Tanu Singhal

Dengue haemorrhagic fever in children in the 1996 Delhi epidemic

An epidemic of dengue haemorrhagic fever (DHF) occurred in Delhi in 1996. A total of 240 children between the age of 4 months to 13 years of either sex, admitted in one hospital, were evaluated. Two hundred and sixteen (90%) children were from Delhi. A clinical diagnosis of dengue fever (DF) was made in 25 (10%), dengue fever with unusual bleeding (DFB) in 22 (9%), DHF in 80 (33%) and dengue shock syndrome (DSS) in 113 (47%) of the children strictly according to the WHO classification. The age peaked at 8 years. There was no association between various grades of severity of illness and age-groups though girls suffered from more severe illness. No association between severity of malnutrition and severity of illness was observed. Tourniquet test was positive in 40% with DF, 18% with DFB, 62% with DHF and 64% with DSS. In DSS haematemesis was present in 55 (49%), epistaxis in 39 (35%), melaena in 27 (24%) and ecchymosis in 34 (30%) patients. Children diagnosed as DFB had haematemesis and epistaxis in 12 (55%) and 10 (45%) respectively. Intravenous fluid requirement was clearly less in DFB patients than in DHF/DSS patients. Unusual clinical features in the form of jaundice were present in 7 (6%), hepatic encephalopathy in 6 (5%) and dengue encephalopathy in 6 (5%) patients. Dengue 2 virus was isolated from 10 of the 50 patients for whom viral culture was done on C6/36 clone of Aedes albopictus cell line. Eighteen patients suffering from DSS died giving an overall case fatality of 7.5%. The mortality rate in DHF/DSS was 9.3%. It is further suggested that DFB is a distinct entity. Most patients could be classified by the WHO classification if a retrospective packed cell volume was used to assess haemoconcentration. We suggest that development of area-specific criteria for diagnosis and management is desirable.

Successful treatment of Acanthamoeba meningitis with combination oral antimicrobials

Acanthamoeba was implicated as the causative agent of chronic meningitis in three apparently immunocompetent children. Diagnosis was established by cerebrospinal fluid wet mount examination and culture. Two children improved rapidly with combination oral therapy composed of trimethoprim-sulfamethoxazole, rifampin and ketoconazole.

Dengue hemorrhagic fever: Clinical manifestations and management

Dengue virus infection may remain asymptomatic or manifest as nonspecific viral infection to life threatening dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Patients with DHF/DSS have fever, hemorrhagic manifestations along with thrombocytopenia and hemoconcentration. Thrombocytopenia and hemoconcentration are distinguishing features between DHF/DSS and dengue fever (DF). Some patients with dengue fever may have significant bleed and mild thrombocytopenia but no hemoconcentration. These patients are labelled to have dengue fever with unusual bleeds.Laboratory findings in DHF/DSS include rising hematocrit, thrombocytopenia and transformed lymphocytes on peripheral smear. There may be increased transaminases, hyponatremia, transient increase in blood urea nitrogen and creatinine. In severe disease there may be lab evidence of diseamination intravascular coagulation. X-ray film of the chest may show pleural-effusion. Ultrasonogram of abdomen may detect thickened gall bladder wall with hepatomegaly and ascitis. In some patients there may be abnormality in electrocardiogram and echocardiogram. The diagnosis of DHF/DSS is based on typical clinical findings. For confirmation of dengue virus infection viral culture can be done on blood obtained from patients during early phase of illness. In later part of illness antibodies against dengue virus can be demonstrated by various techniques.The treatment of DF is symptomatic. For control of fever nonsteroidal anti-inflammatory drugs should be avoided. DHF/DSS are managed by intravenous fluid infusion with repeated monitoring of vital parameters and packed cell volume (PCV).

Efficacy of a home-made spacer with acute exacerbation of bronchial asthma: a randomized controlled trial.

Metered dose inhaler (MDI) with spacer is the preferred method for administration of aerosolized medications in pediatric asthma. The expense of commercial spacers limits their use and indigenous alternatives have therefore been developed. Information on the clinical efficacy of home-made spacers is limited. This study was conducted to compare the efficacy of a valve-less home-made spacer with a commercial spacer in delivering salbutamolvia MDI in acute asthma. Asthmatic children aged 5–15 years who presented with an acute exacerbation to the pediatric chest clinic of a tertiary care hospital were enrolled in a single blinded randomized parallel group study. The study patients received 10 puffs of salbutamol (100(igJ puff)via MDI-home-made spacer or MDI-commercial spacer. Pre and post inhalation measurements of peak expiratory flow rate (PEFR), oxygen saturation (SaO2), respiratory rate (RR), pulse rate (PR) were made and compared. Sixty children were enrolled in the study, 31 were administered salbutamolvia the home-made spacer and 29via the commercial spacer. The median increase in PEFR was similar in both the groups (20.8% vs22.2%, p=0.4), clinical improvement being satisfactory in all patients. The valve-less home-made spacer is equally efficacious and cheaper than the commercial spacer in administering bronchodilators in acute exacerbations of asthma. Further studies on the efficacy of home-made spacer in delivery of inhaled steroids are needed.

