Kawasaki disease experience at tertiary care hospital Rawalpindi, Pakistan

Objective: To study the clinical features, investigations, cardiac complications, effects of treatment and demographic profiles in patients with classical Kawasaki disease [KD]

Study Design: Descriptive study

Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2007 to Dec 2011

Patients and Methods: Twenty five children of either gender aged 2 months to 12 years diagnosed with KD based on the international diagnostic criteria were included in this study. Collected data included patient demographics, clinical features, investigations, echo-cardio graphic findings, treatment and follow-up

Results: A total of 25 patients were evaluated during the above mentioned duration. Mean age at diagnosis was 3.7 years [SD +/- 3.05]. Fever was present in 100 percent of the patients with the other major diagnostic features present in more than 90 percent of the patients. Seventeen [68 percent] patients presented after ten days of fever. Coronary aneurysms were seen in 40 percent of the patients. We administered intravenous immune-globulins [IVIG] in 100 percent of the patients. 12 percent of the patients still had coronary aneurysms after 1 year of diagnosis. There was no mortality

Conclusion: KD needs to be considered in the differential diagnosis of all children with persistent unexplained fever with rash. A great number of cases of KD are missed and treated as common cold or flu. Diagnostic criteria used for KD is helpful in diagnosis of KD and can help in early prompt treatment with IVIG to prevent the life threatening complication of coronary aneurysms

Outcome and Prognostic factors of stroke in children presenting at an Army hospital in Pakistan

Objective: To determine the outcome and prognostic factors of stroke in children presenting at Military Hospital Rawalpindi

Study Design: Cross-sectional study

Place and Duration of Study: This study was conducted at the department of Pediatrics, Military Hospital Rawalpindi, from Oct 2012 to Mar 2014

Patients and Methods: Sixty consecutive children presenting with stroke were included in this study after taking written informed consent from the guardians/parents. A predesigned proforma was used to record patient's demographic details along with the presenting complaints, type of stroke, underlying cause and outcome

Results: The mean age of the patients was 3.49 +/- 3.29 [Mean +/- SD] years. There were 35 [58.3 percent] male and 25 [41.7 percent] female children. Ischemic stroke was the most frequent and was observed in 37 [61.7 percent] patients followed by hemorrhagic [16.7 percent], sinovenous thrombosis [8.3 percent] and ischemia with hemorrhagic findings [6.7 percent]. Mixed lesions and transient ischemic attacks were reported in 2 [3.3 percent] patient each. Mean length of hospital stay was 9 +/- 6 [Mean +/- SD] days. Sixteen [26.7 percent] children recovered completely while 41 [68.3 percent] children had some neurological deficit at discharge. Mild to moderate deficit was recorded in 21 [35.0 percent] children while 20 [33.3 percent] children had severe deficit. Three [5.0 percent] patients expired during hospital stay

Conclusion: Ischemic stroke was the most common cause of paediatric stroke. Important risk factors of peadiatric stroke included congenital heart diseases and intracranial infections. Poor prognostic factors included male gender, age less 5 years and congenital heart disease

Clinical spectrum of seizures and efficacy of anticonvulsive treatment in children

Objective: To study the clinical spectrum of seizures and efficacy of anticonvulsive treatment in children

Study Design: A descriptive study

Place and Duration of Study: Military Hospital [MH] Rawalpindi from October 2011 to March 2012

Material and Methods: One hundred children of either gender aged 1 month to 12 years presenting with seizures at Military Hospital Rawalpindi were evaluated and consented to participate in the study. All children with a febrile seizures were evaluated. The seizures were classified according to international league against epilepsy guidelines. Antiepileptic treatment regimen was evaluated in terms of number of drugs, correct dosage and efficacy in control of seizures

Results: It was observed that generalized seizures were [58%] followed by focal seizures [32%] in children. Valproic acid was prescribed in [51%] cases. Epilepsy was diagnosed in [56%] followed by cerebral palsy [20%], post meningoencephalitis sequalae [11%], intracranial hemorrhage [7%] and leukodystrophies [3%] as underlying cause of seizures. Statistically significant association was seen between age groups and diagnosis [p value=0.001]; age groups and types of seizures [p value=0.046]; correct dosage of antiepileptics and control of seizures [p value=0.007]; compliance to treatment and control of seizures [p value=0.007]

