Yogesh Jain

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.

Is axillary temperature an appropriate surrogate for core temperature

The ideal technique for measuring temperature should be rapid, painless, reproducible and accurately reflect the core temperature. While axillary temperature is commonly used because of convenience and safety, there are conflicting reports abouts its accuracy. To determine whether axillary temperature can act as a surrogate for oral/rectal temperatures, a prospective comparative study was conducted. The axillary and rectal temperatures (Group 1: infants < 1 year age) and axillary and oral temperatures (Group 2: children 6–14 years age) were compared using mercury-in-glass, thermometers. Various tests of agreement were applied to the data obtained. Rectal and axillary temperatures for infants agreed well; the mean difference (95% limits of agreement) between the two being 0.6°C (−0.3°C, 1.4°C). Similarly, the mean difference (95% limits of agreement) between oral and axillary measurements for children aged 6–14 years was observed to be 0.6°C (−0.4°C, 1.4°C). Axillary temperature appears to be an acceptable alternative to rectal/oral temperature measurements in children.

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.

Dengue hemorrhagic fever: Clinical manifestations and management

Dengue virus infection may remain asymptomatic or manifest as nonspecific viral infection to life threatening dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Patients with DHF/DSS have fever, hemorrhagic manifestations along with thrombocytopenia and hemoconcentration. Thrombocytopenia and hemoconcentration are distinguishing features between DHF/DSS and dengue fever (DF). Some patients with dengue fever may have significant bleed and mild thrombocytopenia but no hemoconcentration. These patients are labelled to have dengue fever with unusual bleeds.Laboratory findings in DHF/DSS include rising hematocrit, thrombocytopenia and transformed lymphocytes on peripheral smear. There may be increased transaminases, hyponatremia, transient increase in blood urea nitrogen and creatinine. In severe disease there may be lab evidence of diseamination intravascular coagulation. X-ray film of the chest may show pleural-effusion. Ultrasonogram of abdomen may detect thickened gall bladder wall with hepatomegaly and ascitis. In some patients there may be abnormality in electrocardiogram and echocardiogram. The diagnosis of DHF/DSS is based on typical clinical findings. For confirmation of dengue virus infection viral culture can be done on blood obtained from patients during early phase of illness. In later part of illness antibodies against dengue virus can be demonstrated by various techniques.The treatment of DF is symptomatic. For control of fever nonsteroidal anti-inflammatory drugs should be avoided. DHF/DSS are managed by intravenous fluid infusion with repeated monitoring of vital parameters and packed cell volume (PCV).

Renal tubular acidosis preceding systemic lupus erythematosus.

A 10-year-old girl with distal renal tubular acidosis (RTA) for 4 years (adequately treated for 3 years) developed clinical features suggesting systemic lupus erythematosus (SLE) with supprotive laboratory evidence. Whe had heavy proteinuria and a decreased creatinine clearance (CCr). Renal biopsy showed diffuse proliferative and sclerosing glomerulonephritis with severe tubulointerstitial changes. Following treatment with corticosteroids and cyclophosphamide, she had a clinical remission, an increase inCcr and recovery from systemic acidosis. It is likely that distal RTA in this patient was a manifestation of SLE.

