ABSTRACT
Dengue is an important public health problem with a wide clinical spectrum. The World Health Organization classifes dengue into probable dengue, dengue with warning signs, and severe dengue. Severe dengue, characterized by plasma leakage, severe bleeding, or organ impairment, entails signifcant morbidity and mortality if not treated timely. There are no defnitive curative medications for dengue; management is supportive. Judicious fuid resuscitation during the critical phase of dengue is the cornerstone of management. Crystalloids are the initial fuid of choice. Prophylactic platelet transfusion is not recommended. Organ involvement in severe dengue should be carefully looked for and managed. Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication of dengue that needs to be recognized, as specifc management with steroids or intravenous immunoglobulin may improve outcomes. Several compounds with anti-dengue potential are being studied; no anti-dengue drug is available so far.
ABSTRACT
Objective: To document morbidities in adolescents with cystic fibrosis (CF) from India. Methods: Details of children with cystic fibrosis surviving beyond 15 years of age were extracted from hospital records, and analyzed. Results: 43 children [Median (IQR) age 18.7 (17, 20.6) years, were enrolled. Median (IQR) body mass index was 15.82 (13.5, 19.05) kg/m2. Pseudomonas species were isolated from respiratory specimens of 34 (79%) adolescents. Allergic bronchopulmonary aspergillosis (ABPA) and Cystic fibrosis-related diabetes (CFRD) were seen in 12 (28%) and 11 (26%) patients, respectively. Conjugated hyperbilirubinemia and distal intestinal obstruction syndrome (DIOS) were diagnosed in 15 (35%) and 6 (14%) children, respectively. Pseudomonas species colonization (P=0.04) and multiple pulmonary exacerbations in last one year (P<0.001) were significant predictors of FEV1% predicted. Conclusion: Malnutrition, chronic airway colonization, ABPA, CFRD, conjugated hyperbilirubinemia and DIOS are morbidities observed in adolescents with CF in India. The data support the need for early screening of CF-associated morbidities.
ABSTRACT
Background: Impulse oscillometry is an effort-independenttechnique of assessment of airway resistance and reactance, andcan be performed in children unable to complete spirometry.Objective: To evaluate the utility of impulse oscillometry andspirometry for assessing asthma control in children.Study design: Prospective cohort study.Participants: Children aged 5-15 years, with mild to severepersistent asthma.Intervention: On each 3-monthly follow-up visit, clinicalassessment, classification of control of asthma, impulseoscillometry and spirometry were performed.Outcome: Utility of impulse oscillometry parameters [impedance(Z5), resistance (R5), reactance (X5) at 5 Hz, and R5-20(resistance at 20Hz -5Hz) (% predicted), and area of reactance(AX, actual values)] and FEV1 (% predicted) to discriminatebetween controlled and uncontrolled asthma was assessed byreceiver operating characteristic (ROC) curve. Association ofFEV1 and impulse oscillometry parameters over time withcontrolled asthma was evaluated by generalized estimatingequation model.Results: Number of visits in 256 children [mean (SD) age, 100(41.6) mo; boys: 198 (77.3%)], where both impulse oscillometryand spirometry were performed was 2616; symptoms werecontrolled in 48.9% visits. Area under the curve fordiscrimination between controlled and uncontrolled asthma byFEV1, AX, R5-20, Z5, R5, and X5 were 0.58, 0.55, 0.55, 0.52,0.52 and 0.52, respectively. FEV1 [OR (95% CI): 1.02 (1.01-1.03)]and AX [OR (95% CI): 0.88 (0.81-0.97)] measured over theduration of follow-up were significantly associated withcontrolled asthma.Conclusion: Spirometry and impulse oscillometry parametersare comparable in ascertaining controlled asthma. Impulseoscillometry being less effort-dependent may be performed formonitoring control of childhood asthma, especially in youngerchildren.
