Pankaj C. Vaidya

Pulmonary presentation of Kawasaki disease: an unusual occurrence

Dear Editor, Kawasaki disease (KD) is the most common childhood vasculitis with potential to cause severe complications, significant morbidity and even mortality. It is now one of the commonest causes of acquired heart disease in many developed countries and is increasingly being reported even from developing countries. KD is associated with multiple systemic manifestations involving cardiac, pulmonary, musculoskeletal, gastrointestinal and genitourinary tracts. While the etiology of KD is still unclear, many of its epidemiological and clinical manifestations suggest an infective origin and intravenous immunoglobulin (IVIg) still remains the cornerstone of treatment. Atypical and incomplete forms of KD are now being increasingly recognized. We present here an uncommon pulmonary presentation of KD.

Pulmonary presentation of Kawasaki disease—A diagnostic challenge

Kawasaki disease (KD) is a multisystemic vasculitis with predominant mucocutaneous manifestations. Pulmonary involvement in KD is distinctly uncommon and is not commonly recognized. We describe our experience of managing children with KD wherein the initial presentation was predominantly pulmonary.

Glucose intolerance in children with cystic fibrosis: a developing country's perspective.

Abstract Background Cystic fibrosis-related diabetes (CFRD) is a common comorbidity reported in patients with cystic fibrosis (CF). There is a dearth of data on glucose intolerance or CFRD in children with CF from developing countries. So, we planned to study the prevalence of abnormal glucose tolerance (AGT) in children with CF and its relation with the duration and severity of CF. Methods We performed an oral glucose tolerance test (OGTT) on children (2–18 years old) having CF for at least 6 months. Two-hour plasma glucose levels on OGTT were correlated with various disease-related factors. Results Out of the 25 children enrolled, there were 18 boys and seven girls. The mean age and duration of CF were 7.9±4.3 and 3.16±2.5 years, respectively. AGT was observed in 16 (64%) children with CF including three (12%) children with CFRD. Children with a duration of CF of 3 years had significantly higher prevalence (81.8%) of AGT when compared with duration ≤3 years (p-value<0.05). Twelve out of 17 (70.6%) children were colonized with Pseudomonas and 12 out of 15 (80%) children >6 years of age had AGT. There was a positive correlation of 2-h glucose value on OGTT with duration of CF and number of hospitalizations with acute pulmonary exacerbations. Conclusions The majority of children having CF for >3 years and/or age >6 years developed AGT. In our clinical setting, an annual screening with OGTT to detect AGT may be required at an early age and duration of CF.

Subclavian Artery Pseudoaneurysm Following Lung Abscess in a Child

To the Editor: Subclavian artery aneurysms (SAA) are rare in children. The few cases reported are associated with BlalockTaussig shunt placement, aberrant subclavian artery, thoracic outlet syndrome or trauma [1–3]. We report a child with mycotic (infective) SAA associated with lung abscess. A 7-y-old girl was treated in an outside hospital as a case of right foot abscess and concurrent left lung abscess. The abscess was drained, pus culture was sterile and blood culture grew Escherichia coli. Into four weeks of antibiotic therapy, she developed sudden-onset swelling over left supraclavicular area, with increase in size following fine needle aspiration. Imaging revealed pseudo-aneurysm arising from proximal part of left subclavian artery (SCA), for which she was referred to our hospital. There was no prior central venous catheter (CVC) placement or trauma. At admission, child was noted to have a pulsatile swelling in left supraclavicular region, measuring 3 × 3 cm and she required oxygen support. Examination revealed tachypnea, flattening of left hemithorax and amphoreic breath sounds in left hemithorax. CT angiography revealed aneurysm in proximal 1/3rd of left SCA (Fig. 1). The cause considered was contiguous spread from lung abscess, because of the close proximity. The preferred management for mycotic aneurysms is surgery [4], especially when they are wide necked like in our index child. However, because of financial constraints endovascular embolotherapy with balloon and thrombin injection was done. Post-embolization check run showed complete obliteration of aneurysm, but repeat ultrasonography 12 h later revealed recanalization. So, primary closure of rent using median sternotomy and supra clavicular incisions was done. Post-operatively she received aspirin for 3 mo. At a follow-up of 24 mo, she remains well. This case represents an unusual complication that can arise from apical lung abscess. A pseudo aneurysm occurs due to a breach in tunica media and externa due to iatrogenic trauma from arterial puncture, contiguous infection or penetrating injury [5]. This results in a communicating hematoma, whose wall is formed by extravascular fibrous tissue. The mycotic pseudo-aneurysms have high chance of spontaneous rupture or dissemination of infection. Evidence favours surgery [4], but endovascular embolotherapy [6] is an alternative therapy with fewer complication rates, but higher failure rates.

Salmonella typhimurium Meningitis in an Infant Presenting with Recurrent Meningitis

Salmonellatyphimurium meningitis in infancy is very uncommon and does not respond to usual duration of empirical antibiotic therapy. A 5-mo-old infant presented with clinical picture of acute pyogenic meningitis and was treated with empirical antibiotic therapy for 14 d. But, 2 wk after the discharge, the child presented again with similar complaints. CSF culture had grown Salmonella typhimurium following which dual antibiotic therapy was given for 6 wk.

Intrapleural streptokinase is effective and safe for children with multi-loculated empyema regardless of the time from disease onset

This study compared the efficacy of administering intrapleural streptokinase to children with multi‐loculated empyema within 14 days or at any time after disease onset.

