V. K. Anand

Hepatic dysfunction in childhood dengue infection.

Hepatic functions of 61 children, diagnosed to have dengue infection (DI), aged 2 months to 12 years comprising 37 cases of dengue fever (DF), 16 with dengue hemorrhagic fever (DHF), and eight with dengue shock syndrome (DSS) were prospectively studied during the acute attack. Hepatomegaly (74 per cent), epistaxis (26 per cent), jaundice (25 per cent), and petechial rashes (18 per cent) were the common clinical manifestations of DI. On admission, levels of serum aspartate transaminase (AST), serum alanine transaminase (ALT) and serum alkaline phosphatase (AP) were raised in 80-87 per cent of children with hepatomegaly (group I) and 81 per cent of cases without hepatomegaly (group II). During the second week of hospitalization the proportion of cases with raised levels of AST, ALT, AP and serum bilirubin increased and the mean levels were significantly higher (p < 0.05) in both the groups. These levels gradually declined over the next 2-3 weeks. All the cases with DSS and DHF had raised AST, ALT and AP levels and the mean levels of these enzymes were significantly higher (p < 0.05) as compared to DF. Our results suggest a transient derangement of liver functions in childhood DI, more so in DSS and DHF, with or without hepatomegaly.

Catch-up growth in children with late-diagnosed coeliac disease

Anthropometric parameters and catch-up growth were prospectively evaluated in fifty late-diagnosed children with coeliac disease aged 2.25-10 years after 1-4 years of adhering to a strict gluten-free diet (GFD). The anthropometric parameters were expressed as Z scores relative to National Centre for Health Statistics standards using Epi Info 2000 (weight-for-height Z score (WHZ) and height-for-age Z score (HAZ)). Catch-up growth was evaluated by repeated measures. ANOVA, overall significance by an F test and pair-wise comparisons for estimated marginal means using the least significant difference. At the time of enrolment, no significant difference was observed in WHZ and HAZ between children diagnosed before (group 1) or after (group 2) 4 years of age. On follow-up, HAZ was significantly higher in group 1 after the first and third years of the GFD (P=0.04 and 0.02, respectively), with a non-significant increase after completing 4 years of the GFD (P=0.22). Feeding the GFD resulted in an overall significant (F=3.99, P=0.011) increase in HAZ up to 4 years of follow-up. However, the catch-up in height was incomplete, with stunting in sixteen (55.4%) of twenty-nine children after 3 years and in seven (46.6%) of fifteen children after 4 years on the GFD. Pair-wise comparisons demonstrated a linear catch-up growth during the initial follow-up on GFD. Treatment with the GFD did not result in an overall significant increase in WHZ up to 4 years of follow-up (F=1.01, P=0.42). Our results suggest that, in children with late-diagnosed coeliac disease, treatment with a GFD leads to a normalisation of body mass and a significant but incomplete recovery in HAZ during 4 years of follow-up.

Cladosporium bantianum meningitis in a neonate

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis ofC. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.

Lower Respiratory Tract Infection in Hospitalized Children due to Respiratory Syncytial (RS) Virus During a Suspected Epidemic Period of RS Virus in Delhi

A study of 131 children below 5 years of age seeking hospitalization due to lower respiratory tract infections (LRTI), comprising 56 cases of bronchiolitis, 61 cases of bronchopneumonia, and 14 cases of other lower respiratory tract diseases showed significant occurrence of bronchiolitis in younger age groups (chi 2 = 79.21; P less than 0.001). Employing two rapid techniques, viz. immunofluorescent antibody technique (IFAT) and enzyme immunoassay (EIA) along with tissue culture, Respiratory Syncytial (RS) virus could be detected in higher percentage of bronchiolitis cases (54 per cent by both culture and IFAT, 70 per cent by EIA) compared to bronchopneumonia (36 per cent by both culture and IFAT, 49 per cent by EIA) and other LRTI cases (14 per cent each by culture, IFAT and EIA). The detection rate of RS virus was higher in the age group 0-6 months compared to the remaining age groups combined (7-60 months) in bronchiolitis cases irrespective of the technique employed while no such difference could be noted in bronchopneumonia. Eighteen (90 per cent) out of 20 specimens positive for RS virus by EIA, but negative by culture were found to be true positives as revealed by blocking test. In comparison to culture, sensitivities of IFAT, EIA, and EIA (by blocking test) were found to be 89, 94, and 94 per cent, respectively, while specificities of these techniques were found to be 92, 74, and 76 per cent, respectively. Higher detection rate of RS virus in the present study compared to earlier ones from India is attributed to application of EIA as well as selection of LRTI cases during a period of suspected epidemic of RS virus.

Disseminated infection with Cryptococcus neoformans var neoformans in an 8 years immunocompetent girl.

Disseminated cryptococcosis is a rare and often fatal disease in children. The majority of cases usually occur in individuals with defective cell-mediated immunity, most commonly due to HIV infection. The authors here in report an 8-year-old girl from Nepal who presented with fever, cough, headache, lymphadenopathy, hepatosplenomegaly and cutaneous lesions. Lymph node biopsy revealed multiple granulomas composed of histiocytes and epitheliold cells along with numerous yeast forms of cryptococcus. Cultures of CSF, sputum and urine yielded cryptococcus neoformans. Surprisingly,the immune function in terms of T-cell number, CD4 : CD8 ratio, serum immunoglobulins and HIV serology was normal. After the diagnosis of disseminated cryptococcosis was established, the patient was treated with 5-fluorocytosine (100 mg/kg/day) for initial two weeks and amphotericin B (1 mg/kg/day) for 13 weeks. Patient responded well to the treatment with disappearance of presenting symptoms, cutaneous lesions, and lymphadenopathy, though she still had hepatosplenomegaly, which also decreased. Unfortunately, she developed loss of vision in 10th week of therapy. The patient was discharged on oral fluconazole (6 mg/kg/day) and no recurrence was found during the follow-up period of more than 9 months. This is the first case of disseminated cryptococcosis with no detectable immune deficit, from India.

