Portal Hypertension with Visceral Leishmaniasis.

We conducted this study to observe evidence of portal hypertension in children with visceral leishmaniasis (VL). Eighty-eight consecutive cases (50 male) of VL were subjected to ultrasonography. Those with evidence of portal hypertension also underwent upper gastrointestinal endoscopy and liver biopsy. Eight patients had portal hypertension as evidenced by dilated caliber of portal and splenic veins. Two patients had periportal, splenic and peripancreatic collaterals and one patient had cavernous transformation of portal vein. Out of eight patients, four patients had esophageal and gastric varices. Liver biopsy was done in four patients and revealed hepatic sinusoidal dilations without any evidence of fibrosis. Portal hypertension may be an independent manifestation of VL and remain undiagnosed unless a physician maintains a high index of suspicion.

Miltefosine in children with visceral leishmaniasis: a prospective, multicentric, cross-sectional study.

OBJECTIVE: Miltefosine, an alkyl phospholipid has been found effective against visceral leishmaniasis (VL) in adults in various studies. The authors safety, tolerance and efficacy of Miltefosine and compared with available gold standard anti-Ieishmanial drug, Amphotericin B, a parenteral formulation in children with VL. METHODS: All consecutive children aged 1 yr to 14 yr, presented with fever, splenomegaly and positive LD body in splenic smear examination, admitted in pediatric ward of Nalanda Medical college and Child care center between 1st July 03 to 30th June 05 were taken for study. Patients were randomized into four groups. Group-l and 2 patients were given Miltefosine in dose of 2.5 mg/Kg day o.d. or b.i.d. per orally to a maxiIpum of 100 mg and group 3 and 4 Amphotericin B at a dose of 1 mg/Kg/day (total: 15 mg/Kg). All patients were followed at completion of therapy, 3 months and 6 months for clinical response, splenic size and parasitologically. RESULTS: Out of 125 children, 44 were in group-I, 20 in group-2, 38 in group-3 and 23 in group- 4, 124 patients had parasitological cure with relapse in one patient of group 1 during follow up. One patient in-group II had no response with first course but became parasitologically negative with 2nd course of Miltefosine. In-group I, one patient had persistent splenomegaly and found to have associated portal hypertension. Final cure rate with Miltefosine and Amphotericin B was 93.2%, 95%, 92.1% and 91.3% in-group 1, 2, 3 and 4 respectively, which are statistically insignificant. Majority of patients had pancytopenia. Eievated". AL T (>3 times of normal) were seen in 28, 11, 19 and 13 patients of group 1, 2, 3 and group 4 respectively which returned to normal in subsequent follow up. Raised BUN was observed more in patients who got Amphotericin B i.e. 65.42% and 73.91 % in-group 3 and 4 respectively. GI side effects i.e. diarrhea and vomiting were observed in 26 and 23 patients in-group 1 and 2 respectively. CONCLUSION: Miltefosine is safe, well tolerable, and highly effective and has same efficacy as Amphotericin B in newly diagnosed and SAG resistant children with visceral leishmaniasis.

Miltefosine in children with visceral leishmaniasis.

Sixty four children (38 boys and 26 girls), aged 1 yr to 14 yr, presenting with fever, splenomegaly and positive LD body in splenic smear examination, admitted to pediatric ward of Nalanda Medical college and Child care center between 1st July 03 to 30th June 04 were taken for study. Patients were categorized into two groups: 44 were in Group I (Patients who had not received prior antileishmanial drug) and 20 in Group II (Patients who had received 30 days course of SAG; 20 mg per kg per day). All patients were given Miltefosine in dose of 2.5 per kg per day od or bid per orally to a maximum of 100 mg and were followed at completion of therapy, 1 month and 6 months for clinical response, splenic size and parasite density. 63 patients had parasitological cure with relapse in one patient of Group I during follow up. One patient in Group II had no response with first course but became parasitologically negative with 2nd course of Miltefosine. In Group I, one patient had persistent splenomegaly and found to have associated portal hypertension. GI side effects i.e. diarrhea and vomiting were observed in 26 and 23 patients respectively. Majority of patients had pancytopenia. Elevated ALT (> 3 times of normal) were seen in 28 and 11 patients of Group I and Group II respectively which returned to normal in subsequent follow up. The final cure rates were 93.2 percent and 95 percent in Groups I and II respectively.

Current concept in the management of cerebral palsy.

