Arun K. Baranwal

Diarrhea associated hemolytic uremic syndrome: A 3-year PICU experience from Nepal

diffuse, transverse, and longitudinal.1 Nail discolorations are mainly due to direct toxic effects and stimulation of the matrix melanocytes. Transverse melanonychia seems to occur in relation to intermittent courses of chemotherapy.2 This complex pattern of nail changes is accounted by synergy or an additive effect of chemotherapy agents on cellular proliferation of nail compartments.3 The time interval between the start of therapy and the first signs of nail pigmentation may depend on the rate of nail growth; this could explain the later and less frequent appearance of changes in the toenails.4 These nail changes are benign requiring no specific intervention and resolve spontaneously, by moving distally.

Impacted esophageal foreign body mistaken for chronic pharyngitis

An otherwise healthy well-thriving 18-mo-old boy wasbrought to pediatric emergency department withcomplaints of intermittent fever, vomiting anddysphagia for solid foods for last 3 months. He wastreated as chronic pharyngitis at several hospitalsbefore referral, and no chest radiograph was obtainedbefore. Examination revealed congested posteriorpharyngeal wall, bilateral normal air entry and noadded chest sounds. Chest radiograph revealed acoiled spring impacted in upper esophagus (Fig. 1),which was removed endoscopically. After 48 hours,child was discharged. On one month follow up, patientwas asymptomatic and doing well.Diagnosis of gastrointestinal foreign bodies isstraightforward, if caregivers witness a child taking anyforeign body in mouth. Otherwise, it can lead to delayin diagnosis as patient may present with non-specificsymptoms

Pseudocyst in Pulmonary Acute Respiratory Distress Syndrome (ARDS)

Childhood ARDS is mostly caused by pneumonia. Pulmonary pseudocysts are reported in adults recovering from ARDS, usually in non-dependent lung regions. We present a 1.5-year-old boy, who survived severe pulmonary ARDS with development of pulmonary giant pseudocysts and other structural abnormalities in dependent lung region. To the best of our knowledge, it is the first follow up report of pulmonary abnormality In a toddler with ARDS of extreme severity.

Post-treatment Fulminant Hepatic Failure in an Infant with Visceral Leishmaniasis: Immune Injury or Stibogluconate Toxicity?

An 1-yr-old girl presented with fever, palpable hepatomegaly (3cm) and splenomegaly (6.5cm). Investigation showed hemoglobin 78g/L, TLC 4.2×109/ L (N20L80), platelet count 77 × 109/L, normal coagulogram and serum biochemistry. A diagnosis of VL was made on demonstration of LeishmaniaDonovani bodies (+++) on bone marrow studies. She was put on intramuscular stibogluconate (20mg/Kg/ day) and discharged for domiciliary therapy. On day 26, she was readmitted with complaints of malena and fever. Examination revealed fever, tachypnoea, tachycardia, jaundice, bilateral chest crepitations, hepatomegaly (same as before), but splenomegaly had reduced by 1.5cm. Investigation showed: hemoglobin 100g/L, TLC 12×109/L (N63L37), platelets 117×109/L and coagulopathy (PT 18 “, control 14”; aPTT 45 “, control 36“). Except for abnormal liver functions (bilirubin 3 mg/dL, AST/ALT 1346/1020 IU/L), rest of the biochemistry including Alkaline Phosphatase was normal. CXR showed bilateral infiltrates, but cultures were sterile. Repeat bone marrow examination did not show Leishmania-Donovani bodies. HBV, HCV, HAV and HIV serology were negative; HEV serology, serum ceruloplasmin, copper and auto-antibodies assessment were not available. Stibogluconate was discontinued. She became afebrile 48 hours after intravenous coamoxiclavunate. Blood products were transfused as per need. On day 7 of admission, jaundice deepened and she developed alteration in sensorium and hyperventilation. CXR was normal and neuroimaging showed diffuse cerebral edema. Despite all supportive measures including mechanical ventilation and antibiotics for possible nosocomial sepsis, her condition worsened and she died of refractory shock. Autopsy could not be performed.

Improvement in Lasegue's sign: an early predictor of recovery in childhood Guillain-Barre syndrome.

however, the same has not been evaluated in respect to GBS. We present 3 patients of GBS, in whom improvement in SLR heralded the disease recovery before any other quantitatively demonstrable sign. Nine patients of childhood GBS were managed in Pediatric Intensive Care Unit of a tertiary care center over 3 years period (Sept’2000 to June’03). Three patients (age, 4 -6 years) had Lasegue’s sign at admission. All the three had progressive ascending symmetrical hypotonic hyporeflexic motor weakness, which developed over 3-7 days. Motor power varied from 1/5 to 3/5. All had intercostal muscle weakness, neck rigidity, leg pains, positive Kernig’s sign and 1 had backache. Angles of SLR in third patient were 0o and 30o in right and left legs respectively. He also had autonomic instability in the form of varying heart rate (100-124/min) and blood pressure (90/60-110/70 mmHg) during first 36 hours. EKG was normal. None had had dog bite, immunization or viral illness in recent past, or cranial nerve involvement. Routine investigations were normal in 2 patients. One had hypokalemia (serum potassium 3.2 mEq/L) and compensated respiratory acidosis (pH 7.42, PaCO