Winsley Rose

Costing of severe pneumonia in hospitalized infants and children aged 2–36 months, at a secondary and tertiary level hospital of a not‐for‐profit organization

Objectives  To determine health care provider cost and household cost of the treatment of severe pneumonia in infants and young children admitted to secondary and tertiary level health care facilities.

Intermittent clobazam therapy in febrile seizures.

Objective: To evaluate the efficacy of intermittent clobazam therapy in preventing the recurrence of febrile seizures and to assess its safety.Methods: The study was a prospective, randomized, double-blind placebo-controlled trial conducted in the Department of Child Health, Christian Medical College Hospital, Vellore between July 2001 and September 2002. Neurologically normal children between 6 months and 3 years of age with a history of febrile seizures and no evidence of acute CNS infection or EEG abnormality were included into the study. 19 children in a clobazam group and 20 in the placebo group were randomly allocated. Temperature reduction measures with paractamol and tepid sponging were advised to all children. In addition the dispensed medication was to be administered at the onset of fever and continued for 48 hours irrespective of the duration of fever. The children were then monitored for seizures and adverse effects of clobazam. The children were followed up for a mean period of 9.9 months. The analysis was done on the number of febrile episodes in both the groups.Results: There were a total of 110 episodes of fever during the study period. Mean number of febrile episodes in the clobazam group was 3.1 and in placebo group 2.56. Six (12.5%) of the 48 episodes in placebo group and one (1.7%) of 60 episodes in clobazam group had seizure recurrence. This was statistically significant (p=0.01). Drowsiness and weakness were present equally in both clobazam and placebo group whereas ataxia was present only in the clobazam group, the difference being statistically significant (p=0.04).Conclusion: Intermittent clobazam therapy is an effective measure in the prevention of recurrence of febrile seizures. The ataxia due to clobazam was much lower than that reported with diazepam.

Establishment of the MAL-ED Birth Cohort Study Site in Vellore, Southern India

The Indian Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) site is in Vellore, Tamil Nadu, in south India and is coordinated by the Christian Medical College, Vellore, which has many years of experience in establishing and following cohorts. India is a diverse country, and no single area can be representative with regard to many health and socioeconomic indicators. The site in Vellore is an urban semiorganized settlement or slum. In the study site, the average family size is 5.7, adults who are gainfully employed are mostly unskilled laborers, and 51% of the population uses the field as their toilet facility. Previous studies from Vellore slums have reported stunting in well over a third of children, comparable to national estimates. The infant mortality rate is 38 per 1000 live births, with deaths due mainly to perinatal and infectious causes. Rigorous staff training, monitoring, supervision and refinement of tools have been essential to maintaining the quality of the significantly large quantity of data collected. Establishing a field clinic within the site has minimized inconvenience to participants and researchers and enabled better rapport with the community and better follow-up. These factors contribute to the wealth of information that will be generated from the MAL-ED multisite cohort, which will improve our understanding of enteric infections and its interactions with malnutrition and development of young children.

Distribution of Eschar in Pediatric Scrub Typhus

BACKGROUND Identifying an eschar in scrub typhus is useful for initiation of prompt and appropriate antibiotic therapy. METHODS The distribution of eschars in all children <15 years of age admitted with confirmed scrub typhus over a 5 year period is described. RESULTS Of 431 children admitted with scrub typhus, eschars were present in 176 (40.8%) children with the following distribution: head, face and neck, 33 (19.1%); axillae, 37 (21%); chest and abdomen, 21 (11.9%); genitalia, inguinal region and buttocks, 58 (33%); back, 8 (4.5%); upper extremities, 13 (7.4%); and lower extremities, 5 (2.8%). The commonest sites of eschars were scrotum (27 of 106; 25.5%) and axillae (15 of 106; 14.2%) in males and axillae (22 of 70; 31.4%) and groin (16 of 70; 22.9%) in females. Eschars were seen within skin folds in 100 of 176 (56.8%) children. CONCLUSION Children should be carefully examined for the presence of eschar especially in the skin folds of the genitalia, axillae and groin to make an early diagnosis of scrub typhus.

Relating Tuberculosis (TB) Contact Characteristics to QuantiFERON-TB-Gold and Tuberculin Skin Test Results in the Toronto Pediatric TB Clinic

BACKGROUND Few data relate interferon-γ-release-assay results in children to source case sputum status, the best predictor of infectiousness of tuberculosis (TB) patients. We evaluated the QuantiFERON-Gold-in-tube assay (QFT) and tuberculin skin test (TST) in children with different types of TB exposure. METHODS The TST and QFT were performed in referred TB-exposed children and adolescents who had not undergone prior TST screening (tested in parallel), and the QFT was performed in referred TST-positive individuals. Source case characteristics were obtained from referring public health units. We excluded children with known immunocompromising conditions and those known to have TB disease at the time of evaluation. RESULTS For 103 patients tested in parallel, overall test agreement was very good in the Bacillus Calmette-Guerein (BCG) unimmunized contacts (κ = 0.83) and contacts of household smear-positive (HS+) cases (κ = 0.67), but test agreement was poor in those with lower-risk contact (κ = 0.34). Only 3 of 59 HS+ patients were QFT-positive and TST-negative. On multivariate analysis, a positive QFT was strongly associated with HS+ exposure (odds ratio [OR], 6.6; 95% confidence interval [CI], 2.2-20]) but not BCG; and a positive TST was associated with BCG alone. For 92 referred TST-positive individuals, the QFT was negative in 21% of HS+ contacts, 65% of lower-risk contacts (OR, 6.8; 95% CI, 1.9-25), and 82% of the patients with unknown contact history (OR, 15.5; 95% CI, 5-54). Application of the Canadian 2010 guidelines would exclude from treatment 43 (72%) of the 73 TST+, QFT- patients. CONCLUSIONS For close contacts of HS+ individuals, the QFT added little sensitivity to the TST for detection of TB infection. The QFT correlated much better with exposure than the TST, especially in BCG-immunized children, and it has the greatest potential benefit for evaluation of those at lower risk of latent TB infection.

