Frequency of childhood fungal nail disorders among cases of onychomycosis

Background: Fungal nail infections are reported mostly among developing countries

Objective: To assess frequency of childhood nail fungal infection among cases of onychomycosis

Methodology: Study Design: Cross sectional study. Setting: 1st January 2012 to 31st December 2017. A total of 300 diagnosed cases of onychomycosis were included in this study. Study Setting: Department of dermatology and Department of Microbiology, Quaid-e-Azam Medical College Bahawalpur. Specimen was processed by 20% Potassium hydroxide [KOH] mount for the presence of hyphae or spores were considered as a positive test, and mycological culture was done by using Sabouraud's dextrose agar, for 4 weeks and pathogen was identified by colony characteristics and microscopy. Presences of intensely stained reddish dots or threads like structures in between the cells of nail plate were considered to be positive results on histopathology with periodic acid Schiff [PAS]

Results: Out of three hundredcases, 42 [14%] cases reveal fungal infection in children below 18 years of age. Candida albicans was most common fungal infection 18 out of 42 and Trichophyton Rubrum was found in 14 out of 42 cases

Conclusion: Onychomycosis in children was commonly observed in our population. The commonest pathogens were candida albicans, Trichophyton rubrum, and Aspergillus

Surgical management of suspected enteric ileal perforations in children

To find the outcome of protocol adopted for suspected enteric ileal perforations in children. Descriptive case series. Department of Paediatric Surgery National Institute of Child Health [NICH] Karachi, from December 2010 to November 2011. A total of 23 patients were managed during the study period. The protocol varied depending upon condition of the child at presentation. Tube laparostomy was done as initial procedure in patients who were judged unfit for surgery within 24 hours of admission based upon need of resuscitation. Once optimized, children underwent surgery. Procedure was tailored according to the operative findings and included either primary repair of the perforation or stoma formation [exteriorization of perforation - Ileostomy]. There were 16 male and 7 female patients. Age ranged from 3-13 year [mean 7.82, + 2.94 year]. Duration of symptoms ranged from 7-45 days [mean 15.56, + 9.39 days]. Free intraperitoneal gas under diaphragm on x-ray abdomen was found in 19 patients. Initial tube laparostomy was done in 12 cases. Laparotomy was performed in our hospital in 21 patients while one child had surgery done elsewhere and referred with stoma already made. A single perforation found at antimesenteric border of distal ileum in 20 cases. Primary closure of perforation was done in 5 patients. Ileostomy was made in 16, of whom 11 had reversal in 2 to 5 months time. The patient who had surgery done outside, developed burst abdomen and was re-explored. More perforations were found in proximal ileum and stoma was refashioned. This patient died later. Two patients in whom stoma was made expired in early postoperative period. In one patient only tube laparostomy was performed. He died before any definitive procedure. Overall mortality was 17.3% [n 4]. Patients with enteric perforation had varied presentation. The surgical procedure has to be tailored according to the condition of the child. Mortality remained significant in this condition

Anterior sacral meningocele

Anterior sacral maningocele is a rare condition presenting as a lower abdominal mass. One such case was seen in a baby girl aged 2 months, who was admitted with abdominal distension and urinary difficulty for one week. She had a lower abdominal mass which investigated by MRI, turned out to be an anterior sacral meningosele causing her symptoms. The meningocele was excised successfully via an open abdominal approach. Postoperative recovery and follow-ups remained uneventful. Presentation, various diagnostic modalities and treatment options for an anterior sacral meningocele are briefly discussed

Posterior urethral valves: varied presentations and outcome after preliminary surgical treatment

