Utkarsh Kohli

Profile of Childhood Poisoning at a Tertiary Care Centre in North India

ObjectivesTo determine the profile and outcome (discharge from emergency room after observation, admission or death) of pediatric patients presenting with acute poisoning to a tertiary care centre in north India.MethodsWe retrospectively reviewed the last 2 year (July, 2004 to July, 2006) hospital records of pediatric emergency room to profile all cases of pediatric poisoning during that period and noted their outcome. All cases age ≤ 12 years with definite history of poisoning were included.Results111 patients presented to the pediatric emergency during the study period. Mean age of our patients was 3.12 ± 2.04 yrs (SD). Majority of our patients (63.9%) was in the 1–3 yr age group. Males outnumbered females by a factor of two; majority of our patients resided in urban areas. Kerosene (27.9%), drugs (19.8%) and insecticides (11.7%) were the agents most frequently implicated. Almost all (96.9%) ingestions were accidental in nature. Thirty six patients (32.4%) were asymptomatic after 6 hr of observation in the emergency ward; 75 patients (67.6%) developed symptoms related to toxic ingestion. The common serious symptoms included altered sensorium, respiratory distress, seizures, ataxia, hypotension, cyanosis and burns; three patients required intubation and mechanical ventilation. Almost one third of our patients underwent gastric lavage; no patient with kerosene poisoning or any other inappropriate indication underwent the same.ConclusionThe trends for pediatric poisoning noted at our centre are not very different from those observed in hospital-based studies conducted more than a decade ago, despite the rapid socioeconomic development in our country. In sharp contrast to developing countries, where majority of poisonings are due to common non-toxic household products, most of our patients require hospitalization because of severe symptoms related to dangerous nature of toxins ingested. Consultation with the poison cell results in improved patient management.

Prevalence of MTHFR C677T Polymorphism in North Indian Mothers Having Babies with Trisomy 21 Down Syndrome.

Recent studies have evaluated possible links between polymorphisms in maternal folate metabolism genes and Down syndrome. Some of these studies show a significantly increased prevalence of the C677T polymorphism of the 5,10-methylene tetrahydrofolate reductase (NADPH) gene (MTHFR) among mothers who have had babies with Down syndrome. This study examined the prevalence of the MTHFR C677T polymorphism among 104 north Indian mothers of babies with Down syndrome and 109 control mothers. The prevalence of MTHFR C677T polymorphism observed among mothers of babies with Down syndrome was 28% compared to 35% in controls (C677T/T677T). There was no significant difference between the two groups (p = 0.294). Mean homocysteine level in mothers of children with Down syndrome was lower than the level in the controls. Our data suggests that the MTHFR C677T polymorphism is not associated with an increased risk of Down syndrome in the north Indian population. Homocysteine levels in our study were higher when compared to other studies. Methylcobolamin and folate deficiency or use of random samples for homocysteine determination could possibly account for this observation.

Thrombotic microangiopathy associated with Plasmodium vivax malaria

Sirs, While severe malaria is usually associated with infection due to Plasmodium falciparum, there have been recent reports of life-threatening manifestations in patients with P. vivax infection. Acute renal failure (ARF) is reported to occur in 1–30% patients with falciparum malaria but rarely with vivax malaria [1–3]. We recently reported a case of P. vivax malaria with acute renal failure [3]. We now describe a boy with vivax malaria complicated by anemia, thrombocytopenia, ARF secondary to thrombotic microangiopathy, and acute respiratory distress syndrome. This 11-year-old boy presented with fever, with chills for 5 days, and abdominal pain, rapid breathing, hemoptysis and anuria for 3 days. There was no preceding history of diarrhea or dysentery. Investigations showed a hemoglobin level of 8.8 g/dl, leukocyte count of 7,800/mm and platelet count of 10,000/mm. A peripheral smear showed red cells parasitized with trophozoites of P. vivax (parasite count 200/μl); there was thrombocytopenia, but there were no fragmented red cells. His blood pressure was 120/70 mmHg, and oxygen saturation was 84%. The ratio of the partial pressure of oxygen in arterial blood to the inspired oxygen fraction (PaO2/FiO2 ratio) was 150; a chest radiograph showed diffuse bilateral alveolar infiltrates, suggestive of acute respiratory distress syndrome. The blood level of urea was 239 mg/dl, creatinine 9 mg/dl, glucose 100 mg/dl, pH 7.12, bicarbonate 15 mEq/l, sodium 136 mEq/l and potassium 5 mEq/l. Urinalysis showed 3+ proteinuria and 80–100 red cells per high-power field; no casts or crystals were seen. Serum complement C3 was 46 mg/dl (normal 77–90 mg/dl); tests for antinuclear antibodies and antineutrophil cytoplasmic antibodies gave negative results. There was no evidence of disseminated intravascular coagulation. P. vivax malaria was confirmed by a specific polymerase chain reaction (PCR). Rapid detection test (Parascreen; Zephyr Biomedicals, Goa, India) and PCR gave negative findings for P. falciparum infection. Blood, urine and bronchoalveolar lavage cultures were sterile. Ultrasonography showed normal-sized kidneys with increased echotexture and ascites. The patient was treated with quinine, parenterally (10 mg/kg intravenously, 8 hourly), ceftriaxone and cloxacillin. He also received transfusions of packed red cells and platelets. Over the next 30 h, he underwent peritoneal dialysis for azotemia and metabolic acidosis. The parasite count dropped to nil, and the thrombocytopenia resolved 48 h after the initiation of intravenous (i.v.) treatment with quinine. While the respiratory distress rapidly improved, he continued to have oliguria and azotemia, requiring maintenance hemodialysis for 3 weeks. Five weeks after the onset of illness, the blood level of urea was 44 mg/dl, creatinine 1.1 mg/dl and C3 was 83 mg/dl. A kidney biopsy, during the second week of hospital stay, showed focal cortical necrosis with cortical edema. There was endothelial swelling and myo-intimal hyperplasia in the arterioles (Fig. 1). Immunofluorescence microscopy showed focal deposits of immunoglobulin (Ig)M and C3. Renal histology was considered suggestive of thrombotic microangiopathy. On follow up, 6 months later, his blood pressure was 124/78 mmHg, urinalysis showed 2+ Pediatr Nephrol (2009) 24:623–624 DOI 10.1007/s00467-008-0945-4

