Protective role of BCG vaccination against tuberculous meningitis in Indian children: a reappraisal.

BACKGROUND: The protective role of BCG vaccination against tuberculous meningitis (TBM) is still controversial in India, largely due to the presence of other predisposing factors such as age, nutritional and socioeconomic status, and household contact. Very few Indian studies have focused on the interaction between BCG and these factors on the occurrence of TBM. METHODS: We did an unmatched hospital-based case-control study with prospective enrolment. Children with TBM diagnosed on the basis of predefined criteria were enrolled as cases. For each case, two children admitted on the same day and who did not have any neurological symptoms were enrolled as controls. Demographic data and information on predisposing factors for tuberculosis were collected for both cases and controls and the presence of a BCG scar was charted. Cases and controls were compared by univariate followed by multivariate analysis to obtain significant independent predictors for the occurrence of TBM. To assess the interaction between other predisposing factors and protective efficacy of BCG, a stratified analysis was also done. RESULTS: A total of 91 cases and 182 controls were enrolled over a one-year study period, of which 37 cases and 111 controls had a BCG scar. The crude odds ratio for the occurrence of TBM in the absence of a BCG scar was 2.28 (range: 1.32-3.94). The time elapsed since vaccination was significantly longer in the cases. Also, the proportion with a household contact was significantly higher in the cases, the mean age of the cases was higher than that of the controls, and the mean weight and height for age percentage were significantly lower. The cases had a significantly lower socioeconomic status. On multivariate analysis, the significant independent predictors for the occurrence of TBM were positive household contact with tuberculosis (adjusted OR 4.26; 95% CCI 2.26-8.04), absent BCG scar (adjusted OR 1.98; 95%ClI 1.09-3.57) and rural residence (adjusted OR 2.07; 95% ClI 1.02-4.17). CONCLUSION: Vaccination with BCG was found to be protective even after controlling for the effect of other variables. Stratified analysis showed that protection due to BCG failed to reach significance for those > 5 years of age, if the weight was <6 0% of that expected for age, in the presence of a household contact with tuberculosis, and in socioeconomic classes III, IV and V.

A clinical study of the patients with dengue hemorrhagic fever during the epidemic of 1996 at Lucknow, India.

This paper describes the clinical findings in 206 patients with dengue fever (DF) or with dengue hemorrhagic fever (DHF) during the epidemic of 1996 at Lucknow. The age group affected most was 11 to 30 years and 21% of the patients were less than 10 years old. The male:female ratio was 1.9:1. The onset was abrupt in all the patients, severe frontal headache was observed in 97%, myalgia in 90%, skin rash in 40%, vomiting in 29% and arthralgia in knee and hip joints in 9%. Anuria was seen in two patients. Lymphadenopathy was noted in 14%, hepatomegaly in 4%, being associated with mild jaundice in one patient, and splenomegaly in 2% of the patients. Involvement of the heart and lungs was seen in one patient each and no case with encephalitis was recorded. Hemorrhages from various sites were observed in 54% patients and 17 patients had profound shock. The commonest bleeding site was gums. Profound shock was preceded by various warning signs, the commonest being sudden hypotension. Among the patients with profound shock the mortality was 47% while the overall fatality rate was 3.8%. A number of the risk factors existed for a long time in this part of the world, but what precipitated the present epidemic at this time, is not known.

Diagnosis of tuberculous meningitis by detection of antigen and antibodies in CSF and sera.

OBJECTIVE: To evaluate diagnostic potential of three immunological tests, namely, detection of H37Rv antigen of M. Tuberculosis in CSF, detection of antibodies (IgG) against H37Rv in CSF and detection of antibodies (IgG) against H37Rv in serum for diagnosis of tuberculous meningitis in children. SUBJECTS: 50 children diagnosed as patients of tuberculous meningitis were included as cases and 48 children with CNS diseases of nontubercular etiology [pyogenic meningitis (n = 31), encephalitis (n = 10), seizure disorder of unknown etiology (n = 5), brain tumor (n = 2)] served as controls. METHODS: H37Rv antigen of M. tuberculosis was detected in CSF by Dot ELISA, and antibodies (IgG) against H37Rv in CSF and serum were detected by Plate ELISA. RESULTS: Detection of H37Rv antigen in CSF was the most sensitive (90%) and specific (95.83%) with positive and negative predictive values of 95.74% and 90.19%, respectively, followed by detection of antibodies in CSF (sensitivity-74%, specificity-89.58%, positive predictive value-88.10%, negative predictive value-76.78%). Detection of antibodies in serum had low sensitivity (50%), specificity (91.67%), positive predictive value (86.21%) and negative predictive value (63.76%). CONCLUSIONS: Detection of antigen in CSF is a rapid, sensitive and specific test for diagnosis of tuberculous meningitis in children. Detection of antibody in CSF may be useful in some cases but needs further evaluation. Detection of antibody in serum does not appear to be useful for diagnosis of tuberculous meningitis.