To find out various modes of presentation and outcome after preliminary surgical treatment of posterior urethral valves in pediatric population. Surgical Unit B National Institute of Child Health, Karachi, during the years 2004-2005. All consecutive patients coming in outpatient / emergency departments, diagnosed as having posterior urethral valves and those who had received initial treatment and came for follow up, were included in the study. All the neonates underwent vesicostomy initially, followed by valve ablation at appropriate age with plan for undiversion at later date. In infants valve ablation was performed if urethral size admitted pediatric cystoscope while older children underwent primary valve ablation. There were total of 22 patients managed during the study period. They included 5 neonates [0-1 month], 11 infants [1-12 months] and 6 older children [1year-12 years]. The main presenting complaint in majority of neonates was inability to pass urine and one had urinary ascites. Infants presented mainly with either difficulty in passing urine [n 5] or dribbling and acute urinary retention in 2 patients each. Majority of older children [n 3] presented with poor urinary stream and dribbling while two had diurnal enuresis and one came with straining at micturition. In all the neonates' vesicostomy was performed. Out of these 3 received valve ablation therapy, followed by undiversion. Two of them improved while 1 had bladder dysfunction. Of the remaining 2 patients with vesicostomy 1 is still waiting for definitive procedure while the other is lost to follow up. Of infant group, 8 were subjected to vesicostomy and valves ablated at later stage whereas 2 received primary valve fulguration therapy. One patient of this group died before any intervention performed. In older age group, 3 received valve ablation as initial treatment while 3 were lost to follow up before any intervention. Outcome assessed clinically, biochemically and radiologically. Out of total 22, four had not received any intervention. Of the remaining 18, treatment completed in 12 patients, 8 of these improved and 4 had residual disease. Two patients expired and 4 were lost to follow up. The overall improvement rate observed at the end of our study was 44%. In 22% patients there were still residual ongoing problems that need to be addressed on long term basis

Surgical management of renal tumors in children

To analyze case records of children with renal tumors. Case series. Surgical Unit B, National Institute of Child Health, Karachi during years 2004-2005. Case records of all patients managed during the study period were reviewed for clinical presentation, investigations and surgical management. National Wilms' Tumor Study. Group [NWTSG] and International Society of Pediatric Oncology [SIOP] protocols were used depending upon stage in cases of Wilms' tumor. Trucut biopsy was done for tissue diagnosis as proposed by UK Children's Cancer Study Group [UKCCSG]. Touch imprints were also made. Surgical procedure was analyzed in terms of ease of dissection, tumor spillage and extent of excision. Twenty-one patients of renal tumors were managed in two years period. Nearly 60% of patients were less than 2 years of age. Majority [n 14] presented with abdominal mass. Few had complaints of abdominal pain. One patient an infant, presented with profuse hematuria. Trucut biopsy was done in 18 cases to have tissue diagnosis. Three patients underwent primary exploration. There were 17 cases of Wilms' tumor and in one case it was suspected on touch imprints. Fourteen patients of Wilms' tumor were given pre operative chemotherapy [SIOP protocol]. Twelve of them were in stage III and IV. Nine out of this have undergone nephrectomy. Marked tumor regression in size of tumor was noted. The tumor also became firm. Only one tumor ruptured during excision. In one tumor with horse-shoe kidney, residual tumor left at margins of dissection. Three patients underwent primary nephrectomy. Two of these were in stage I and one in stage III [NWTSG protocol]. Patient in stage III died in immediate post operative period because of hemorrhage. There was one case each of mesoblastic nephroma, cystic nephroma and rhabdoid tumor. In all these nephrectomy was done following trucut biopsy. Patient with rhabdoid tumor received pre operative chemotherapy. This tumor ruptured during surgery and gross spillage occurred. Wilms' tumor was the most common pediatric renal tumor. Most of the patients were younger than the reported age and presented with advanced stage of disease. SIOP protocol found more appropriate in our group of patients