Goldenhar syndrome with rare associations

Goldenhar syndrome is a malformation complex involving the structures arising from first and second branchial arches, the first pharyngeal pouch, first branchial cleft and primordia of the temporal bone. Though the syndrome itself is not very rare, the presence of polydactyly and hydrocephalus, which are rare associations, prompted us to report this case.

ARI Control Programme: Results in Hospitalized Children

One hundred cases of pneumonia with chest indrawing were treated according to the treatment protocol of the ARI control programme. The majority of children were > 2 months old (85 per cent) with male predominance (61 per cent). All cases with severe pneumonia survived. A mortality rate of 7.7 per cent was seen in cases of very severe pneumonia. Three children in the severe pneumonia group deteriorated on benzyl penicillin to very severe pneumonia but subsequently improved on chloramphenicol. Six patients were treated as cases of Staphylococcal pneumonia and one of them died. Thirteen children (21.3 per cent) in the severe pneumonia group required oxygen for breathing rates > 70 per minute. Seventy-four per cent in the very severe pneumonia group required administration of IV fluids. Blood counts did not prove to be of help in differentiating the children at risk of dying. There was no significant difference in roentgenographic findings in the two groups. Congestive cardiac failure was the most common complication, seen in 33.3 per cent of cases of the very severe pneumonia group. The duration of stay was significantly less in cases of severe pneumonia (4.21 +/- 1.59 days) as compared to very severe pneumonia (9.35 +/- 2.39 days). The data from this study suggest that the treatment protocol for the ARI control programme for hospitalized children is reasonably effective and can be implemented in small hospitals.

Henoch schonlein purpura with rheumatic carditis

Henoch Schonlein Purpura with acute rheumatic carditis is a rare entity and only few cases have been reported. An 8 year-old-girl presented with abdominal pain, arthralgia and rashes and was diagnosed as a case of Henoch Schonlein Purpura. She was managed conservatively and discharged. She was readmitted after 1 week with abdominal pain, fever and cough. She developed tachycardia with gallop rhythm on the third day of admission and pansystolic murmur of mitral regurgitation. Echocardiography showed features of myopericarditis, mild pericardial effusion and mitral regurgitation. She was diagnosed and managed as a case of acute rheumatic carditis

Progressive bulbur paralysis(Fazio-Londe disease)

Progressive bulbar paralysis of childhood is characterised by progressive paralysis of muscles innervated by cranial nerves. The authors report a case of progressive bulbar paralysis of childhood in a 12-year-old child. Child was admitted with the complaints of drooping of eyelids, difficulty in swallowing and hoarse voice. She had involvement of III, VII, IX, X, XI and XII cranial nerves and the corticospinal tracts. Electromyography revealed spontaneous activity in the form of fasciculations, giant motor unit potential and discrete recruitment of motor neurons suggestive of denervation pattern. Hearing assessment was normal. Muscle biopsy was also suggestive of neurogenic atrophy.

Brush cytology: an adjunct to diagnostic upper GI endoscopy.

Endoscopic brush cytology (EBC) was performed in antral and duodenal brushings of children subjected to upper GI endoscopy for the detection of H. pylori (Hp) and trophozoites of Giardia lamblia (Glt) in addition to routine endoscopic grasp biopsy (EGB). It was hospital based prospective study. EBC was performed in children subjected to upper GI endoscopy with a sheathed cytology brush. Mucosal brushings were collected from antrum, body of the stomach and second or third part of duodenum by gently rubbing the surface of the brush with the mucosal wall in all the directions, brush withdrawn and brushings performed on a glass slide. The smears were placed in 95% ethyl alcohol and later examined for Glt and Hp using Giemsa and Hematoxylin & Eosin stain. EGB was taken from antrum, body of the stomach and duodenum from sites other than those used for brushings. One hundred and seventy children between 1–13 years (median age = 5 years) were subjected to upper GI endoscopy for malabsorption (n= 94), recurrent abdominal pain (n= 49), failure to thrive (n= 16) and recurrent vomiting / regurgitation (n= 11) and EBC was performed in addition to routine EGB. Thirty five children (20.4%) were colonized by Hp, 14 (8.2%) were detected to have Glt and in 6 cases (3.5 %) both Hp as well as Glt were detected. Out of 41 cases colonized by Hp, 24 cases (58.5 %) were detected by EGB and 27 cases (65.8%) were detected by EBC. Out of 20 children in whom Glt were detected from their duodenum, the detection was by EBG in 12 cases (60%) and by EBC in as many as 19 cases (95%).Comparison of EGB and EBC suggested that detection rates with EBC were higher than EGB. Detection by EBC was significantly higher for Glt than Hp. There were no complications attributed to EBC and procedure time for endoscopy was not significantly prolonged. On the contrary, detection of Hp and particularly Glt in higher proportion of cases with the help of EBC was helpful in their appropriate management. Our results suggest that EBC is a safe and useful tool to enhance the value of diagnostic endoscopic procedure when used in combination with routine EGB.