Kirtisudha Mishra

Liver abscess in children: an overview

BackgroundLiver abscess (LA) in the pediatric population has become relatively uncommon in developed countries but it continues to have a high incidence among children in developing countries. This article aims to review the trends in all aspects of LA in children, both temporally and geographically.Data sourcesThe PubMed and Google Scholar database were searched with the keywords “liver abscess”, “children”, “predisposing causes”, “clinical signs and symptoms”, “treatment” from 1975 to 2009 and all kinds of retrospective and prospective studies, reviews, case series were included.ResultsPyogenic LA constitutes the majority of cases, followed by amebic and fungal LA. Staphylococcus aureus is the most common pathogen worldwide. Ultrasonography (US) and computed tomography (CT) are widely used as diagnostic tools. There are varying opinions regarding the treatment of LA in children. The general trend is towards less invasive modalities of treatment like percutaneous drainage along with antimicrobial drug therapy. However, in selected patients, open surgical drainage still plays an important role. The mortality rate for pyogenic LA has shown a decline from about 40% before the 1980s to less than 15% in the recent years. At the same time, the mortality rate of amebic LA cases reported to be around 11%–14% before 1984 has reduced to less than 1% at present.ConclusionsEtiological pattern of LA in children has remained the same over the years, and in most regions, it is associated with Staphylococcus aureus and amebic LA is quite uncommon. US or CT scan is the most frequently employed diagnostic modality for LA, and follow-up is usually performed by serial US scans. Antimicrobial therapy along with, if necessary, drainage of the abscess by either percutaneous or open surgical route remains the treatment of choice.

Tetanus – still a scourge in the 21st century: a paediatric hospital-based study in India

Tetanus remains endemic in India. A retrospective hospital-based study was conducted to review the profile of all children admitted with diagnosis of tetanus between January 2009 and December 2010. A total of 140 cases of tetanus were admitted; 45 cases of neonatal tetanus (NT) and 77 cases of post-neonatal tetanus (PNT) were studied. Age of presentation of NT was 9.4 ± 1.2 days. Home-delivered children accounted for 86.7% of cases, with 77.8% being attended by untrained birth attendants. Unimmunized mothers accounted for 93.4%. In PNT, otogenic route of infection and trauma were present in 58.4% and 23.3% of cases, respectively. The rate of hospital admission of tetanus remains high. Unlike previously published reports, otogenic route is the most common mode of PNT infection in this study. Improving immunization, increasing deliveries by skilled birth attendants and prompt treatment of suppurative otitis media are the main areas in which public health initiatives need to be focused.

Fever with rash in a child in India

Fever with rash is common among children and are seen by both dermatologists and pediatricians. Most of them are benign viral exanthems without much clinical significance. This article gives an overview of the infectious and noninfectious causes of fever with rash in children and how to diagnose them, with special emphasis on the Indian scenario as well. It also differentiates them from fever with rash caused by drugs. This review emphasizes that although benign in many cases, it is necessary to identify the signs of serious illnesses to prevent mortality or sequelae.

The impact of pediatric nephrotic syndrome on parents' health-related quality of life and family functioning: An assessment made by the PedsQL 4.0 family impact module

The multi-dimensional impact on the quality of life (QOL) of families of children with the nephrotic syndrome (NS) has not been studied sufficiently in the literature. We aimed to study this aspect and the predictors of poor QOL among Indian families having children with NS. A cross-sectional study was conducted to compare the parents of children with chronic NS on treatment for at least one year with parents of a matched healthy control group. The parents of both groups were asked to complete the standard self-administered multi-dimensional questionnaire of Pediatric Quality of Life Inventory 4 (PedsQL TM ) Family Impact Module (FIM). Descriptive and analytical statistics were performed to compare scores between the two groups. Possible predictors of poor outcome in each of the summary scales among the cases were assessed by both univariate and multivariate analysis. The parents of 61 cases and 72 controls completed the PedsQL TM FIM questionnaire. The scores in each of the categories, namely FIM Total Scale Score, Parent HRQOL Summary Score, Family Functioning Summary Score and eight individual domains, were found to be significantly higher among controls. Female gender of the affected child was an independent risk factor for poor Family Functioning Summary Score. Also, presence of serious complications during the course of the disease independently predicted poor Total FIM and Parent HRQOL Summary Scores. Even a relatively benign and potentially curable chronic disorder in children, like the NS, can disturb the QOL of parents in multiple domains of functioning.

Neonaticide in India and the stigma of female gender: report of two cases

Abstract Neonaticide is known to occur across the globe in both developed and developing countries, but has rarely been reported from India. Two similar cases of female neonaticide are presented which were committed by their mothers while in the maternity ward. The social issues and maternal provocation highlighted in this report are different from those reported in world reviews of neonaticide.