ABSTRACT
Background & objectives: Pulmonary disease is the main cause of morbidity and mortality in cystic fibrosis (CF). The infection occurs with a unique spectrum of bacterial pathogens that are usually acquired in an age-dependent fashion. The objective of this study was to find out the aetiological agents in respiratory specimens from children with CF during pulmonary exacerbation and relate with demographic variables. Methods: In this observational study, airway secretions from children (n=104) with CF presenting with pulmonary exacerbations were collected and tested for bacteria, fungi, mycobacteria and viral pathogens using appropriate laboratory techniques. The frequencies of isolation of various organisms were calculated and associated with various demographic profiles. Results: Bacteria were isolated in 37 (35.5%) and viral RNA in 27 (29.3%) children. Pseudomonas was the most common bacteria grown in 31 (29.8%) followed by Burkholderia cepacia complex (Bcc) in three (2.8%) patients. Among viruses, Rhinovirus was the most common, identified in 16 (17.4%) samples followed by coronavirus in four (4.3%). Fungi and mycobacteria were isolated from 23 (22.1%) and four (3.8%) children, respectively. Aspergillus flavus was the most common fungus isolated in 13 (12.5%) children. Interpretation & conclusions: Pseudomonas was the most common organism isolated during exacerbation. Non-tuberculous mycobacteria were not isolated, whereas infection with Bcc and Mycobacterium tuberculosis was observed, which could probably have a role in CF morbidity. Polymicrobial infections were associated with severe exacerbations.
ABSTRACT
Objectives: To compare propofol and fentanyl to induceconscious sedation in children undergoing flexiblebronchoscopy.Study design: Randomized controlled trial.Setting: Pediatric Pulmonology division at a tertiary care centerin Delhi, India.Participants: Children aged 3-15 years who underwentflexible bronchoscopy.Intervention: Children received either intravenous propofol 1mg/kg administered as a slow bolus over 1 minute followed by 2mg/kg/hour infusion, or intravenous Fentanyl 2 μg/kgadministered as a slow bolus over one minute.Outcomes: Primary outcome was time to achieve conscioussedation (Ramsay score 3). Secondary outcomes were need foradjuvant midazolam, physician satisfaction, level of cough,recovery features, and side-effects in the groups.Results: 53 children (propofol 27, fentanyl 26) were enrolled inthe study. The mean (SD) time taken to achieve Ramsay score 03was lower in propofol than fentanyl [15.7 (4.4) s vs 206 (55) s,P<0.001]. Propofol arm had significantly higher physiciansatisfaction, less requirement of adjuvant midazolam, lesscoughing and faster regain of full consciousness. There was nodifference in drug side-effects between the groups.Conclusion: Propofol has a shorter sedation induction time, lesscoughing during procedure, less recovery time, and betterphysician satisfaction compared to fentanyl for flexiblebronchoscopy in children.
ABSTRACT
Griscelli syndrome is a rare autosomal recessive inherited disorder characterized by hypopigmentation, silver colored hair, and associated immunological deficiency, which proves fatal in the absence of timely intervention. Our patients diagnosed with Griscelli syndrome-2 presented with fever, hepatosplenomegaly, and deranged hematological and biochemical parameters. Both cases underwent detailed investigations comprising of hair mount microscopic examination, degranulation assay, and mutational studies. Our cases showed defective degranulation activity by NK cells and gene mutation analysis revealed RAB27A mutation that causes defect of cytotoxic granule exocytosis from natural killer (NK) and T-cells, manifesting clinically as hemophagocytic lymphohistiocytosis (HLH). Hematopoietic stem cell transplantation in one of the patients resulted in stable chimerism; however, the second case relapsed within a month after SCT. Stem cell transplantation is the only curative therapeutic option for GS2; thus, improvement in posttransplantation management may reduce mortality and posttransplant complications. Hence, any child who presents with partial albinism and clinical features suggestive of HLH, a peripheral blood, hair shaft mount examination along with basic immunological NK and T-cell cytotoxicity assay by flow cytometry will help clinch the diagnosis early. It can subsequently be confirmed by molecular study. Timely therapeutic intervention can prevent relapses and severe infection and improve outcome in these cases.