Complications of inguinal hernia surgery in children

To determine the postoperative complications of elective inguinal hernia surgery in children. Descriptive study. Surgical Unit B, National Institute of Child Health, Karachi, from February 2004 to November 2005. Children with inguinal hernia, admitted electively through surgical outpatient, were included. Patients operated earlier and presenting with complications were excluded. Patients with concomitant diseases, regarded as predisposing factors for hernia development, were also excluded. Physical examination and relevant investigations [hemoglobin level and ultrasound of scrotum] were performed. Inguinal hernia was repaired electively by Rehbein procedure. Patients were followed at day 7, 1 month, 3 months and 9 months to note the postoperative complications of the surgery. Ultrasound was repeated at 6 and 9 months postoperatively for the size of testes. A total of 223 patients with inguinal hernia were included in the study. Age ranged from 8 days to 12 years. There were 188 males with 75 patients under 1 year of age. The longest follow-up was upto 9 months in 133 patients. The complications of scrotal edema occurred in 6 [2.97%], haematoma in 1[0.49%], wound infection in 2 [0.99%] and 5 events of recurrence of hernia in 4 patients. All appeared within 3 months of follow-up. Four recurrent hernia were operated. In all cases intact sac was found. No patient developed decrease in size of testes nor ascent of testes was noted at follow-up. In this series, there were minimal complications observed in relation to inguinal hernia surgery

Correlation the size of undescended testis with its location in various age groups

To assess the correlation of the size of undescended testis with its location in children of various age groups, peroperatively. Cross-sectional study. Surgical Unit B, National Institute of Child Health, Karachi from February 2004 - November 2005. Children presenting with undescended testis at surgical outpatient were recruited. Physical examination and relevant investigations [haemoglobin, ultrasound for location and size of testes] were performed. Patients were divided randomly into three age groups, group I [8 months - 2.5 years], group II [2.6 - 8 years], group III [8.1-13 years]. At orchiopexy location and size of undescended testis were noted. Patients were further sub-divided into groups according to peroperative location of undescended testis, group A [intra-abdominal], group B [intra-canalicular], group C [distal to superficial inguinal ring - pubic]. Where no testis was found, a separate group D was assigned. The size of undescended testis at different locations in various age groups was compared with reference to normal descended testicular size in the respective age group, for statistical significance. ANOVA test was used for intergroup comparison for the size of undescended testis and Student t- test was applied for comparison with reference to normal values of the size of testis. A total of 102 patients with undescended testis were included in the study. The total number of 107 testicular units were assessed. Group I had 28, group II, 41 and group III, 38 testes. There were 24 intra-abdominal, 68 intra-canalicular and 12 pubic in location. In 3 cases, no testis was found at exploration. We found no statistically significant difference amongst groups [p- value=0.090] between the size of the undescended testis at different peroperative locations. The size of undescended testis grew with the age as undescended testis of larger size were found in older age group as compared to younger age group. By applying Student t-test, we did not find statistically significant difference in relation to The size of undescended testis in various age groups in comparison to the reference of mean volume of normally descended testis in the respective age groups. Pre-pubertal size of undescended testis does not differ significantly from that of normal reference value of descended testis in relation to age and location. The ultimate size of the testis can only be assessed after puberty whether it is a normally descended or undescended testis

Post operative analgesia in infants

To compare the effects of local wound infiltration of bupivacaine with intramuscular nalbuphine in infants as post operative analgesia. Comparative study. Place and Duration of study: Department of Paediatric Surgery, National Institute of Child Health, Karachi, during years 2002-2003. A total of 60 patients included in this study. They were divided into 3 groups of 20 patients each. All were selected for elective inguinal herniotomy and randomly distributed in 3 groups. Group I was control group in which no analgesia was given and patients were observed for pain. Group II consisted of patients who were given nalbuphine post operatively and in group III bupivacaine was infiltrated into the wound margins just before wound closure. Observational pain assessment was performed according to Infants Pain Scale of Barrier et al. Results of the mean of 3 groups were compared with each other to assess severity of pain. Group I [control] showed signs of moderate to severe pain. Out of 20 patients, 16 had moderate and 4 had severe pain. In Group II [nalbuphine] 18 patients demonstrated mild pain while only 2 patients remained symptom free and in group III [bupivacaine] out of 20 patients 9 developed mild pain while 11 patients had no pain at all. Thus bupivacaine proved significantly better than nalbuphine [p<0.01] as post operative analgesia in infants. Bupivacaine as compared to nalbuphine is more effective as a post operative analgesia. This makes the drug most suitable for routine use, especially in day care surgery

