Cg Wilson

DIFFERENTIAL DIAGNOSIS IN PAEDIATRIC RADIOLOGY

Imaging procedures are of immense help in arriving at a diagnosis in paediatric practice. However, after initial radiographic or ultrasound examination, differential diagnosis may often elude the paediatrician. A systematic and practical approach to the findings can help arrive at a diagnosis earlier, often obviating the need for costlier procedures. In this book, eminent radiologists have pooled their years of experience. This will definitely help Paediatricians and Radiologists to co-relate the clinical features with results of imaging studies. The book is divided into seven sections on anatomy and subdivided into many chapters covering major childhood disorders. Illustrations are very lucid and biometric data very useful. Format and organisation of chapters is extremely logical and it is easy to locate a particular condition in differential diagnosis. Great emphasis has been laid on radiographic and ultrasonographic findings which are very useful guides for a clinician. Contrast studies, computed tomography and magnetic resonance imaging have been illustrated wherever required. Photographic illustrations have been given in some sections to illustrate congenital and genetic disorders. However, the book lacks in certain areas. Disorders which are more common in developing countries have not been given the attention they deserve. In fact, they have been listed as rare disorders and only texts have been provided eg. Tuberculosis. Meningitis. Cysticecrosis etc. Vitamin deficiency disorders like rickets and scurvy deserve better images than provided. All in all, a good reference book in paediatric radiology for Paediatricians and Radiologists alike and is certainly recommended for departmental libraries.

INCIDENCE AND ETIOLOGY OF RESPIRATORY DISTRESS IN NEWBORN

Screening of 1986 consecutive live births was done for evidence of Respiratory Distress by administering Downes scoring in a prospective study at level II nursery of a medical college. A detailed antenatal, natal and postnatal history along with detailed examination supported by relevant investigations was carried out to arrive at the etiological diagnosis of Respiratory Distress Syndrome (RDS). RESULTS 48 newborns developed RDS during the observation period. The incidence of RDS was 2.42%. Out of these 40.4% were <1500g, 16.6% above 2500 g and the rest between 1500-2500 g. Preterm were thirty times more prone to develop RDS than full term neonates. There was no significant difference in incidence of RDS in male and female neonates. The commonest cause of RDS was hyaline membrane disease (HMD) 18.8% followed by transient tachyopnea of the newborn (TTNB) 14.5% and meconium aspiration syndrome (MAS) 12.5%. HMD was predominantly seen in the preterm in the gestational age of 29 to 32 weeks, TTNB was seen equally in term as well as preterm neonates, where as MAS was common in the term than in the preterm neonates.

STUDY OF GLOMERULAR FUNCTIONS IN NEONATES

Glomerular function of neonates (25 full term and equal number of preterm neonates) at birth, on day seven and day fourteen were estimated by endogenous Creatinine clearance (CCr). The Preterm were divided into three groups viz. Group I (Gestation age (GA) 30-32 weeks), Group II (GA 33-34 weeks) and Group III (GA 35-36 weeks). Group IV consisted of 25 term neonates. Serum creatinine (in mg/dl) in all the groups of preterm ranged from 0.92 ± 0.153 to 1.204 ± 0.154 and in term neonate from 0.562 ± 0.175 to 1.148 ± 0.247 showing that the levels were inversely proportional to the period of gestation. Besides the Serum Creatinine levels in all groups of Preterm as well as term neonates were found to fall significantly (p < 0.001) during the first and second week. Glomerular filtration rate (GFR) in Group I were 16.603 ± 2.519, 19.786 ± 2.078 and 23.720 ± 2320 on day one, seven and fourteen respectively showing progressive improvement during the first two weeks. The GFRs were also found to be directly proportional to the GA. In addition the levels of GFR were found increasing significantly during the second week compared to that on day seven in all the groups of preterm neonates. GFRs in Group I & II on all the three occasions were significantly lower (p < 0.001) than those of term counterparts, however the GFR on the first day in Group III neonates was lower than group IV, the difference was insignificant (p > 0.05). The increase in GFR in Group I on the three occasions was linear but insignificant (p > 0.05). The rise was more rapid & significant (p < 0.001) during the second week in Groups II & III. On the contrary the rate of improvement of GFR in full terms was quite rapid during the first week and gradual over the second week of life.

ENTERIC FEVER – CULTURE AND SENSITIVITY PATTERN AND TREATMENT OUTCOME

One hundred cases of enteric fever in the age group of 6 months to 12 years were analysed with respect to culture sensitivity pattern and treatment outcome. Patients were divided into 5 treatment groups - chloramphenicol, amoxycillin, trimethoprim-sulfamethoxazole + furazolidine, gentamicin + cephalexin and ciprofloxacin. Out of 91 culture positive cases, 100% were sensitive to ciprofloxacin followed by gentamicin (84.9%), cephalexin (83.6%), furazolidine (36.6%), trimethoprim-sulfamethoxazole (34.1%), chloramphenicol (34.0%) and amoxycillin (23.8%). In 60 cases resistant to chloramphenicol, resistance to other drugs varied from 20 to 88.3%. The treatment response was 100% to ciprofloxacin, 72.7% to chloramphenicol, 50% to gentamicin + cephalexin, 38.5% to trimethoprim-sulfamethoxazole + furazolidine and 12.5% to amoxycillin. Out of 48 cases who did not respond to initial regimen, 33 were treated successfully with ciprofloxacin and remaining with other drug regimens. Time taken for defervescence was shortest with gentamicin + cephalexin (4.6±2.0 days) followed by ciprofloxacin (6.1±2.5 days) and chloramphenicol (6.4±3.5 days). There were 3 deaths in this study.