The authors have described, in depth, the current concept along with the management of cerebral palsy in the present article.

Oral atropine sulfate for infantile hypertrophic pyloric stenosis.

This study aimed to evaluate the effectiveness of oral atropine in the management of IHPS. Cases were diagnosed clinically and confirmed sonographically. Atropine was given orally from the outset at a dose of 0.18 mg/kg/day in eight divided doses, increased daily by 1/4th of the commencing dose till vomiting ceased. Ultrasonographic evaluation of pyloric muscle thickness and length was done at the commencement of treatment, after completion of treatment and at 3, 6, 9, 12 and 15 months follow up. Oral atropine was effective in 11/12 (91.06%) cases. Vomiting ceased in 14 to 21 days in all cases. One case required initial 7 days of i.v. treatment followed by 18 days oral treatment to stop vomiting. USG evidence of normalization of pylorus was observed in all these cases, 3-15 months after completion of treatment. We conclude that oral atropine proved to be a simple, effective, safe, very cheap and acceptable treatment option for IHPS.

Department of Paediatrics, Nalanda Medical College, Patna.

Cysticercosis is the most common parasitic disease of the central nervous system. The disease has worlwide distribution. The cysticerci might lodge in the brain parenchyma, spinal cord, eyes, ventricular system, subarachnoid space and muscle. These are most often seen in basal meninges. The presence of human lymphocyte antigen-related antigens on the surface of cysticerci has a direct relationship with microscopic signs of damage to cysticerci. The clinical manifestations depend upon number and topography of lesions, the individual immune response to the parasite and the sequelae of previous infestations. The diagnostic criteria of neurocysticercosis can be based on absolute criteria, major criteria, minor criteria and epidemiological criteria. Computerised tomography (CT) head is still most useful diagnostic tool for the diagnosis of neurocysticercosis but magnetic resonance imaging has some advantages over computerised tomography. The mainstay of therapy lies on medical and surgical intervention. Medical therapy consists of cysticidal drugs. Surgical therapy is indicated in intraventricular and subarachnoid neurocysticercosis. Steriods are used for anti-oedema measures. Anti-epileptics can also be tried. The measures for prevention of cysticercosis are proper disposal of human waste, treatment of water contaminated with human faeces before its use in irrigation of vegetable cultivation, proper cooking of pork and repeated treatment in taenia carriers.

Miltefosine: an oral drug for visceral leishmaniasis.

Miltefosine, a phosphocholine analogue originally developed as antimalignant drug, has been found to be highly active against leishmania in vitro and animal model. Based on these experiences this drug was tried against human visceral leishmaniasis and found to be highly effective and achieved 97% and 94% cure in phase 2 and phase 3 trial in children.

Congenital hypertrophic pyloric stenosis.

Congenital hypertrophic pyloric stenosis, an important cause of intractable vomiting in infants is diagnosed clinically and confirmed ultrasonographically. Other useful interventions are plain radiography and barium study. Differential diagnosis includes pylorospasm and gastroesophageal reflux. Management protocol includes correction of dehydration and electrolyte imbalance and either Fredet Ramstedt pyloromyotomy or medical treatment with atropine sulphate. Atropine is initially given intravenously till vomiting is controlled and then orally at double the effective i.v. done for another 3 weeks. Atropine sulphate is generally well tolerated and side effects are few like tachycardia, raised SGPT and hyperthermia. Atropine sulphate is very effective, cheap, safe and perhaps more acceptable treatment option for CHPS.

Management of diarrhoea in practice.

Diarrhoea, a major cause of morbidity and mortality can be produced by a variety of etiological factors. Management protocol includes assessment of the child, physical examination, lab-evaluation, assessment of severity of dehydration and rehydration therapy using either of the following - WHO - ORS, Home available fluids (HAF), sugar salt solution (SSS), improve WHO-ORS, Amino acid fortified ORS, rice based ORS, low osmolarity ORS. Intravenous fluids are required if patients can't accept orally. Commonly observed electrolyte disturbances are hypernatremia, hyponatremia and hypokalemia. Concussion is a common problem and can result due to electrolyte imbalance, cavernous sinus thrombosis, associated meningitis, shigella encephalopathy and hypoglycemia in undernourished children. Treatment includes i.v. diazepam and i.v. glucose and correction of electrolyte imbalance. Additional treatment interventions include antimicrobial drugs including antibiotics, antimotility drugs, absorbents, nutritional and micro and macro nutrient supplementation.