Invasive nosocomial aspergillosis associated with heart failure and complete heart block following recovery from dengue shock syndrome.

Objective: To report a case of invasive aspergillosis, associated with complete heart block and heart failure, in an immunocompetent child recovering from dengue shock syndrome. Design: Case report and literature review. Setting: Pediatric intensive care unit in a tertiary care center. Patient and Results: A 9-yr-old boy was admitted to our pediatric intensive care unit with dengue shock syndrome, for which he was successfully managed. During the recovery phase, the child developed recurrence of fever and signs of congestive heart failure. Thereafter, he developed complete heart block and died. Myocardial biopsy revealed myocarditis and invading fungal elements with branching septate hyphae suggestive of Aspergillus. A renal biopsy specimen also showed glomerular invasion with Aspergillus and patchy necrosis. This suggested the diagnosis of invasive aspergillosis. Conclusions: This case highlights an unusual manifestation of invasive aspergillosis in a critically ill immunocompetent child.

Myocardial cell injury is common in children with septic shock.

Objective: To determine the prevalence of myocardial cell injury in children with septic shock by estimating the levels of biochemical markers of myocardial injury, troponin I (TnI) and creatine kinase MB (CK‐MB).

Familial systemic lupus erythematosus with hypercalcemia

An 8-yr-old girl with familial systemic lupus erythematosus and several severe manifestations, including persistent thrombocytopenia, rapidly progressive renal failure and hepatic failure is described. The course was complicated by the occurrence of hypercalcemia, hypophosphatemia and elevated levels of parathormone, an association not previously reported in children.

Prevalence of cholera in pediatric patients with acute dehydrating diarrhea

ObjectiveTo estimate the prevalence of culture-confirmed cholera in patients with acute dehydrating diarrhea, at a tertiary care center in north India, during a 6-month period from March to August, 2006.MethodsWe studied 145 children, who presented to the pediatric emergency services of a tertiary care teaching hospital in north India with acute dehydrating diarrhea. Each patient had his/her stool sample collected for Vibrio cholerae culture and hanging drop preparation for darting motility. The stool specimen for hanging drop analysis was immediately transported to the emergency laboratory, where a trained technician prepared the slides and examined them for darting motility characteristic of Vibrio cholerae.ResultsV. cholerae was isolated in 36 (24.8%) patients. Forty-nine (33.7%) patients had a positive hanging drop examination. Hanging drop examination had a sensitivity and specificity of 85.8% and 81.7%, respectively. Severe dehydration (OR 4.3; P<0.01) and hanging drop positivity (OR 12.42; P<0.001) were associated with higher odds of cholera after adjustment for other risk factors.ConclusionCholera is an important cause of acute watery diarrhea in pediatric patients in urban north India and should be ruled out in all children presenting with acute dehydrating diarrhea, particularly those with severe dehydration. Hanging drop test is useful for diagnosis in the emergency setting.

Idiopathic neonatal aortic thrombosis.

We report a term neonate with severe aortic thrombosis involving the aorto-iliac segment and leading to renal failure. This patient did not have any predisposing risk factors. The authors have also reviewed the literature on neonatal aortic thrombosis and discuss the need for evolving evidence based consensus guidelines for management of this catastrophe.