Anemia in the newborn

In neonatal period anemia is a complex problem owing to the unique blood picture. The erythrocytic system undergoes serial adaptation to meet progressively changing demands of oxygen in th embryo, the fetus and neonate. This leads to rapid change in normal hematological change in post-birth period. Definition of anemia is difficult because as described earlier, several important factors influence normal blood in the newborn infants. The etiology of neonatal anemia can be classified into i) hemorrhage (ii) hemolysis (iii) failure of red cell production. Severe fetal hemorrhage may accompany various placental anomalies like placenta praevia, abruptio placenta and accidental incision of placenta during the caesarian section. It is reported that 10% of all infants born following placenta praevia and 4% of infants born following abruptio placenta present with severe anemia. The passage of fetal erythrocytes in maternal circulation occurs commonly during pregnancy. In 50% of pregnancies some fetal cells are passed in maternal circulation sometimes during gestation or during birth process. Treatment of a neonate with anemia due to blood depends on the degree of hypovolemia or anemia and whether the blood loss has been acute or chronic. Newborn with pale skin should be differentiated from an asphyxiated baby.

Management of severe malaria.

Prompt diagnosis and early institution of therapy is an important determinant of outcome in severe falciparum malaria. Thick smears are the gold standard for diagnosis; in situations where reliable microscopy is not available, tests based on HRP-2 antigen/parasite LDH are useful. As there is widespread resistance to chloroquine in P falciparum in India, the choice for specific antimalarial therapy is between quinine and artermisinin derivatives. Randomized controlled trials have not revealed any significant benefit of the artemisinin derivatives over quinine in quinine sensitive areas. Also, if quinine is administered in the recommended way, the side effects are no greater than artemisinins. However, as the artemisinin derivatives are easier to administer, their use in severe malaria in India is increasing. It is vital that we use these drugs in a rational and judicious manner to prevent development of drug resistance. Supportive care, early diagnosis and management of complications are as essential as antimalarial therapy. The role of exchange blood transfusion in the management of severe malaria is still controversial. It may be considered in the presence of high parasites counts (> 10%) with multiorgan dysfunction if adequate quantities of safe blood are available.

CNS germinoma in a boy with simple virilizing 21-hydroxylase deficiency and precocious puberty.

A 6 year-old boy presented with peripheral precocious puberty and was diagnosed as having simple virilizing 21-hydroxylase deficiency based on clinical features and elevated 17-hydroxyprogesterone levels on ACTH stimulation. He was managed with glucocorticoids and mineralocorticoids. Two years later he presented with features of CNS involvement in the form of seizures and raised intracranial pressure with rapid progression of puberty. Contrast enhanced CT scan of brain showed an intraventricular tumor with cerebrospinal fluid cytology suggestive of germinoma. Serum and CSF levels of human chorionic gonadotropin (hCG) and alphafetoprotein (AFP) were elevated, confirming the diagnosis of germinoma.

Trypanosomiasis in a Young Infant from Rural Gujarat, India

BackgroundHuman trypansomiasis due to infection by animal trypanosomes is rarely reported from India.Case characteristicsWe describe clinical presentation of a 2-month-old boy from a rat infested house in rural Gujarat who was diagnosed to be havinginfection with the rodent parasite Trypanosoma lewisi.ObservationThe fever and parasitemia resolved on treatment with liposomal amphotericin B, Ceftriaxone and Amikacin, and there was no recurrence of parasitemia over a 2 month follow-up.MessageThe case highlights the need for increased awareness and heightened surveillance for this rare zoonotic infection.

Delayed diagnosis of infective endocarditis in a child with a normal heart.