Griscelli syndrome type 2: a novel mutation in RAB27A gene with different clinical features in 2 siblings - a diagnostic conundrum

Griscelli syndrome type 2 (GS2) is a rare autosomal recessive disease caused by mutations in the RAB27A gene. It is characterized by cutaneous hypopigmentation, immunodeficiency, and hemophagocytic lymphohistiocytosis. We describe 2 brothers who had GS2 with clinically diverse manifestations. The elder brother presented with a purely neurological picture, whereas the younger one presented with fever, pancytopenia, hepatosplenomegaly, and erythema nodosum. Considering that cutaneous hypopigmentation was a common feature between the brothers, genetic analysis for Griscelli syndrome was performed. As the elder sibling had died, mutation analysis was only performed on the younger sibling, which revealed a novel homozygous mutation in the RAB27A gene on chromosome 15 showing a single-base substitution (c.136T>A p.F46I). Both parents were heterozygous for the same mutation. This confirmed the diagnosis of GS2 in the accelerated phase in both siblings. The atypical features of GS2 in these cases are a novel mutation, isolated neurological involvement in one sibling, association with erythema nodosum, and 2 distinct clinical presentations in siblings with the same genetic mutation.

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.

Hemothorax and hematocele: unusual presentations of vitamin K deficiency bleeding disorder.

Sir, Hemothorax and hematocele are rare manifestations of Vitamin K deficiency bleeding disorder in newborns; hematocele being hitherto unreported in English literature. An exclusively breastfed, 1-mo-old male infant presented with sudden onset respiratory distress associated with swelling of left scrotum. Examination revealed that the infant was in shock with severe pallor, tachycardia, tachypnea, reduced air entry and vocal resonance over right hemithorax with dull percussion note on the same side. Heart sounds were normal with no organomegaly. The left scrotal sac was enlarged with a mild bluish hue (Fig. 1); the swelling being irreducible. Investigations showed a negative septic screen with hemoglobin 5 g/dl and platelets 200,000/cumm. Chest radiograph showed homogenous opacity involving right hemithorax with mediastinal shift to the left. Needle thoracentesis revealed a bloody tap and 100 ml of blood was drained by a water-seal drainage tube. Ultrasonography of the scrotum confirmed the presence of hematocele in left testis. Prothrombin Time (PT) and activated Partial Thromboplastin time (aPTT) were markedly deranged. Fibrinogen levels were normal. A review of history revealed no history of maternal intake of any drugs antenatally and no bleeding diathesis in the family. The patient had not received vitamin K at birth. He was managed with oxygen, intravenous fluids, red cell transfusion and intravenous vitamin K. Symptoms resolved within hours. A repeat PT and aPTT after 8 h showed normalization of values. Considering the clinical picture of hemothorax and hematocele in an exclusively breast fed baby with normal septic screen, in the context of deranged aPTT and PT which normalized after administration of vitamin K, a diagnosis of Late onset Vitamin K Deficiency Bleeding (VKDB) of the newborn was made. VKDB is characterized by hemorrhagic manifestations with INR≥4 with normal platelet and fibrinogen level. Diagnosis is confirmed by rapid (within 2 h) normalization of coagulation V. Aggarwal :K. Mishra : B. Rath : S. Chaudhary : P. Kumar Department of Pediatrics, Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, New Delhi, India

Clinico-socio-demographic profile and predictors of poor outcome in children with liver abscess: a hospital-based study in northern India

Summary Liver abscess (LA) is a common health problem among children in tropical countries. We conducted a prospective, observational study at a tertiary-care medical college in order to examine the clinico-socio-demographic profile and assess a possible association between certain predictors of a poor outcome in children admitted with LA. Of a total of 53 children, only 24.4% were malnourished. Staphylococcus aureus was the most common organism observed. Amoebic LA was noted in 7.5%. Right-sided pleural effusion was the most common complication recorded (20.7%). The most successful treatment modality was therapeutic percutaneous aspiration with antimicrobials (90.5% success). An elevated alkaline phosphatase and open surgery were associated with a poor outcome (P = 0.04 in each case). The rate of hospital admissions of children with LA remains high and most are of pyogenic origin. Of the different treatment modalities, therapeutic aspiration along with antimicrobials achieved the best results. Raised alkaline phosphatase and open surgery were predictors of a poor outcome.

Extensive cutaneous necrosis in a 12-year-old girl: an unusual complication of secondary cold agglutinin syndrome.

Cold agglutinin syndrome (CAS) secondary to infection is rare, usually presenting with anaemia and minor skin changes. A 12-year-old girl with secondary CAS associated with extensive cutaneous necrosis is reported. She presented with fever and multiple necrotic lesions over both cheeks, the tip of nose, ear margins, hands and buttocks, along with pallor, hepatospenomegaly, acrocyanosis and gangrene of the fifth digit of the right hand. She had anaemia, unconjugated hyperbilirubinaemia and a positive direct antiglobulin test owing to cold agglutinins of the IgM type with anti-i specificity and titres of 1:512 at 4°C. Results of bone marrow examination were normal and cryoglobulins were negative. Cold antibodies released even during a brief, self-limited febrile illness can cause widespread cutaneous gangrene. We believe this is the first report in the paediatric age group.