Conclusion: Generalized seizures are the commonest form followed by focal seizures. Epilepsy was the common etiology of seizures in all age groups in children. Cerebral palsy was the second leading cause of seizures in children followed by post meningoencephalitis, stroke and leukodystrophies. Valproic acid was the most commonly prescribed antiepileptic. Normal delivery with delayed cry was the major risk factor for cerebral palsy. Prescription of appropriate antiepileptics according to diagnosis in optimum dosage and compliance to treatment affect control of seizures in children

Need for notifying and prevention of congenital anomalies

Objective: To determine the frequency of different systems involved in congenital anomalies to prevention and notifying strategies

Study Design: Descriptive observational study

Place and Duration of Study: The study was carried out at Military Hospital, Rawalpindi, from Jan 2011 to Aug 2013

Material and Methods: The study was carried out at Military Hospital, Rawalpindi. The data of all the neonates with congenital anomalies was analyzed in term of sex and various system involved. Various type of tests were used for the diagnosis of different defects like, barium studies, computed topography, magnetic resonance imaging, echocardiography, x-rays, ultrasound

Results: Total number of admissions during the study period were 4201 out of which 371 [8.83%] were diagnosed cases of congenital anomalies. Of these babies 220 [59.30%] were male, 142 [38.27%] were females and the remaining 9 [2.43%] were with ambiguous genitalia 215 [57.95%] were delivered by normal vaginal delivery and rest 156 [42.05%] by lower segment caesarian section. The most common system involved was central nervous system [CNS] 89 [23.99%], followed by gastro intestinal tract 74 [19.95%], cardiovascular system 61 [16.44%], respiratory system 35 [9.43%] and genito urinary system 18 [4.85%]. Babies with dysmorphic features were 48 [12.94%] and with cleft lip and palate 17 [4.58%]. The remaining 29 [7.82%] were grouped in miscellaneous category

Conclusion: Congenital anomalies are an important cause of admission to NICU. The prevalence of congenital anomalies was found more in males than in females. In our set up the most common system involved in congenital anomalies is central nervous system followed by gastrointestinal tract and cardiovascular systems

Methylmalonic acidemia

Methylmalonic Acidemia [MMA] is an inborn error of metabolism that results in accumulation of methylmalonic acid in blood and increased excretion in urine. The effects of MMA vary from mild to life threatening and it usually presents in early infancy. Affected infants can have vomiting, dehydration, hypotonia, developmental delay and failure to thrive. The emergency treatment of the newborn with MMA mainly comprises rehydration and promotion of anabolism, followed by long-term dietary management by both the restriction of precursor amino acids using a low protein diet and avoidance of prolonged fasting. Prognosis depends on the type of MMA and whether the condition is well controlled in general and during episodes of metabolic decompensation. We report here the presentation and management of a 2-year boy with MMA who failed to achieve expected milestones for age. To the best of our knowledge, only one case of MMA has been reported from Pakistan

Frequency of helicobacter pylori [HP] infection in children with recurrent abdominal pain [RAP]

To study the frequency of Helicobacter Pylori [HP[infection among children with recurrent abdominal pain [RAP]. Cross-sectional comparative study. Military Hospital [MH], Rawalpindi from December 2011 to February 2012. One hundred children of either gender aged 2 to 12 years presenting with RAP were tested for HP at Paediatric OPD MH, Rawalpindi who consented to participate in the study. Those children who tested positive for Helicobacter Pylori Stool Antigen Test [HPSAT] were labeled as those having Hp infection. The stool assay was performed using the HpSAT kit and the socio-demographic and clinical profiles of children were associated. Out of 100 children included in the study HpSAT was positive in 38% children. Frequency of Hp infection was significantly associated with source of drinking water [p = 0.014], socioeconomic status [p =0.001] and positive family history of dyspepsia [p= 0.023]. While age and gender have no significant association with HP infection. Hp infection is very common in children presenting with RAP in our Paediatric OPD. Children with family history of dyspepsia, from low socioeconomic class and those drinking filtered water are at greater risk for HP infection. It is recommended that children from other populations in our country should also be tested in their medical health facilities in order to have a wider analysis of this problem in our setup

Effect of place of birth, mode of transport and medical skills of the accompanying person on mortality of neonates

Objective: To determine the effect of place of birth, mode of transport and medical skills of the accompanying person on mortality of neonates

