infective action against
tuberculosis
f allele of the FokI VDR polymorphism is associated
with reduction in anti-infective action against
tuberculosis
annual disease frequency : increases Ff
polymorphism and decreases ff polymorphisms.

 Average serum 25-(OH) vitamin D levels

were in the normal range in both groups, it
was significantly lower in the children with
frequent tonsillopharyngitis (p < 0.01)
Two randomized controlled trails reported
that, vitamin D supplementation is effective
for prevention of upper respiratory tract
infections

 Aydin and colleagues prospective

research serum 25-(OH) vitamin D
levels in tonsillectomy patients with
recurrent tonsillitis = no statistical
differences with the control group.

CONCLUSION
Low serum vitamin D level can be a risk factor for
recurrent tonsillopharyngitis.
In children having recurrent tonsillopharyngitis,
serum 25(OH) vitamin levels were lower than
those of healthy children.
No difference in vitamin D receptor gene
polymorphism.

In the future,
giving vitamin D support to the children with
recurrent
tonsillopharyngitis,
then
measuring their serum vitamin D levels and
observing the decrease in annual disease
frequency after the supportive treatment
would exactly explain the relation between
vitamin
D
and
having
recurrent
tonsillopharyngitis.

THANK YOU