Vimlesh Seth

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.

Clinico-immunological profile in juvenile rheumatoid arthritis--an Indian experience.

From a Pediatric Rheumatology Clinic 361 children diagnosed as juvenile rheumatoid arthritis (JRA) according to American Rheumatism Association-JRA criteria were studied retrospectively for their clinico-immunological profile. The mean age of onset in systemic, pauciarticular and polyarticular onset, JRA subtypes were 5.2, 6.8 and 7.2 years respectively. There was male preponderance in systemic and pauciarticular JRA. In seropositive polyarticular JRA, girls outnumbered boys. The frequency of occurence of systemic, pauciarticular and polyarticular disease was 87 (24%), 108 (30%) and 166 (46%) respectively. The systemic onset disease was dominated by extra-articular manifestations in terms of fever (100%), rash (57%), hepatomegaly (51%) and lymphadenopathy (25%). The pauci- and polyarticular illnesses were commonly dominated by joint involvement, morning stiffness, and in few patients, by extra-articular manifestations also. The joints were involved symmetrically. Most commonly involved joints in order of decreasing frequency were knee, ankle, wrist and elbow in all the subtypes. Anemia and leucocytosis were observed in majority with higher frequency in systemic onset JRA. The rheumatoid factor (RF) was present in 15% of polyarticular JRA. RF was also present in 7 and 9% of patients with pauciarticular and systemic subtypes respectively. The antinuclear antibody was positive in only 3 out of 66 patients in whom the test was carried out.The demographic profile and trends in clinical features were similar to the studies reported on caucasian population with difference in the actual frequency of various clinical features.

Tubercular lymphadenitis: Clinical manifestations

One hundred and thirteen children suffering from tubercular lymphadenitis proven histopathologically, were studied for clinical and laboratory features. Age distribution was equal in all age groups except during infancy when it was rare. Sex ratio indicates a male preponderance with male to female in the ratio of 1.5∶1 (67∶46). Family history of contact with known tuberculous patient was positive in 19 (17%) children, 44 (40%) had received BCG, and 98 (88%) were either normal nourished or had mild malnutrition. Cervical, axillary and inguinal nodes were found in 90 (80%), 14 (12%), and 8 (7%) children respectively. Epitrochlear node was found in only 1 child. 11 (10%) children had discharging sinus, all being in cervical group. The consistency of nodes was firm in 98 (87%), fluctuation was present in 15 (13%). In 87 (77%) lymph nodes were matted. Hepatomegaly of more than 2 cm was present in 13 (11%) and spieen was enlarged (>2cm) in 4 (4%) only. Mantoux test was positive in 96 (85%) children and chest X-ray was abnormal in 25 (22%) cases. Findings suggest that tubercular adenitis occurs in all age groups with equal frequency. It can occur in vaccinated children also. It may be a sole manifestation of tubercular infection. The cervical nodes are predominantly involved. There is no typical location of nodes in individual groups but multiplicity and matting of nodes are characteristic features of tubercular adenitis in children.

Ketotifen for asthma in children aged 5 to 15 years: a randomized placebo-controlled trial

BACKGROUND The prophylactic agent ketotifen has been studied in mild-to-moderate asthma. Various trials showed benefit from 10 to 12 weeks of therapy, but no trial in children with followup beyond 12 weeks of the drug is available. OBJECTIVES We studied the efficacy of ketotifen, 1 mg twice a day, orally as a prophylactic drug in children with asthma. METHODS The double-blind, placebo-controlled trial studied 120 asthmatic children of either sex between the ages of 5 to 15 years at a tertiary care hospital. After an observation period of 4 weeks, children were randomly assigned to receive either ketotifen, 1 mg twice a day, or placebo for 6 months. Antiasthma drugs were continued as required. Main outcome measures included average duration for regular antiasthma drugs, average symptom scores, symptom free days, peak expiratory flow rate, FEV1, and need for emergency room visits. RESULTS Of the 120 children enrolled, 13 could not complete the trial. Thus 58 children remained in the treatment group and 49 were in the placebo group. Both groups were comparable in their baseline characteristics. The average number of days that required antiasthma drugs were significantly less in the treatment group: salbutamol (27+/-4.7 versus 37+/-3.5 P < .05), theophylline (37+/-4.7 versus 51+/-4.8 P < .05), oral steroids (2+/-0.4 versus 5+/-1.6 P < .05), and inhalation steroids (18+/-2.7 versus 16+/-10.8 P < .05). The average symptom scores and symptom free days for cough, wheeze, and breathlessness also favored the ketotifen group. Emergency room visits were also significantly lower in the ketotifen group (20 versus 10 P < .05). Statistically significant improvement in all the above parameters were observed after 14 weeks of therapy. The mean PEFR, FEV1 and side effects of medications were comparable between the two groups. CONCLUSIONS Ketotifen, 1 mg twice a day, is an effective prophylaxis for asthma in children between 5 to 15 years. Significant clinical improvement is evident after 14 weeks of therapy.