ABSTRACT
Objectives: To study the utility of aquagenic wrinkling asscreening test for children with cystic fibrosis.Design: Evaluation of diagnostic test.Setting: Pediatric Chest Clinic, and Pediatric Wards of a tertiarycare hospital in New Delhi.Participants: Three groups (children with cystic fibrosis,carriers of cystic fibrosis, and controls).Method: Time taken to develop aquagenic wrinkling wasmeasured. The test was performed by asking the enrolled subjectto put their one hand in water and was checked for development ofwrinkling every minute, and a photograph was also taken everyminute.Results: A total of 64 children with cystic fibrosis, 64 controls and64 carriers were enrolled in the study. Median (IQR) time todevelop aquagenic wrinkling in the three groups was 2 (1.5,3)minutes, 4 (3,5) minutes and 8 (5,11) minutes, respectively. Theoptimal cut-off was calculated as 3 minutes by Receiveroperating characteristic curve with a sensitivity and specificityfor identification of children with cystic fibrosis as 81% and 57%,respectively. The area under curve was 76.5%. The 3 minutecut-off for development of aquagenic wrinkling was applied to 54children referred for sweat test. 20 children had sweat chloridevalues of ≥60 mEq/l and diagnosed as cystic fibrosis. 15 of thesedeveloped aquagenic wrinkling at ≤3 minutes, giving a sensitivityof 75%.Conclusion: In places with no facility for sweat test, childrenwith phenotype compatible with cystic fibrosis who developaquagenic wrinkling in 3 minutes may be diagnosed as probablecystic fibrosis and referred for confirmation by sweat tes
ABSTRACT
Background & objectives: Antimicrobial resistance is a major challenge in the treatment of typhoid fever with limited choices left to empirically treat these patients. The present study was undertaken to determine the current practices of antibiotic use in children attending a tertiary care hospital in north India. Methods: This was a descriptive observational study in children suffering from enteric fever as per the case definition including clinical and laboratory parameters. The antibiotic audit in hospitalized children was measured as days of therapy per 1000 patient days and in outpatient department (OPD) as antibiotic prescription on the treatment card. Results: A total of 128 children with enteric fever were included in the study, of whom, 30 were hospitalized and 98 were treated from OPD. The mean duration of fever was 9.5 days at the time of presentation. Of these, 45 per cent were culture positive with Salmonella Typhi being aetiological agent in 68 per cent followed by S. Paratyphi A in 32 per cent. During hospitalization, the average length of stay was 10 days with mean duration of defervescence 6.4 days. Based on antimicrobial susceptibility ceftriaxone was given to 28 patients with mean duration of treatment being six days. An additional antibiotic was needed in six patients due to clinical non-response. In OPD, 79 patients were prescribed cefixime and additional antibiotic was needed in five during follow up visit. Interpretation & conclusions: Based on our findings, ceftriaxone and cefixime seemed to be the first line of antibiotic treatment for typhoid fever. Despite susceptibility, clinical non-response was seen in around 10 per cent of the patients who needed combinations of antibiotics.
ABSTRACT
Objectives: To document clinical features and outcome of children with sarcoidosis.Methods: Case records of 18 children (mean (SD) age 9 (2.2) years) diagnosed withsarcoidosis between 2006 and 2016 were reviewed. All children were followed up every 2-3months and monitored for clinical and laboratory parameters. Their treatment and outcomewere recorded. Results: Clinical features at the time of diagnosis were fever (83%), uveitis(50%), difficulty in breathing (44%), hepatosplenomegaly, weight loss, arthritis and peripheraladenopathy. Imaging findings included: hilar adenopathy (94%), abdominal nodes (50%) andpulmonary infiltrates (44%). All children were treated with steroids (range 6-12 months) andweekly low dose oral methotrexate. All patients showed significant improvement over a mean(SD) duration of follow-up of 3.1 (0.9) years, as assessed by resolution of clinical symptoms,and improvement in spirometry parameters, erythrocyte sedimentation rate, and serumangiotensin converting enzyme levels. Conclusions: Children with sarcoidosis seem torespond well to systemic steroids and low dose methotrexate. Delayed diagnosis and ocularinvolvement are probably associated with poor outcome.
ABSTRACT
Objective: To evaluate utility of XpertMTB/RIF in bronchoalveolar lavage fluid in childrenwith probable pulmonary tuberculosis. Methods: Children with probable pulmonarytuberculosis with negative smear and Xpert on induced sputum/gastric aspirate weresubjected to bronchoalveolar lavage (BAL) for Xpert assay and mycobacterial liquid culture.Data of children <14 y undergoing bronchoscopy for suspected MDR-TB (n=12) were alsoanalyzed. The sensitivity of Xpert in BAL fluid for diagnosis of probable and confirmedpulmonary tuberculosis was calculated with clinico-radiological diagnosis and culture as goldstandards, respectively. Results: Of 41 enrolled children, 24 (58.5%) had Xpert positive inBAL fluid and 11 (26.8%) had culture confirmed tuberculosis (BAL fluid;10; sputum,1). Thesensitivity of Xpert in BAL fluid among probable and culture confirmed tuberculosis caseswas 58.5% (24/41) and 81.8% (9/11), respectively. Conclusion: Xpert in bronchoalveolarlavage fluid has good sensitivity in both probable and confirmed pulmonary tuberculosis inchildren
ABSTRACT
Objectives: To compare patient outcomes using the Pediatric Index of Mortality-3 (PIM-3)model with PIM-2 model for children admitted to the intensive care unit. Methods: Weprospectively recorded the baseline characteristics, variables of PIM-3 and PIM-2 atadmission, and outcomes of children ?17 years over a period of 11 months. We used AreaUnder Receiver Operating Characteristics (AU-ROC) curves and Goodness-of-fit (GOF)tests to determine which of the two models had better discrimination and calibration.Results: Out of 202 children enrolled, 69 (34%) died. Sepsis and pneumonia were thecommon admitting diagnoses. The AU-ROC was better for PIM-3 (0.75) as compared to PIM-2 (0.69; P=0.001). The GOF-P value was 0.001 for both models, that indicated poorcalibration of both (P<0.001). The AU-ROC curves were acceptable across different age anddiagnostic sub-groups. Conclusion: PIM-3 had better discrimination when compared toPIM-2 in our unit. Both models had poor calibration across deciles of risk.
