Ankit Parakh

Tracheobronchial Foreign Body Aspiration in Children

Foreign body aspiration is a common pediatric problem and requires prompt diagnosis and management. The spectrum of manifestation of foreign body aspiration often varies from acute life-threatening airway obstruction to a persistent pneumonia, recurrent wheezing, or may remain asymptomatic for a longer period. Because of lack of specific clinical manifestation, diagnosis is often difficult and can lead to various serious and long-term complications. There is requirement of a specific clinical or radiological diagnostic criterion that can help health care personnel identify the accidents at an earlier stage even at a primary health care level. Rigid bronchoscopy is the first choice for foreign body removal. But recent literature has shown that fiberoptic bronchoscopy is a better and easier modality not only for diagnosis but also for retrieval foreign body from airways.

Successful management of airway hemangioma with propranolol.

Airway hemangiomas can be difficult to manage and cause anxiety in both the parents and the treating physician. Propranolol, a nonselective beta‐blocker, has recently been used for treating proliferating infantile hemangiomas. We report successful management of a proliferating, large, mixed infantile hemangioma with subglottic extension in an Indian infant using oral propranolol in a dose of 2mg/kg/day without any side effects. Induction of early involution and freedom from the side effects of steroid therapy seem encouraging for using propranolol as a first line treatment modality in the management of troublesome hemangiomas.

Acute transverse myelitis: an unusual complication of typhoid fever

Abstract Typhoid fever is associated with a wide spectrum of neurological complications. Acute transverse myelitis is a rare complication with only a few reports in adults and none in children. A 15-year-old boy with typhoid fever is reported who developed acute transverse myelitis in the 3rd week of illness. He was treated with antibiotics and corticosteroids and made a complete recovery.

Enteric fever presenting as acute ataxia.

Enteric fever is a common infection of tropical countries that can have a variety of neurological complications with an incidence varying from 5% to 35%. Acute cerebellar ataxia as an isolated neurological complication of enteric fever is very rare with limited evidence. A 13-year-old boy presented with high-grade intermittent fever for 5 days. He also developed progressive unsteadiness in walking and difficulty in speech since the fourth day of fever. There was no associated rash, ear pain/discharge, altered sensorium, seizures, headache, vomiting or any other significant symptoms. On examination, the child was febrile, conscious, oriented, with slurred speech and stable vital signs. Abdominal examination revealed hepatosplenomegaly (liver: 2 cm; spleen: 1 cm). Cranial nerves and sensory system were normal. There was hypotonia in all four limbs, normal power and marked ataxia. Co-ordination was affected on both sides, with presence of dysmetria, dysdiadokokinesia and impaired knee-heel test. Pendular knee jerks were elicited bilaterally. He had a widebased gait, and tandem walking was not possible. There was no nystagmus. Investigations revealed haemoglobin of 11 gm/dL, total leukocyte count of 2200/cu.mm. and platelet count of 70 000/ cu.mm. Peripheral blood smear for malarial parasite was negative. Renal and liver function tests were normal. Magnetic resonance imaging of the head was normal. Widal test after 3 days (eighth day of illness) was positive with titres of Anti’O’1:320 and Anti’H’ 1:320. Blood culture isolated Salmonella typhi, which was sensitive to ceftriaxone. The child was hence diagnosed to have enteric fever with ataxia. Intravenous ceftriaxone was started, and the patient became afebrile after 4 days. The total leukocyte count and platelet count normalized over 7 days. Cerebellar signs improved over 2 weeks of hospital stay. Ceftriaxone was given for a period of 14 days. There was persistence of mild ataxia and incoordination at discharge, which gradually improved over next 4 weeks during follow-up. Acute cerebellar ataxia as an isolated neurological manifestation of enteric fever is rare. Wadia et al. described 28 cases of enteric fever with cerebellar ataxia with only two of them presenting with isolated cerebellar ataxia, the rest having a combination of ataxia with pyramidal, extrapyramidal signs, deafness or protracted confusional states. Most studies show a mean time of onset of ataxia to be around 10–14 days after the onset of fever. Enteric fever presenting with isolated cerebellar ataxia within first few days of illness, like in our case, is uncommon with only three reported cases of early onset of cerebellar ataxia in enteric fever. The most probable aetiopathogenesis appears to be typhoid encephalitis/cerebellitis due to predominant affliction of cerebellum with non-specific inflammatory changes like capillary thrombosis, haemorrhage, peri-vascular infiltration, demyelination, oedema and secondary neuronal changes. In conclusion, acute cerebellar ataxia is an uncommon neurological complication of childhood enteric fever and can appear in the first week of illness. Being a treatable condition, enteric fever should be considered in the differential diagnosis while investigating a case of fever with cerebellar ataxia.

Hypoplastic epiglottis in a nonsyndromic child: a rare cause of chronic cough.

We describe a 2-year-old girl born out of a nonconsanguineous marriage who presented with dry cough since birth, which was often associated with feeding. She never had any choking or cyanotic/apneic spells. Her voice and cry were normal. She was born at term with no obvious congenital anomalies or perinatal problems. The child never had any other significant illness or respiratory distress to warrant hospital admission. On examination, she was a healthy-looking child without any abnormal syndromic facies or craniofacial or any other congenital anomaly. Flexible bronchoscopy done under sedation and local anesthesia revealed a rounded, short, stump-like hypoplastic epiglottis with a smooth contour. The rest of the laryngeal apparatus and the trachea-bronchial tree had normal appearance. The parents were advised to feed the child in a propped-up position and thickening of feeds to avoid aspirations. She remains well under follow-up. Hypoplastic epiglottis is a rare congenital anomaly of the upper airway, which can present with chronic cough. Endoscopic evaluation of the upper airway should be considered early in children presenting with cough associated with feeding problems.

Hair Strands Within a Congenital H-Type Tracheoesophageal Fistula

Sir, A tracheoesophageal fistula (TEF) without esophageal atresia (type H or N) is rare, accounting for approximately 2% to 4% of congenital tracheoesophageal malformations [1]. This report describes a unique case of an infant with H-type TEF in whom there were strands of hair extending from inside the trachea, through the fistula, into the esophagus. A 1 mo 20 d-old breast-fed boy was brought with cough and fever of 5 d duration. There was a history of cough, hiccups and regurgitation after feeds since birth, and two previous hospitalisations for pneumonia. On examination, the child was febrile with mild respiratory distress, and auscultation of the chest revealed conducted sounds bilaterally. Blood counts showed a TLC of 12,500/cu mm with 68% neutrophils. Chest radiograph was normal. As an Htype TEF was suspected, oral feeding was stopped and the child was kept on nasogastric tube feeds. A non-ionic watersoluble contrast esophagogram delineated both the tracheobronchial tree and the esophagus and, although not clear, showed a small tract of dye passing from the posterior tracheal wall caudally towards the anterior esophageal wall at the level of the thoracic inlet (Fig. 1). Flexible tracheobronchoscopy showed a 2-mm opening in the posterior midline of the trachea, 2.5 cm distal to the vocal cords. Hair-like strands were seen to come out of this opening and extend up to the arytenoid cartilages. Surgical exploration revealed a 2-mm wide TEF 1 cm above the thoracic inlet which contained a small ball of hair with long adulttype strands of hair extending into the trachea and the esophagus (Fig. 2). The hair strands were removed and the fistula closed with interrupted sutures. Recovery was uneventful. The early diagnosis of H-type TEF is still a challenge although cineradiography and tracheo-bronchoscopy are considered the methods of choice [2, 3]. In our patient, preoperative tracheoscopy was beneficial as it clearly