Use of injectable depot medroxyprogesterone acetate in lactating Indian women

Depo-Provera injectable depot medroxyprogesterone acetate (DMPA) has been licensed in India for use as a contraceptive in lactating women. This use has been ruled safe by Upjohn (the manufacturer) the Drugs Controller of India and the World Health Organization (WHO) based on assessment of 3 criteria: 1) transfer of the drug in breast milk; 2) changes in milk composition and volume; and 3) resultant effect on infant. However a study in New Zealand has demonstrated that women using DMPA had significantly lower bone density in the lumbar spine (mean difference 7.5% 95% CI 1.9-13.1% p = 0.002) and femoral neck (6.6% 0.8-12.3% p = 0.007) than control premenopausal women. This reduction was equivalent to that seen in other estrogen deficient states. Extended lactation is associated with bone loss. In the United States a prospective cohort study of 98 women showed that those with a lactation duration greater than 6 months had mean bone mineral density (BMD) losses of 5.1% (lumbar spine) and 4.8% (femoral neck) compared to controls and in spite of increased dietary intakes of calcium to more than meet the nutritional needs of the infant. Although there was a return to baseline BMD 12 months after parturition these women had increased their dietary intake of calcium during lactation and in India women are malnourished. A study by Nordin indicates that osteoporosis is common in Indian women over age 34 that fractured hips occur at all ages (reflecting the age distribution of osteomalacia) and that there is an earlier reduction in spinal density and metacarpal cortical thickness among Indian women. In view of these findings the authors have grave reservations concerning the use of Depo-Provera in breastfeeding women in a population where there is a high prevalence of calcium deficiency.

burden & pattern of illnesses among the tribal communities in central India : a report from a community health programme

Tribals are the most marginalised social category in the country and there is little and scattered information on the actual burden and pattern of illnesses they suffer from. This study provides information on burden and pattern of diseases among tribals, and whether these can be linked to their nutritional status, especially in particularly vulnerable tribal groups (PVTG) seen at a community health programme being run in the tribal areas of Chhattisgarh and Madhya Pradesh States of India. This community based programme, known as Jan Swasthya Sahyog (JSS) has been serving people in over 2500 villages in rural central India. It was found that the tribals had significantly higher proportion of all tuberculosis, sputum positive tuberculosis, severe hypertension, illnesses that require major surgery as a primary therapeutic intervention and cancers than non tribals. The proportions of people with rheumatic heart disease, sickle cell disease and epilepsy were not significantly different between different social groups. Nutritional levels of tribals were poor. Tribals in central India suffer a disproportionate burden of both communicable and non communicable diseases amidst worrisome levels of undernutrition. There is a need for universal health coverage with preferential care for the tribals, especially those belonging to the PVTG. Further, the high level of undernutrition demands a more augmented and universal Public Distribution System.

Neuropsychological abnormalities following CNS prophylaxis in children with acute lymphatic leukemia

The pattern and prevalence of neuropsychological abnormalities in children receiving combination CNS prophylaxis (2000 rads cranial irradiation and intrathecal methotrexate) during therapy for acute lymphoblastic leukemia (ALL) were studied. Thirty five children (25 boys) in the age group 5–15 years (mean 9.3) with no evidence of CNS leukemia were included and 20 age matched normal siblings served as controls. Neuropsychological parameters of general intelligence (Malins modification of WISC test); attention and concentration (colour cancellation test); memory (modified PGI memory test) and visuomotor perception (Bender Gestalt test) were evaluated at least 6 months after CNS prophylaxis. Six (17.1%) patients had mean intelligence quotients (IQ) less than 85, while all controls had IQ>85 (p<0.05). The mean IQ of the patient population (93.4±11.9) was significantly lower than the control group (107±8.4) (p<0.001). Scores on the colour cancellation test were lower in the patients as compared to controls (148.7±27.7 versus 184.9±23.9; p<0.01). The mean memory quotient in the patient population was also lower than in controls (74.5±12 versus 93.6±9.2; p<0.001). Scores on the Bender-Gestalt test did not show a significant difference. The presence of significant neuropsychological abnormalities in patients of ALL indicates the need for modification of the schedule of CNS prophylaxis. A comprehensive psychometric evaluation at regular intervals is essential for longterm rehabilitation.

Vaccine delivery to disease control: a paradigm shift in health policy

Indias Universal Immunisation Programme (UIP) has resulted in the creation of infrastructure, human resources and systems for the procurement and delivery of vaccines. Recently, new vaccines have been added and there are plans for the introduction of more. However, the outcomes in terms of reduction of the diseases for which the vaccines are being administered remain ambiguous. This is evident from the persistent health issues that children continue to experience, despite immunisation. This situation raises a fundamental ethical question for public health: vaccinations are one of the tools of disease control, but are they properly aligned to the control of disease so as to produce the expected public health utility or benefit?