A case of Fracture in a Newborn delivered by Caesarian Section.

It is considered by many that caesarian section is a safe mode of delivery. However, in certain difficult cases, injury may be sustained by the newborn as a result of the mechanics of delivery. In these situations, it is useful to have a high index of suspicion so as to detect the same. We report one such case sustaining fracture of the humerus in caesarian delivery.

Management of the child with a serious infection or severe malnutrition : Guidelines for care at the first referred level in developing countries

This is a manual that supports the Integrated Management of Childhood illness (IMCI). It is meant for use by doctors, nurses and other senior health workers. The manual provides resource material for common childhood illness and strategy for treating children in both inpatient and outpatient departments in small hospitals having basic laboratory facilities and essential drugs. Many countries have adopted the IMCI strategy and once India adopts it, this manual becomes a must for all health care providers. The manual has various chapters describing the process right from the admission of a sick child, prioritization of care, assessment of the child and dealing with specific common diseases like ARI, diarrhoea, malnutrition etc. It also deals with supportive care and has appendices giving information on practical procedures, drug dosages etc. There is one drawback in the manual, that, it does not cover the early neonatal period when neonatal and infant mortality is quite high. However, many WHO publications have been incorporated to give useful information for common illnesses with appropriate illustrations. The manual is recommended for all those caring for children at the first referral level in developing countries like India.

A CASE OF BRAIN ABSCESS

Intracranial infections still constitute a significant neurosurgical problem. The classical triad of headache, focal neurological deficit and fever is found only in 25% cases [1], Diagnostic techniques like CT and MRI result in early and efficient diagnosis of brain abscess. Antibiotics have revolutionized the management of brain abscess and early institution of specific treatment has reduced mortality as well as sequelae. Case Report 8 year old boy was admitted with complaints of low-grade intermittent fever, without chills and rigor of 5 days duration and excessive but easily arousable sleepiness of 2 days duration. A practitioner prior to admission treated him with cloroquine and ciprofloxacin. Examination revealed an average built boy weighing 21 Kg(< 5th%ile), drowsy, with pulse 70/minute, respiration 30/minute, temp 98°F and BP 100/60mm Hg right arm supine phase IV. There was no pallor, icterus, rash, cyanosis, and lymphadenopathy. There was no neurological deficit; pupils were of normal size and reacting to light. Fundus was normal. Other systems were essentially within normal limit. Haematological parameters were essentially normal. LFT, blood urea and serum creatinine values were within normal range. He was being treated symptomatically. Lumbar puncture (LP) was done which was found to be under intense pressure and only few drops were collected which showed lymphocytes as the predominant cells. Other tests could not be done. However, within six hours of admission, the child developed bradycardia and hypertension of 120/90 mm of Hg. Urgent CT scan showed hypo dense ring enhancing lesion in the left tempora parietal region measuring 3×4.5 cm in size, suggesting cerebral abscess with significant mass effects (Fig-1). Child was then treated with Inj Sodium Penicillin 10 lac IV 4 hourly, Inj Gentamycin 50 mg IV 12 hourly and Inj Chloromycetin 150 mg IV 8 hourly (Inj Cefotaxime and Inj Amikacin could not be afforded by the patient). Child was also continued on Inj Dexamethasone and Inj Sodium Dilantin. Abscess was drained with twist drill method and 20-ml thick brown pus was aspirated. Repeat aspirations were dry. The pus was sterile. Antibiotics were continued for 4 weeks. Child improved gradually within 48 hours and was later subjected to detailed ENT, dental and cardiovascular checkup. Dental caries was found without odontogenous cyst. No septic focus from otologic or cardiovascular source was detected. Fig. 1 Hypodense ring enhancing lesion in temporo parietal region Discussion Sir William Macewen of Glasgow performed surgery on 19 patients of brain abscess out of whom 18 recovered [3]. Amongst 384 cases of brain abscess treated at All India Institute of Medical Sciences (AI-IMS). New Delhi. 472 at Post Graduate Institute of Medical Sciences (PGI) Chandigarh and 480 at Medical College Trivandrum. nearly 40% were reported to be otogenic and etiology could be established in 15.8% cases [4]. Brain abscess can also occur spontaneously [5]. The presenting symptoms and neurological features in brain abscess depend upon factors like location, size, number, virulence of organisms, degree of cerebral edema and host response to infection. Intractable headache, unresponsive to therapy due to rapidly expanding intra-cranial mass lesion, is the most common presenting symptom [4]. Other presenting features being vomiting, papilloedema, focal deficits, convulsion, meningism and altered sensorium. This child presented with fever and excessive sleepiness. Fundus was normal. There was no neurological deficit and no history of convulsion. The classical triad of headache, focal neurological deficits and fever was missing. In temporal lobe abscess, the sign earliest to appear, but often not looked for, is a homonymous hemi-anopia commencing in the superior quadrant. This is easily detected in conscious cooperative patients, but is more difficult to demonstrate when the patients are drowsy. Symptoms are present for less than a week in more than 50% of patients and for less than 2 weeks in 75% cases [6], Rapid onset and progression is the hallmark of brain abscess. This case had only drowsiness, and within 6 hours of hospitalization developed hypertension and bradycardia. This emphasizes the importance of careful and frequent clinical monitoring in children. A brain abscess causes an expanding intra-cranial mass effect due to cerebritis. Hence, LP should be approached cautiously and patients with brain abscess have been noted to die shortly after LP [7], In a known case of brain abscess, LP is not only hazardous but pointless also. In this case, there was no pointer to cerebral abscess, hence, LP was attempted and no more than a few drops could be collected. Urgent CT scan clinched the diagnosis. MRI and CT are appropriate and definitive tests during the stage of cerebritis. Magnetic resonance spectroscopy may be useful in differentiation of an abscess from a neoplasm [8]. Majority of brain abscess arise by direct spread from para nasal sinuses, middle ear or mastoid infections [9]. The more common primary sites of infections include skin pustules, dental or tonsillar abscess, chronic pulmonary infections, septicemia and bacterial endocarditis. The vite is unknown in 20 to 37% of patients [9], In a review of 1200 cases of brain abscess, 40% were otogenic in origin. Our case had dental caries but no odontogenous cyst. Steroids should be used in the treatment of brain abscess to help reduce cerebral edema and so an altered level of consciousness. Aspiration and excision are perfect mode of treatment. The former can be performed at any stage of brain abscess and excision is advised when the abscess is encapsulated [9]. Because of difficulty in diagnosis and management of brain abscess, mortality is high and sequelae are frequent [7]. Serial imaging will definitely reduce the morbidity and morality. Chronic seizure disorders are common after brain abscess.

