Vidushi Mahajan

Locked-in syndrome as a presentation of snakebite

Snake bite is a common condition in tropical countries. Neurotoxic features of snake bite vary from early morning neuroparalytic syndrome to various cranial nerve palsies. Locked in syndrome (LIS) is a rare presentation. We present four children that had LIS; three patients had total and one had incomplete LIS. All patients made successful recovery with polyvalent anti-snake venom and supportive management. This case series highlights the importance of early diagnosis of LIS in snake bite.

Salivary lactate dehydrogenase levels can provide early diagnosis of hypoxic–ischaemic encephalopathy in neonates with birth asphyxia

Timely detection of hypoxic–ischaemic encephalopathy (HIE) is crucial for selecting neonates who are likely to benefit from neuroprotective therapy. This study evaluated the efficacy of salivary lactate dehydrogenase (LDH) in the early diagnosis of HIE among neonates with perinatal asphyxia.

Modifiable factors for prevention of childhood mortality

ObjectiveTo know the disease-related causes of child mortality and identify socially modifiable factors affecting child mortality among hospitalized children aged >1 month-18 years in a referral hospital of North India.MethodsCauses of death (ICD-10 based) were extracted retrospectively from hospital files (n=487) from 17 March 2003 to 30 June 2012. Modifiable factors were prospectively studied in 107 consecutive deaths from 6 October 2011 to 30 June 2012.ResultsPneumonia, CNS infections and diarrhea were the most common disease-related causes of child mortality.ConclusionsAmongst modifiable factors, administrative issues were most common followed by family-related reasons and medical-personnel related problems.

Clinical predictors of hospital admission in acute lower respiratory tract infection in 2 months to 2-year-old children.

Acute lower respiratory tract infections (ALRI) are a common cause of paediatric emergency visits in young children. We studied risk factors for hospitalization and developed a clinical score for predicting hospitalization among 2 months to 2‐year‐old children with ALRI.

Successful Use of Entecavir in Hepatitis B-associated Membranous Nephropathy

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 μg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

Decade long unexplained anemia: alert to ANCA associated vasculitis.

A 13-year old girl presented with a decade long anemia, diffuse alveolar hemorrhage and interstistial lung disease; was eventually diagnosed as ANCA associated vasculitis. High index of suspicion is thus warranted for alternative diagnosis in chronic anemia, despite increased prevalence of infectious diseases and nutritional anemia.

Subcutaneous Fat Necrosis of Newborn: Unfamiliar Histomorphology of a Familiar Lesion

Subcutaneous fat necrosis of the newborn (SCFN) is an uncommon panniculitis affecting preterm and term infants. A straightforward diagnosis in most cases, it may mimic lymph nodes in cervical and axillary locations. This 8-week-old female, otherwise healthy, developed multiple discrete, nontender, subcutaneous nodules in the submental and bilateral submandibular regions. An excision biopsy was performed with suspicion of lymphadenopathy, which revealed a nodular lesion in the subcutaneous tissue (Figure1a) composed of collections of large adipocytes with foamy vacuolated cytoplasm and crystallized intracytoplasmic fat (Figure 1b). Numerous multinucleated giant cells and aggregates of mononuclear inflammatory cells were seen (Figure 1c). Usually a self-limiting condition, SCFN may be complicated by hypercalcemia, hypoglycemia, anemia, and thrombocytopenia. Hypercalcemia may require treatment when symptomatic and a 4 to 6 weekly calcium level monitoring. Infants exposed to local hypoxia due to obstetric trauma or macrosomia and therapeutic hypothermia are at risk of development of SCFN. The brown fat in infants is prone to crystallization on exposure to cold due to a higher percentage of saturated fatty acids. Other clinical 751052 IJSXXX10.1177/1066896917751052International Journal of Surgical PathologyBharani et al research-article2018

Access and Acceptability of Digital Technology Amongst Caregivers/Parents in Government Sector