ABSTRACT
Background & objectives: Bartonella henselae causes infections which closely resemble febrile illness and chronic diseases such as tuberculosis and haematological malignancies. There are not many studies on Bartonella infections from India. The present study was undertaken to diagnose B. henselae infection in diverse clinical conditions in a tertiary care hospital in north India. Methods: A total of 145 patients including those with fever and lymphadenopathy, infective endocarditis and neuroretinitis were enrolled in the study. Whole blood, serum and lymph node aspirate and valvular vegetations if available, were obtained. Samples were plated on chocolate agar and brain-heart infusion agar containing five per cent fresh rabbit blood and were incubated at 35°C for at least four weeks in five per cent CO2with high humidity. Immunofluorescent antibody assay (IFA) was done for the detection of IgM antibodies in the serum using a commercial kit. Whole blood was used to perform polymerase chain reaction (PCR) for the citrate synthase gene (gltA). Results: IFA was positive in 11 of 140 (7.85%) patients and PCR was positive in 3 of 140 (2.14%) patients. Culture was negative in all the cases. A higher incidence of Bartonella infection was seen in patients with fever and lymphadenopathy (n=30), seven of whom were children. In ophthalmological conditions, four cases were IFA positive. Interpretation & conclusions: The present study shows that the threat of Bartonella infection is a reality in India. It is also an important treatable cause of fever and lymphadenopathy in children. Serology and PCR are useful tests for its diagnosis. Clinicians should consider Bartonella infection in the differential diagnosis of febrile illnesses and chronic diseases.
ABSTRACT
We report a case of dystrophic calcification presenting as soft cystic swelling in a patient with juvenile dermatomyositis. A 15-year-old boy with lumbosacral cystic swelling, which was considered a cold abscess clinically, was evaluated for nonresponse to antitubercular therapy. The cystic swelling had liquefied calcium with a well circumscribed calcified wall on imaging, which was subsequently excised. Natl Med J India 2016;29:87–8
ABSTRACT
We share our experience with biological agents in children with juvenile idiopathic arthritis with an aim to highlight the adverse events and response to treatment. Out of a total of 10 children treated with biological agents, one patient had serious infection, all showed good response and none had tuberculosis. High cost was limiting factor for their use.
ABSTRACT
Objective: This study was devised to translate Cystic Fibrosis Questionnaire-Revised to Hindi and administer it to Indian children and adolescents diagnosed with cystic fibrosis. Design: Cross-sectional study. Setting: This study was carried out in cystic fibrosis patients attending Pediatric Chest Clinic of a tertiary-care hospital in Northern India from July 2012 to December 2012. Participants: 45 children (6-13 years) and their parents, and 14 adolescents. Patients with unstable health in the past two weeks were excluded. Intervention: Cystic Fibrosis Questionnaire- Revised translated in Hindi was administered. Clinical evaluation and scoring, throat swab cultures and spirometry were also done during the same visit. Main Outcome Measures: Health Related Quality of Life scores were the primary measures, and clinical scores, swab cultures and spirometry were secondary measures. Results: Cronbach’s alpha ranged from 0.020-0.863.The Factor analysis indicated that most test-items correlated more with competing scales than the intended scales. Convergence between self and proxy-rating was found to be dependent on the domain. The Cystic Fibrosis Questionnaire- Revised scores correlated well with clinical scores (r=0.65,P=0.011), Pseudomonas spp culture data and pulmonary function tests. There was an inverse relation between Health Related Quality of Life scores and age at diagnosis (r=-0.339, P=0.02). Conclusions: Hindi versions of Cystic Fibrosis Questionnaire- Revised: Child, Adolescent and Parents’ instruments will act as an important step towards data on Health Related Quality of Life of Indian patients with cystic fibrosis.