Drug reaction with eosinophilia and systemic symptoms in a child on multiple antiepileptics

Goswami JN, Vaidya PC, Saini AG, De D, Radotra BD, Singhi PD. Drug reaction with eosinophilia and systemic symptoms in a child on multiple antiepileptics. Turk J Pediatr 2017; 59: 197-199. Drug reaction with eosinophilia and systemic symptoms (DRESS) is an adverse drug-reaction that may mimic systemic illnesses and have a fulminant presentation. We describe an 8-year-old girl with epilepsy and exposure to multiple anti-epileptics who presented with fever, extensive maculopapular rash, cervical lymphadenopathy, hepatomegaly, progressive anemia and transaminitis. Infections, autoimmune disorders and hematological or reticuloendothelial malignancies were excluded. Based on the proposed diagnostic criteria, a diagnosis of DRESS was concluded. Her skin biopsy showed atypical findings consistent with erythema multiforme. Suspected anti-epileptic drugs were discontinued. She was administered pulse methyl-prednisolone therapy and broad-spectrum antibiotics along with adequate supportive management. Unfortunately, the child succumbed to nosocomial sepsis. Our case highlights the importance of early suspicion for diagnosis of pediatric DRESS, avoidance of polytherapy and institution of early immunomodulation to improve the outcomes in children in this condition.

Systemic cryptococcosis in an immune-competent child

Crytococcus neoformans is an encapsulated yeast that frequently affects immune-compromised patients, although increasingly being detected in the immune-competent host as well. We report a case of disseminated cryptococcosis in a young child in whom no immune deficiency was yet identified. A 4-year-old child presented with high-grade fever, intermittent abdominal pain and generalized skin eruptions for the past two months. He had pallor, firm lymphadenopathy, skin lesions with scarring and firm hepatosplenomegaly. Magnetic resonance imaging of brain and bone-marrow aspiration were normal. Fine-needle-aspiration-cytology of cervical lymph nodes demonstrated Cryptococcus. Serum latex-agglutination test showed a positive titer (1:256). Cryptococcus culture was sterile. The patient received intravenous liposomal amphotericin-B and oral flucytosine for 8 weeks followed by oral fluconazole. Disseminated cryptococcosis with involvement of reticuloendothelial and dermatological systems is rare. Early diagnosis and timely management of associated complications would be life saving.

Multiple brain abscesses due to Enterobacter cloacae in an immune-competent child

Brain abscesses due to Enterobacteriaceae in immune-competent children are rare, and those due to Enterobacter cloacae are even rarer. We report an interesting case of community-acquired E. cloacae neuroinfection resulting in multiple brain abscesses in a young child with no underlying risk-factors. A 10 year-old-boy presented with low-grade fever, headache, neck pain and progressive deterioration of sensorium. On examination, he was conscious but drowsy with photophobia, normal fundii, meningeal signs, mild hypertonia, brisk muscle stretch reflexes and extensor plantar responses. Magnetic resonance imaging of brain showed bilateral, multiple pyogenic abscesses. Culture of the abscess material aspirated at the time of surgical drainage showed growth of E. cloacae. He received intravenous imipenem for 18 weeks guided by clinical and radiological response. A pragmatic approach combining early surgical drainage, targeted antimicrobial therapy and patient-tailored duration based on the clinico-radiological response is needed in such difficult cases.

Indian Pediatric Postgraduate’s Perspective on Future Career Intentions: Correspondence

To the Editor: We read with interest the article by Sneha et al [1]. The authors have studied a much discussed topic in the current era of up-coming super/sub-specialties in Pediatrics. Though the topic chosen was relevant and the study design was correctly selected, the main objective to Bdetermine the factors that influence pediatric residents to pursue a subspecialty career and establish their choice of future workplace^ was not completely satisfied by the questionnaire used in the study. We wish to highlight a few points related to the article: The study population chosen was of pediatric postgraduates who attended a short course at the author’s medical college. Surveying conference attendees limits the generalizability of the results of the study [2]. It would have been more representative if pediatric postgraduates from different colleges of the country would have been contacted from their places in large numbers. This sampling element is not sufficient to be taken as a representative of the desired sampling frame. The main objective of the study was to identify the factors that influence the choice of sub-specialty. However, the questionnaire fails to focus on the main objective as mostly closed ended questions were used. There could be many more reasons other than those mentioned in the questionnaire options, like availability of the course per say in their locality etc. The subjects were not given the option of any response other than those in the questionnaire. During questionnaire testing, Bother^ response option/s can help to identify new issues or elaborate on closed response formats [3]. Similarly, there was no option to choose if more than one factor played a role in the decision making and hence the subjects would have been either forced to choose any one option or not to respond at all to the question, which in turn would have decreased the response rate. In-fact the validity of a questionnaire based study is reduced when the subjects are unable to provide accurate information. Adequate exposure to the sub-specialty and the availability of role model teachers are important factors which influence the decision making; however the current study questionnaire does not seem to have collected adequate information about the same and therefore such conclusions which have been made cannot be derived at from the present study. Regarding the choice of the sub-specialties, the current study has derived data about the most and the least chosen specialties. The authors have also concluded that there is a huge shortage of doctors in certain specialties like developmental pediatrics, hepatology etc. The reason for shortage of doctors in these specialties is primarily limited number of seats in the specialties rather than preference by the students. If the number of seats available are limited in certain specialties, head to head comparison between the specialties cannot be made. To conclude that there are fewer takers in certain specialties compared to others, there must be equal opportunities for the students to pursue. The article mentions that interest in the subject is the most common reason for choosing pediatrics as a career and compares it with the results of the study by Freed et al. [4]. On the contrary, the reference study discusses the factors influencing the workplace selection post-training, which is not equivalent to selection of pediatrics as a course of choice.