Trends in poisoning in children: experience at a large referral teaching hospital.

BACKGROUND: Poisoning is a major problem in the paediatric population. The offending substances used vary from place to place. Information on poisoning trends in India is meagre and there is an impression among clinicians that there has been a change in the commonly used poisons over the years. This retrospective study aimed to determine the pattern of poisoning in children and to study the nationwide trend over the past five decades. METHODS: Case records of children (age group: 1 month and above) admitted to the Department of Paediatrics, King George's Medical College, Lucknow, Uttar Pradesh in three alternate calendar years, i.e. 1989, 1991 and 1993 were screened. All children were grouped into three categories based on the poison: (i) bites and stings, (ii) medicinal compounds, and (iii) non-medicinal compounds. The Indian literature on poisoning in children was reviewed and decade-wise data from a total of 22 studies (including the present study) were used to determine the changing trend. RESULTS: Childhood poisoning constituted 2.1% of the total paediatric admissions and 1.2% of total deaths. Non-medicinal compounds were the largest contributors (69.2%), of which kerosene alone was responsible for 47% of cases. Medicinal compounds, and bites and stings accounted for 21.6% and 9.2% of these cases, respectively. The case-fatality rate was 9.2%. Comparison of our data, after excluding bites and stings, with a previous study (1977-79) from our institution showed that kerosene poisoning continues to be responsible for a substantial part of the morbidity (51.8% v. 31.5%). Also, poisoning due to insecticides and pesticides has increased (13.7% v. 2.1%) while that due to plant poisons (primarily dhatura) has reduced markedly (4.8% v. 19.2%). CONCLUSION: Mortality due to poisoning in children has remained high over the last five decades (2.9%-4.7%). Kerosene has remained the single largest contributor to childhood poisoning (51.5% in the 1960s v. 52.8% in the 1990s).

Predictors of outcome in fulminant hepatic failure in children.

OBJECTIVE: To identify the predictors of outcome in fulminant hepatic failure (FHF) in children. STUDY DESIGN: Prospective cohort study. METHODS: 41 children with FHF were studied. Patient characteristics and findings on examination at the time of hospitalization were noted. Serum biochemistry and screening for hepatotropic viruses (A, B and C) were done in each patient. Patients were treated using a predefined protocol and followed up till death or discharge. Univariate and multivariate analysis was done to find the predictors of outcome. RESULTS: Hepatitis B was the commonest cause of FHF (11 children; 26.9%). Markers for hepatitis A and C viruses were present in one and two patients, respectively. Serology was negative in 27 children (65.9%), of whom two had history of ingestion of hepatotoxins (antitubercular drugs). The overall mortality was 61%. Irrespective of etiology, the following factors were associated with poor outcome on univariate analysis: presence of gastrointestinal (GI) hemorrhage, serum bilirubin more than 10 mg/dL, age 6 years or less, coma of grade 3 or more, presence of infection, prolongation of prothrombin time > 8 s over control, prothrombin concentration < 50%, hypoglycemia (blood glucose < 45 mg/dL), hyponatremia (serum sodium < 125 mEq/L) and hyperkalemia (serum potassium > 5.5 mEq/L). On multiple logistic regression analysis, presence of GI hemorrhage (p = 0.005), degree of coma (p = 0.02) and serum bilirubin level (p = 0.025) were identified as independent predictors of mortality.

Pulmonary function tests in normal Indian children and changes in respiratory disorders.