Antituberculous therapy in children

The advent of effective chemotherapeutic agents for the treatment of tuberculosis necessitates parallel emphasis in designing various short-course chemotherapy regimens in treating tuberculosis in children. Direct extrapolation from studies in adults is not appropriate because of differing pharmacokinetics and adverse drug reactions of antituberculous drugs in children. The pharmacological basis of antituberculous drugs and guidelines for using various drug regimens in relation to the varied clinical profile of tuberculosis in children have been discussed. It has been observed that the commonest type of tuberculosis in children is the pulmonary primary complex (71·4%), followed, by, progressive, primary disease (71·4%). Pleural effusion, bronchopneumonia and miliary tuberculosis are much less frequent. The 3 drug regimen does not seem to offer any advantage over the two drug regimen in the treatment of the primary pulmonary complex, as assessed by radiological clearance. Compliance is poorer in long-term and intermittent therapy as compared to short-course, continuous therapy.

The Enigma of Childhood Cirrhosis in India

In our particular unit it seems advisable to make the accepted routine breast feeding. Our obstetric colleagues agree and we have eased the pressure upon them by means of a simple procedure. Stilbestrol is not prescribed by an obstetrician for the suppression of lactation unless the mother has already spoken to the pediatrician on this. Experiences so far give the impression that those mothers who request that lactation be suppressed are either already determined not to breast feed or are uncertain on this. The pediatrician’s personal conversation with &dquo;uncertain&dquo; mothers generally results in encouraging them to breast feed. This simple policy seems to pay off, though to a limited degree.

Infantile diarrhoea in relation to feeding practices.

SummaryWhereas a higher proportion of rural infants in the 3–5+months ageperiod on supplementary feeds suffered from diarrhoea, as compared to purely breast fed infants, the proportion was reversed in the case of urban infants of the same age. In older rural infants of the 6–8+ and 9–11+ month age-periods, there was no significant difference in the proportion of infants who suffered from diarrhoea with the two modes of feeding. At all ages a significantly higher proportion of rural infants suffered from diarrhoea as compared to urban infants.

Age at which chest circumference overtakes head circumference in children

Maximum likelihood method with probit transformation was applied to estimate median age at which chest circumference (CC) overtook head circumference (HC) in 1206 children from rural areas of Ballabhgarh in Haryana and in 1505 children from a slum population in Delhi. The results showed that, in case of rural area, this phenomenon occurred at an average age of 31.36 months and in children from urban slums, at an average age of 28 months. In both the areas, this phenomenon occurred at an average age of 20 to 21 months in normally nourished children. In children with grade I malnutrition, this was delayed by about 10 months as compared to those with normal nutrition and in children with grade II or worse malnutrition, this was further delayed by another 9 to 13 months on an average as compared to those with grade I malnutrition. These differences were found to be statistically significant (p<0.001). These results indicate that the longer the delay in CC overtaking HC, the chance is higher for the children to be severely malnourished. Considering the relative ease of measuring head and chest circumferences, this parameter (age of CC crossing HC) could be useful in assessing the long term trend in the improvement of childhood nutrition in developing countries.

Management of Childhood Asthma

Asthma can be considered a combination of three features, airways obstruction with spontaneous and pharmacologic reversibility, increased airways responsiveness to exogenous and endogenous stimuli and airways inflammation. ~he current view is that the airway inflammation is central to these changes. The inflammatory response mobilizes and activates mast cells, neutrophils, macrophages, platelets and eosinophils with the release of chemical mediators such as histamine, leukotrines, prostaglandin, thromboxane and platelet activating factors. I From the advances in understanding the pathogenesis of asthma, it is clear that use of antinflammatory drugs form the mainstay of long term treatment of asthma.

Alcaligenes fecalis scpticemia

The bacteriumAlcaligenes fecalisis a ubiquitous, gramnegatiue bacillus of the Family Achromobacter, first described in 1896 bv Petruschky, who isolated it from stale beer. Itis an aerobic, motile organism which oxidises arsenite to arsenate and is regarded as an intestinal saprophyte in animals as well as man. Systemic infection with this organism is very uncommon with only about 40 cases appearing in the world literature till 1960. By scanning Indian literature, it seems that this is only the second report ofAlcaligenes fecalissepticemia from India.