Acute pancreatitis as the initial presentation in pediatric systemic lupus erythematosus

It is exceptionally rare for acute pancreatitis to be the presenting manifestation of childhood systemic lupus erythematosus. We report a 14-year-old girl who presented with a history of fever, generalized rash, arthralgia and abdominal pain. Her serum amylase was 1472U/L and lipase 3316 U/L suggestive of acute pancreatitis. Other investigations revealed pancytopenia, low complement, high 24-hour urinary protein and elevated ANA and dsDNA. She was treated with IV methylprednisone, followed by oral steroids.

Prolonged Neurologic Course of Familial Hemophagocytic Lymphohistiocytosis

Familial hemophagocytic lymphohistiocytosis is a very unusual cause for demyelination and the clinician would do well to be aware of the condition, especially when children present with atypical findings on magnetic resonance imaging associated with fever, pancytopenia, and hepatosplenomegaly. This is a rare autosomal recessive, multisystem inflammatory disorder characterized by widespread organ infiltration by macrophages and activated lymphocytes. It is usually diagnosed in the first 2 years of life and is rapidly fatal if untreated. Reported here is the case of a 12-year-old boy, from a poor family, with a 6-year history of visual loss and fever for 5 months, and transient hemiparesis with hepatosplenomegaly and pancytopenia. Cranial magnetic resonance imaging showed multiple areas of hyperintense signal, predominantly involving white matter. The boy also had elevated triglycerides and ferritin, with low fibrinogen level. Bone marrow aspiration revealed hemophagocytosis. He was diagnosed as having familial hemophagocytic lymphohistiocytosis and treated with the HLH 2004 protocol. A sibling also had evidence of hemophagocytosis. Remission was achieved, but his parents could not afford the cost of hematopoietic stem cell transplantation. He relapsed after 8 months and later died.

Thyroid dysfunction in Indian children with Down syndrome.

This record review of 82 children with Down Syndrome (DS) between April 2004 and March 2014 who had thyroid dysfunction, showed that majority (76, 92.6%) had subclinical hypothyroidism. Of the 60 patients who underwent radionuclide scan, 63.3% had a normal gland; the rest exhibited only impaired tracer uptake. Ultrasonograms done in 20 patients showed reduction of thyroid gland size in 3 (15%) patients only.

Scrub Typhus as a Cause of Acute Encephalitis Syndrome, Gorakhpur, Uttar Pradesh, India

Outbreaks of acute encephalitis syndrome (AES) have been occurring in Gorakhpur Division, Uttar Pradesh, India, for several years. In 2016, we conducted a case–control study. Our findings revealed a high proportion of AES cases with Orientia tsutsugamushi IgM and IgG, indicating that scrub typhus is a cause of AES.

Acquired Neonatal Chikungunya Encephalopathy

To the Editor:Re-emergence of Chikungunya has been reported worldwide. We report 3 neonates with postnatally acquired Chikungunya encephalopathy. Neonate A, a 19-d-old girl presented with tonic seizures and poor feeding. Her cerebrospinal fluid analysis, serum sodium (140 mmol/dl) and calcium (8.5 mg/dl) were normal. Neonate B, a 23-d-old boy presented with fever andmultifocal clonic seizures. He had CSF pleocytosis (total count 70neutrophils: 13 %, lymphocytes: 60 %, monocytes: 27 %, sugar: 53 mg%, protein: 87 mg/dl, culturesterile) and normal electrolytes (sodium 133 mmol/dl, calcium 8.8 mg/dl). Neonate C, a 25-d-old girl presented with poor feeding and multifocal clonic seizures. She had normal electrolytes (sodium 135 mmol/dl, calcium 8.5 mg/dl) and cerebrospinal fluid analysis showed total counts: 12 (neutrophils 82 %), protein: 115 mg/dl, sugar: 61 mg%. All the three neonates developed a blistering hyperpigmented rash involving the face, limbs, trunk and tip of the nose on the 3rd day of illness (Fig. 1). Chikungunya IgM performed using the OnSite Chikungunya IgM Rapid Test, a chromatographic immunoassay (sensitivity 90.3 % and relative specificity 100 %) were found to be positive [1]. The diagnosis of Chikungunya was based on the typical clinical presentation and positive Chikungunya IgM results. However RT-PCR assay or paired acute and convalescent sera to compare anti-Chikungunya antibody titers was not performed. The differentials of Herpes virus, O’nyong’nyong virus and Semliki Forest virus were considered unlikely, based on