Sir, A 12 yold boy was admitted with high fever, and poor oral intake of 1 wk duration. Enteric fever was suspected and treatment with ceftriaxone initiated. Fever continued with rise in WBC count and CRP and fall in platelets. The blood culture was sterile and WIDAL was negative. Repeat malarial smears were negative and an abdominal ultrasound showed mild hepatosplenomegaly. Fever persisted and features of pneumonia appeared with tachypnea, hypoxemia and left sided consolidation on CXR. CT scan chest showed bilateral pneumonia with mild effusion. In view of non response to standard therapy, other unusual etiologies such as mycoplasma, scrub typhus, community acquired MRSA were considered and antibiotics upgraded to imipenem, linezolid, doxycycline and levofloxacin. The repeat blood culture grew methicillin sensitive S. aureus (MSSA). Owing to isolation of S. aureus and appearance of a soft systolic murmur on the precordium, a 2D ECHO was done which showed large pedunculated freely mobile vegetation attached to the septal leaflet of the tricuspid valve with mild dilatation of right atrium and moderate tricuspid regurgitation. This clinched the diagnosis of staphylococcal infective endocarditis with septic pulmonary embolism. Antibiotics cloxacillin and gentamycin were started as per standard recommendations. Over the next 1 wk, the fever completely resolved but the vegetation became more friable and mobile. Hence, vegetectomy and tricuspid valve repair was performed. Culture from tricuspid vegetation was sterile. IV cloxacillin was given for 4 wks. At 3 mo follow up the child is asymptomatic with a near normal ECHO. The absence of classical risk factors, the faint murmur of tricuspid regurgitation and failure to auscultate on a daily basis possibly led to delay in the diagnosis in the index case. The usual risk factors for TVE (Tricuspid Valve Endocarditis) include intravenous drug use, intracardiac catheterization, cardiac anomalies, immunodeficiency and indwelling central venous lines [1]. However TVE in children and adults with normal hearts and no risk factors have been reported with a high incidence of pulmonary embolism, sudden death, need for surgical intervention and poor surgical outcome [2-4]. The classical indications for surgical intervention in right sided endocarditis are persistent sepsis (intractable right heart failure or recurrent pulmonary embolism [5]. In the index case clinical and microbiologic cure had been achieved. However, in view of the largemobile and friable vegetation and in light of a previous case reports wherein children died suddenly due to pulmonary embolism, a decision to surgically intervene was taken. Infective endocarditis should be considered as a differential diagnosis in patients with prolonged pyrexia even if classical risk factors are absent. Meticulous and daily clinical cardiovascular evaluation is a must in all patients.

Symposium on infections old and new. Editorial.

It gives us great pleasure to present this symposium on pediatric infectious diseases. Infectious disease is a very dynamic branch with emerging/ reemerging diseases and evolving treatment strategies; thus the need to regularly update oneself. The topics included in the symposium have been chosen carefully and are an assorted mix of new pathogens, often forgotten pathogens, new diagnostic tests, and new preventive strategies. The sentinel event of the past year has been undoubtedly the H1N1 pandemic. Fortunately, the virulence of the virus and attributable morbidity andmortality have been lower thanwhat was anticipated. In this symposium, Abdel-Haq et al. discuss in detail clinical features, diagnosis, treatment, prevention and infection control issues of the novel H1N1 virus. Since the disease is mild and self limiting and the case fatality rate is very low, it is crucial that testing and antiviral treatment be limited to people with severe disease and those at risk for severe disease. The article on rickettsial infections by Atul Kulkarni from Sholapur, Maharashtra emphasizes the importance of considering rickettsia as a diagnostic possibility in febrile illnesses in endemic areas. Furthermore since diagnostic testing is not easily available and not sensitive enough, empiric therapy with tetracyclines is recommended in suspected cases. The article on “TORCH” infections by Anita Shet provides a bird’s eye view of some of the important vertically transmitted infections. It discusses the often misused TORCH screen and highlights the need to use it sparingly and interpret it rationally. In their excellent review on nosocomial infections and multidrug resistant organisms in the pediatric intensive care unit, Eric MC Grath stresses the need to adopt rigorous infection control measures and promote rational use of antibiotics to mitigate the rising menace of antimicrobial resistance. All this is important since there are no new drugs especially against gram negative organisms in the antibiotic pipeline. In their article on newer methods for diagnosis of pediatric infections, Rodrigues et al. discuss the role of automated culture methods, antigen detection methods and molecular methods all of which reduce the turnaround time for microbiologic diagnosis. Especially notable is the use of molecular methods to ascertain drug sensitivity in M. tuberculosis, a test which would cut down the lag time for diagnosis of multidrug resistant tuberculosis by 3–6 weeks. In their exhaustive review of prevention of mother to child transmission of HIV Chokechai Rongkavilit et al., discuss in detail newer regimes that cut down the risk of transmission associated with breastfeeding. These are especially relevant in resource limited settings where the benefit achieved in formula fed babies of reduced HIV transmission are offset by increased mortality due to diarrhea and malnutrition. Finally, Singh et al. in their article on preventive therapy of tuberculosis review an issue of every day importance to paediatricians. Investigation of all childhood (below age 5) contacts of adults with sputum positive tuberculosis is extremely important to reduce the risk of post primary disease and reactivation disease. At the same time, indiscriminate use of prophylaxis in latently infected older children should be avoided. Six months therapy with isoniazid alone is still the recommended regime. The editors hope that this symposium will prove useful to the readers and positively impact their practice of pediatric infectious diseases A. Kumar Department of Pediatrics and Human Development, Biomedical & Health Science IRB (BIRD) and Community Research IRB (CRIRB), Michigan State University, B-240 Life Sciences, East Lansing, MI 48824-1317, USA