Anti-leukotrienes in Childhood Asthma

Bronchial asthma is an inflammatory condition. The inflammatory actions of leukotrienes (LT) B4, C4, D4, and E4 have been shown experimentally to play a role in inflammatory mechanisms, producing asthma. Antileukotrienes (ALT) or leukotrienes antagonists (LA) is a new class of anti-asthma drugs with anti-inflammatory role. LT modifiers from the groups of 5 lipoxygenase inhibitor and Cys LT1 receptor antagonists, are found useful in asthma therapy. LAs are of main use in young infants and toddler with recurrent wheezing, children with moderate to severe chronic asthma on steroid therapy and in allergic rhinitis. In chronic asthma they are required to be used for prolonged periods with other anti-asthma agents. Except for Montelukast and Zafirlukast, which can be used in children above two and six years of age respectively, the paediatric use of other agents is yet to be established. However, these agents are essentially safe. The cost of LAs is reasonably high. At present, with available evidence, these drugs are considered promising in management of asthma in children. However, there is need to do more long term clinical trials for ascertaining their effectivity in different types of asthma to compare their effects with long acting B2 agnoists and chromones, so as to optimally explore their utility.

MULTIDRUG – RESISTANT TUBERCULOSIS (MDRTB) IN CHILDREN

The World Health Organization has estimated that 90 million cases of tuberculosis will occur throughout the world in the 1990s and 30 million people will die from the disease [1]. Drug resistance is emerging as a major obstacle to tuberculosis control in the world and is exacerbated by the growing epidemic of Human Immunodeficiency Virus (HIV) [2]. Treatment of drug-resistant tuberculosis is complex, requiring the use of several toxic drugs over 9 to 18 months. Here we present a case of multidrug resistant tuberculosis in a child.

DISEASES OF THE LIVER AND BILIARY SYSTEM IN CHILDREN

Hepatic and Biliary diseases in children are becoming increasingly common and Paediatric Hepatology is establishing itself as a distinct speciality in Paediatrics owing to the peculiarities of liver and biliary diseases in children. This book is likely to fulfill the long felt need of students and teachers to share their global experiences in this field and to focus on certain clinical problems in day to day practice. This book covers a wide range of topics - from genetic disturbances of bilirubin and bile salt transport in neonates to psychology of parents of children on transplantation waiting lists. The highlight of the book includes number of useful algorithms and provides a practical approach to paediatric liver disease. Information on hepatitis has been updated, and non-viral Hepatitis and liver abscesses have been described well. Disorders of Copper metabolism also includes Indian Childhood Cirrhosis. There are chapters on liver and intestinal transplantations, useful investigations, altered drug and protein metabolism in liver diseased which are very lucid and interesting. Neonatal liver disorders are also well covered. The academic quality is enhanced by a collection of 75 photographs. This book fills a real gap in our knowledge of liver disease and is a well needed addition of a reference material which will be very useful for postgraduate students. Paediatricians and Paediatric Hepatiologists.