To document the normal values of pulmonary function tests in children and changes occurring in their values with various respiratory disorders, a study was carried over a period of one year in 95 healthy controls (39 females and 56 males) of 8-13 years of age and 51 cases with respiratory disorders (bronchial asthma-31, pneumonia-10, empyema-10) of matched age, sex and height distribution. The lung functions studied were FVC, FEV1, FEV1/FVC, PEFR and FEF25-75%. In children with bronchial asthma, the FEV1/FVC%, PEFR and FEF25-75% were reduced in accordance with the severity of the disease. A typical restrictive pattern of equivalent decrease in FVC and FEV1 along with insignificant lowering of flow rates, i.e., PEFR and FEF25-75% was observed in pneumonia whereas in patients of empyema a combined pattern of significantly decreased FVC and FEV1 along with mildly reduced FEV1/FVC%, PEFR and FEF 25 75% was observed.

Outcome in relation to Apgar score in term neonates.

Sixty four asphyxiated term babies (Apgar score of 6 or less at 5 minutes) and 90 non-asphyxiated term babies (controls) were studied. Of these, 40 cases and 48 controls could be followed up. Mortality and neurodevelopmental outcome were studied in both the cases and controls. Mortality and poor neurodevelopmental outcome correlated inversely with the Apgar scores at 5 and 10 minutes. The outcome of babies with low 5 minute Apgar scores was significantly better than those with the same scores at 10 minutes. Symptomatic neonates when compared to asymptomatic neonates with same Apgar score showed significantly poorer outcome. Babies with Apgar scores of 6 at 5 or 10 minutes behaved like the controls both in terms of mortality and neurodevelopmental outcome.

Computed tomography of brain in symptomatic birth asphyxia.

Twenty five asphyxiated newborns (seventeen term and eight preterm) with mean gestational age of 37 weeks (range 28-48 weeks) and mean birth weight of 2.4 kg (range 0.75 kg to 3.5 kg), respectively, constituted the cases in present study. Normal CT scan was found in five term (29.4%) and two preterm babies (25%). CT abnormalities noted in term babies included hemorrhage (subarachnoid 5.8%, intracerebral 11.6%), hypodensity (mild 23.2%, moderate 11.6% severe 5.8%); hypodensity with hemorrhage 5.8% and cerebral atrophy 5.8%. In the preterm babies abnormalities included intraventricular hemorrhage in 25%, isolated hypodensity in 37.5% and hypodensity with hemorrhage in 12.5% cases. Where as mild hypodensity on CT scan in the absence of hemorrhage or other gross abnormality was indicative of a favourable outcome, moderate to severe hypodensity was indicative of ischemic brain injury and an unfavourable outcome. The presence of intraventricular hemorrhage irrespective of the size of bleed was associated with mortality in all in the present study.

Renal failure in symptomatic perinatal asphyxia.

The study included seven term newborns developing acute renal failure due to symptomatic perinatal asphyxia in early neonatal period. Its diagnosis was based on clinical and biochemical indices. Urinary output, serum and urinary sodium, potassium and creatinine, and blood urea nitrogen were evaluated in all of them. All the patients had oliguria not responding to fluid challenge and/or diuretic therapy, high serum K, FeNa of greater than 2.5% and RFI of greater than 3 indicative of intrinsic renal disease. The condition was associated with a very high mortality.

Serum and hair zinc in Indian childhood cirrhosis.

Zinc levels in serum and hair were estimated in 32 cases of Indian Childhood Cirrhosis (ICC)--14 in Stage II and 18 in Stage III. Levels were compared with 20 cases of age matched healthy controls. Mean serum zinc level in ICC was 62.0 +/- 13.10 micrograms/dl as compared to 115.7 +/- 12.62 micrograms/dl in controls. The difference was statistically significant. Further, mean level of serum zinc (70.78 +/- 12.95 micrograms/dl) in Stage II was significantly higher than the level 55.88 +/- 8.16 micrograms/dl in Stage III, thereby showing an inverse relationship with the severity of the disease. Mean hair zinc level of 144.53 +/- 23.26 micrograms/g in ICC was much lower than that of 172.5 micrograms/g in controls. The study revealed an altered state of zinc nutrition in children with ICC.