Childhood nephrectomies for benign renal lesions

To conduct an audit of nephrectomies done in children for benign renal pathology. Evidence based study. Place and Duration: National Institute of Child Health, Karachi, during the year 2004-2005. The record of all the paediatric age group patients undergoing unilateral nephrectomy for benign renal diseases over a 2-year period were reviewed for the underlying diagnosis and indication for nephrectomy. Patients of Wilms` tumor subjected to nephrectomy were excluded. In the study nephrectomy was carried out in a total of 12 patients. There were 8 males and 4 females. The age range was 4 to 12 years. Nephrectomy was performed for renal tuberculosis in 5, pelvi-ureteric junction obstruction [PUJO] in 5, congenital hypoplastic kidney in 1 and one for multicystic dysplastic kidney. All the patients following nephrectomy remained well in the immediate post operative period and thereafter. Late presentation and delay in diagnosis of benign lesions of the kidney remained the main culprit in loosing a vital organ in childhood

Management of idiopathic rectal prolapse in children

To determine the percentage of patients of idiopathic rectal prolapse improving on spontaneously over the period of observation [phase I], and to determine the outcome of patients with rectal prolapse who received injection sclerotherapy [phase II]. Quasi-experimental study. National Institute of Child Health, Karachi from April 2001 to March 2002. The study was conducted in two phases. In phase I of the study, newly diagnosed patients of idiopathic rectal prolapse were followed without any treatment, till the spontaneous resolution of rectal prolapse. The time period at which 50% patients improved clinically was called 'time for spontaneous resolution 50%, [TSR 50%]. In phase II, injection sclerotherapy [IST] was given to those patients whose prolapse was of more than three months duration. This was a separate cohort of patients. One hundred patients were inducted in the study. They all had idiopathic rectal prolapse and their ages ranged from 6 months to 12 years with mean age of 5.30 + 2.30 years. In phase I, out of a total 50 patients, 40 could be followed with non-interventional strategy. In more than 50% of patients, the prolapse disappeared within 3 months. This was called TSR 50%. In phase II study, out of 50 patients who received IST, 29 improved within 2 weeks of single injection while 12 more improved with second injection within two months. Overall rate of resolution of prolapse at two months [41/50] was highly significant in comparison with proportion of improvement in phase I patients with p-value of 0.001. Four patients received third injection. At the end of three months prolapse disappeared in all patients of this phase [p-value <0.0001]. No complication related to injection occurred. Both non-operative and injection sclerotherapy are effective in managing idiopathic rectal prolapse in paediatric population, but in terms of early recovery injection sclerotherapy is recommended as it is associated with less morbidity and is cost-effective

Management of simultaneously ingested and aspirated foreign bodies in an infant

This report describes the management of a 7-month-old baby who aspirated one and ingested two paper pins at a time. Bronchoscopic removal was done for aspirated pin and ingested pins were observed for spontaneous passage in stool, which occurred in 48 hours without any untoward incidence

Congenital pyloric atresia: Isolated and associated with aplasia cutis congenita

Two cases of congenital pyloric atresia [CPA] are, hereby, reported. One was suspected on antenatal ultrasound and turned out to be an isolated anomaly. Other patient had a rare association of aplasia cutis congenita with congenital pyloric atresia. The lesions of aplasia cutis congenita were multiple while congenital pyloric atresia was of type II. The patient with an isolated lesion survived following surgery while the other baby died of sepsis in postoperative period