To the Editor: Digital technology has tremendous potential in delivering health related information to general public. However data regarding accessibility and delivery of health related information through internet is lacking. We evaluated the proportion of pediatric caregivers accessing healthcare information through internet and their comfort level, using a pretested questionnaire [1]. Caregivers, accompanying children attending the Pediatric OPD of a tertiary-care hospital of North India, were interviewed from July 2013 through July 2014 by a single investigator (AA), who was trained before beginning the study. Each household was interviewed only once using a 22 items questionnaire. Ethical approval was obtained from institute’s Ethics committee. The comfort level and openness of the respondents towards acquiring online health information was assessed by 5-point Likert scale. Assuming 40 % internet usage in general population with a precision of 5 %, we required to enrol 960 subjects. We approached 1050 caregivers in Pediatrics OPD, of which 1036 (98.6 %) responded. The respondents predominantly were parents (92 %); in 30–40 y age group (50 %). Only 33 % (N = 345) respondents were using internet. Following factors were associated with internet usage: urban inhabitants [251 (73 %) vs. 332 (48 %), p < 0.001]; Service class [163 (47 %) vs. 123 (18 %), p < 0.001]; graduates and postgraduates [267 (78 %) vs. 120 (17 %), p < 0.001] compared to non-users respectively. Of all internet users, 33 % accessed >1/d, 36 % once daily, 24 % once weekly and rest 7 % occasionally. The internet users used internet for communication (e-mail =89 %), web browsing (75 %), social networking (72 %), news/ music (37 % each), chat/ instant messenger (16 %), shopping (13 %), gaming (11 %) and internet television (3%). Two-third of the internet users accessed internet on their smartphones. Health information was accessed on internet by one-third respondents. Of all 345 internet users, 95 % were willing to use internet for health information in future. Majority (95 %) believed that such information would be reliable and 72%were comfortable to access health information through internet. Seventy-six percent expressed willingness to receive discharge summaries online instead of hard copies. To conclude, pediatric caregivers are opening up to access health information through digital technology, however, their blind faith on internet sources as a medium of information was worrisome.

Improving AEFI surveillance in India

We read with interest the position paper of Indian Academy of Pediatrics on AEFI surveillance [1]. In addition to the web –based facilities and SMS alerts, we propose that a mobile application should be developed for prompt reporting of AEFI. Mobile app is immensely useful in expedited delivery of such information to the concerned authorities by the caregiver and can function offline. It can be linked directly to the database which could reduce the missing cases. There are 898 million mobile subscribers in India with more than 50 per cent accessing the internet only via mobile devices [2]. Apart from this, a toll-free number can be created for easier reporting of adverse events. The operator can do realtime data entry, thus improving reporting. VIDUSHI MAHAJAN AND *SHIV SAJAN SAINI Department of Pediatrics, Government Medical College and Hospital, and Neonatology Unit, Department of Pediatrics, Post Graduate Institute of Medical and Research, Chandigarh, India. sajansaini1@gmail.com

Laryngoscope Bulb - An Unusual Foreign Body in Nasopharynx

To the Editor:We report a case of a four-year-old boy admitted in pediatric emergency with the diagnosis of tubercular meningitis with raised intracranial tension. He required intubation for low Glasgow coma scale (E2M2V2). During endotracheal intubation, the light source of laryngoscope became nonfunctional. On inspection, the laryngoscope bulb was found to be dislodged. Child was intubated immediately with another laryngoscope. The position of bulb was found to be in nasopharynx on lateral X-ray neck (Fig. 1a). However, on direct laryngoscopy, the bulb could not be located by ENTsurgeons. A repeat X-ray showed displacement of the bulb into stomach (Fig. 1b). Gastroenterology opined for a conservative approach. Repeat X-ray after three days depicted displacement of bulb in ileocecal region. Unfortunately, the child expired 5 d later due to primary disease. This case highlights the importance of proper checking of instruments before any procedure and, emphasises the need of rapid sequence intubation and proper sedation while performing elective endotracheal intubation [1]. Use of laryngoscope with fibreoptic illumination is another option to completely circumvent this complication [2]. However, it is costly and therefore, not recommended in routine practice. The case also alerts us on prompt reporting and management of this rare but potentially dangerous situation, if such an incident happens.