Jhuma Sankar

Acute phenytoin intoxication in a 4-year-old mimicking viral meningoencephalitis

We report here the case of a 4-year-old female preschooler who presented to the emergency department with generalised tonic-clonic convulsions and history of vomiting, irritability and dysarthria of short duration. On examination she was found to be responsive only to painful stimulus, had terminal neck stiffness and bilateral extensor plantars. In view of her clinical presentation, an initial diagnosis of viral meningoencephalitis was made in the emergency room and the child treated accordingly. On subsequent transfer to the intensive care unit (ICU), the parents revealed additional history of an elder sibling taking phenytoin for seizures. Therefore, a suspicion of acute phenytoin toxicity was made and phenytoin levels sent for confirmation. Her serum phenytoin level was 80 μgm/mL (normal: 10–20). The child was managed conservatively and discharged after 5 days of hospitalisation. We chose to report this case to highlight the unusual presentation of this rare intoxication.

Near fatal iron intoxication managed conservatively

We report here the case of an infant who presented to the emergency department after unintentional ingestion of almost 130 mg/kg of elemental iron. The infant had evidence of serious toxicity in the form of hypotension, metabolic acidosis and excessive irritability. Her serum iron levels were 360 µg/dl, which was well above the normal range for her age. Despite such high serum levels, the infant made an uneventful recovery with medical management alone and did not require exchange transfusion. We chose to report this case to highlight her uneventful recovery with conservative therapy alone.

Death in an Adolescent Girl with Methemoglobinemia and Malaria

A 16-year-old girl working in a paint and dye-casting factory of aniline dyes presented to the emergency with cyanosis, fever and altered sensorium. She had been diagnosed as a case of malaria and treated with chloroquine elsewhere. At admission, her saturation was 79%, which did not improve despite mechanical ventilation with 100% oxygen. Her PaO2 levels, however, remained high-140 mmHg. The observed difference in PaO2 and SpO2 prompted us to investigate her for methemoglobinemia, which was confirmatory. Despite symptomatic and specific treatment, she succumbed to her illness possibly due to late presentation and prolonged cerebral anoxia. Though the girls raised methemoglobin levels may be explained by her history of exposure to aniline dyes, the temporal association of her methemoglobinemia related symptoms with chloroquine administration cannot be ignored. We believe that this rare complication of chloroquine therapy should be kept in mind before prescribing it to any child with malaria.

O-117 Comparison Of Superior Vena Caval Oxygen Saturation (scvo2) And Femoral Venous Oxygen Saturation (sfvo2) In Children With Septic Shock

Background and aim Femoral vein catheterization is very commonly performed while managing children with septic shock. However, the agreement between superior venal caval (ScvO2) and femoral venous oxygen saturation (SfvO2) has not been reported in children till date. Our aim was to evaluate the agreement between ScvO2 and SfvO2 values. Methods Children with septic shock in whom femoral vein catheter was inserted before shifting to the ICU were eligible. Paired blood samples from subclavian/Internal jugular vein and femoral catheters were drawn simultaneously after initial fluid resuscitation in these children and analysed. Agreement was assessed by Bland and Altman (BA) analysis. The study was approved by IRB. Results A total of 32 patients were enrolled. The mean ScvO2 and SfvO2 were 72.3% and 76% respectively (p < 0.001). BA analysis showed relatively poor agreement between ScvO2 and SfvO2 with mean bias of 3.6 and 95% limits of agreement of -1.95 to 9.25 (r=-0.28, p = 0.14) (Figure 1). In general, SfvO2 values were higher than ScvO2 values with 14 of the 32 children having values ≥5%. The SfvO2 had poor sensitivity (45.5%) but 100% specificity for detecting low saturations. The PPV was 100% and the NPV was 77.8%. As SfvO2 values were generally higher than ScvO2 values, we tried a higher cut-off for SfvO2 to detect low mixed venous saturations. With a SfvO2 cut off of 72%, the sensitivity and specificity were both 100%. Conclusions A higher cut off of 72% for SfvO2 may be used in place of ScvO2 in situations where ScvO2 estimation has failed or is impractical. Our study findings however, need further validation. Abstract O-117 Figure 1 Agreement between ScvO2 and SfvO2 values at 1 h

PO-0042 Prevalence And Outcome Of Diastolic Dysfunction In Children With Fluid Refractory Septic Shock – A Prospective Observational Study

Background and aims Severe sepsis is often characterised by disturbances in cardiac function, popularly known as sepsis induced myocardial dysfunction (SIMD). SIMD may be systolic (SD), diastolic (DD) or global. Diastolic dysfunction has been infrequently reported in only a few studies on adult patients till date. Detecting DD early in the course has important therapeutic and prognostic implications in the management of septic shock. Our aim was therefore, to determine the prevalence and outcome of DD in children with septic shock and to generate evidence for possible early clinical predictors of DD in such patients. Methods Consecutive children ≤17 years of age with fluid refractory septic shock and not on mechanical ventilation admitted to our ICU from June 2011 to August 2012 were included. DD was defined as an abnormal ‘E’, mitral annulus velocity on tissue Doppler imaging at admission. Results A total of 56 children were included. The prevalence of DD was 41.1% (95% CI: 27.8 to 54.4) and the mortality rate was 43% in those with DD. On univariable analysis of possible early predictors of DD, we observed that children with DD tended to have higher mean CVP (13 vs. 6; p < 0.0001) and greater positivity for cTnT (70% vs. 36%, p = 0.01) as compared to others. On multivariable analysis, only an increased CVP remained significant (adjOR: 1.6; 95% CI: 1.12, 2.14, p = 0.008). Conclusion Diastolic dysfunction is common in children with fluid refractory septic shock and immediate outcome may be poorer in such patients. Increased CVP after initial fluid resuscitation may be an early indicator of DD and warrant urgent bedside echocardiography.

Peanut aspiration leading to pneumorrhachis in a pre-schooler

Pneumothorax, pneumomediastinum (PM) and subcutaneous emphysema (SE) due to foreign body aspiration (FBA) are rarely reported in clinical practice.1 ,2 We present here a 3-year-old boy who posed a diagnostic dilemma to us at presentation with SE following a subacute history of respiratory tract infection of 2 weeks duration. The child had been treated with oral antibiotics for 7 days prior to presentation, but the symptoms did not resolve and seemed to …

Isolated immunoglobulin A (IgA) deficiency presenting with cytomegalo virus pneumonia

A 5-month-old infant with an uneventful perinatal period was presented with lower respiratory tract symptoms and abnormal X-ray findings of 1-month duration. At admission, the baby was in respiratory distress requiring oxygen therapy and supportive care. Despite optimal supportive care and antibiotic therapy, he continued to be symptomatic necessitating further investigations for nonresolving pneumonia. His bronchoalveolar lavage and urine were positive for cytomegalovirus (CMV) and workup for immunodeficiency showed undetectable immunoglobulin A(IgA) levels. Rest of the workup was inconclusive. We investigated the mother for a carrier status, but the workup was negative for CMV and/or other intrauterine infections. In view of severe CMV-associated lung disease, the baby was started on ganciclovir therapy for 6 weeks on which he recovered completely. Although the associated isolated IgA deficiency may be an incidental finding in this case, it is indeed intriguing and requires further research.