Antibiotic sensitivity pattern in burn wound cultures

To find out the pattern of microbial flora and their sensitivity to antibiotics in burn wounds cultures. Design: Descriptive study. Place and Duration During year 2003, at Burns unit, National Institute of Child Health, Karachi. Subject And Twenty five consecutive patients were included in the study and pattern of most common pathogens was studied with special reference to their antibiotic sensitivity. The bacterial cultures were taken at different intervals during the hospital stay, first on the second day of admission and then subsequently, following every 7-10 days. Antibiotic sensitivity pattern was correlated to the antibiotic the patients were receiving. Our results revealed that the most frequent isolate was pseudomonas [80%] followed by staphylococcus aureus [40%], klebsiella [28%], proteus [16%] and streptococcus [8%]. Time related changes showed that the bacterial isolates were predominantly gram negative rods [70%]. in the first culture taken on the 2nd day of admission and remained high throughout the hospital stay and was up to 90% in the final culture. There is a specific pattern of burn wound microbial colonization, with time related changes in dominant flora. Antibiotic sensitivity profile is helpful to make guidelines for dealing with the burn wound at the outset and for which antibiotic to start with. Following this protocol the morbidity and the resistant flora could be avoided

Thymolipoma in a child [a case Report]

A 2 year old male child with history of mild respiratory difficulty and repeated chest infection on CT scan, found to have an anterior mediastinal mass, which pre operatively was suspected as thymolipoma. Through median sternotomy mass was removed in totto. Histopathology confirmed the pre operative diagnosis. Post operative recovery was uneventful. At 6 months follow up there was no recurrence

Neonatal intussusception: a rare entity

Intussusception is a common cause of intestinal obstruction in infancy. It has been reported in pre-matures and during fetal life as well. In full term neonates it is a rare entity. In this case report we describe our experience of management of a six days old male baby. Who turned out to be a case of idiopathic ileoileal intussusception. As the gut was non viable, resection and anastomosis were performed. Post operative recovery were uneventful

Congenital midline cervical cleft: a case report

A 4 months old baby girl was brought with the history of mucoid discharge from small midline defect on the ventral aspect of neck since birth. She had no other associated congenital defect. Family history of facial deformity such as cleft lip or palate or of thyroid disease was negative. On examination the lesion consisted of a cephalad skin tag, a mucosal surface and a caudal sinus in the midline of ventral neck between the chin and suprasternal notch. It was approximately 3 cm long and 1 cm wide. Sinogram of the lesion showed a blind tract going behind sternum. The patient was treated surgically and the cleft with its underlying fibrous cord that was attached with sternum excised. The vertical wound was closed with multiple Z plasties. On histological examination the cleft was partly lined by keratinized stratified epithelium with sebaceous gland and partly by non- keratinized stratified squamous epithelium. Underlying the epithelium were small collection of seromucous salivary glands. Surrounding tissue was densely fibrocollagenous and richly supplied with blood vessels. The post- operative course was uneventful. Patient is on follow up

Hypertrophic pyloric stenosis in a premature. A case report

A four day old baby girl weighing 1.3 kg admitted with respiratory distress. She was delivered by Caesarean section prematurely at 30'h week of gestation due to early rupture of membrane without labor pains. There was no birth asphyxia. She was provided incubator care. As baby was vomiting NG tube was placed. She had non bilious vomiting whenever trial feed given. Surgical opinion was the sought. X ray abdomen showed large gastric shadow with paucity of gas in rest of the abdomen [Figure I]. A diagnosis of malrotation was made. Baby was thus explored. At laparotomy gut was found normally placed with normal caliber of the duodenum. Pylorus was found thickened with dilated stomach. Its appearance was not very classical. Pyloromyotomy was attempted. During the procedure perforation occurred at duodenal end that was closed. Post-operative recovery was uneventful. Baby was put on TPN for 4 days. Trial feed started which was tolerated and then beast feed allowed. She was later discharged