Study Design: A descriptive study

Place and Duration of Study: Military Hospital [MH], Rawalpindi from October 2011 to March 2012

Patients and Method: One thousand two hundred and ninety three neonates of either gender under the age of 28 days admitted to NICU either as indoor or outdoor were entered in the study. Data included high risk obstetric factors, gestational age, birth weight, APGAR score, gender, need for resuscitation, diagnosis, complications, place of delivery, mode of delivery and outcome. The associations between the place of delivery, mode of delivery and medical skills of the accompanying person with the neonatal mortality were associated using the Pearson Chi-Square method

Results: A total of 1293 neonates were included in the study and their data regarding place of delivery and mode of transport was evaluated. Four hundred and two [402/1293] cases died in our NICU and the mortality rate of the neonates admitted in our setup was 31.1%. The breakup of neonatal deaths was further subdivided into the patients born in health care with NICU facility [25%], those born in health care without NICU facility [33.60%] and those born in the community setting [40.54%]. The aforementioned percentages were calculated out of the total live births in that particular setup and do not represent mere breakup of total mortality. A total of 50.32% neonates brought to hospital in an unequipped vehicle expired versus 2.28% mortality of neonates that were brought in a medically equipped vehicle. The neonatal mortality rate in patients accompanied by unskilled personnel was 40% versus skilled personnel which was 1.62%. Statistically significant associations using Pearson Chi-Square method were seen between the place of delivery, mode of transport, the skills of the person accompanying the patient in the transport and neonatal mortality [p value = 0.001 each]

Conclusion: Results of this study prove that the quality of birth services and patient transport mechanisms directly affect the neonatal survival and babies who are born in community setting, transported in unequipped vehicle without a skilled medical attendant are at a higher risk for mortality than the patients born in NICU facility, transported in an equipped vehicle and accompanied by skilled medical attendant

Eleven-year-old-girl with membranous sore throat

Diphtheria is caused by Corynebacterium diphtheriae primarily affecting mucous membrane of upper airways. Global incidence of diphtheria has reduced due to worldwide immunization programs. Yet cases of diphtheria are reported across the world because of poor vaccine coverage, large population and low socio economic status. We report here a case of diphtheria in an 11-year-old girl who presented with fever, sore throat, difficulty in swallowing and hoarseness of voice for 3 days. Hematological analysis showed neutrophit leukocytosis with normal lymphocytes, CRP was raised, cardiac profile, renal function test, hepatic functions and chest x-ray were normal. Microscopy of throat swab revealed rods containing metachromatic granules .on Albert stain. Intramuscular penicillin was started and diphtheria antioxin was administered. The child recovered uneventfully and was kept on follow up

Neonatal seizures; types, etiology and long term neurodevelopmental outcome at a tertiary care hospital

To study the types, etiology and long term neurodevelopmental outcome in neonates with seizures.A descriptive cross-sectional study. PNS Shifa Naval hospital Karachi from Jan 2011 to Feb 2014.Population: Ninety six neonates of either gender presented with seizures at NICU PNS Shifa Naval hospital Karachi were studied. Method: All neonates with seizures were evaluated. The seizures were classified according to the simiology. They were investigated according to NICU protocol to confirm the underlying diagnosis and timely management. The patients after discharge were regularly followed up for one year to assess the long term neurodevelopmental outcome. A total of 96 neonates with seizures were studied and it was observed that 60 [62.5%] were male babies and 56 [58.33%] were term with a male to female ratio of 1.6:1. Majority of the neonatal seizures were seen in 1stweek of life [85%]. The most common type of seizures was clonic 40 [41.67%] followed by subtle 20 [20.84%], mixed 16 [16.67%], tonic 10 [10.41%], myoclonic 5 [5.20%] and unclassified 5 [5.20%]. Antiepileptics were used in 82 [85.41%] patients. Phenobarbitone 49 [59.76%] was most commonly prescribed drug. The most common cause of seizures was birth asphyxia 48 [50%] followed by metabolic 16 [16.68%], sepsis 10 [10.41%], intracranial hemorrhage 6 [6.25%], bilirubin encephalopathy 4 [4.16%], inborn errors of metabolism 2 [2.08%], birth trauma 2 [2.08%] and unknown etiology 5 [5.20%]. 25 [26.04%] patients develop adverse neurodevelopmental outcome i.e. cerebral palsy with epilepsy 10 [40%] and cerebral palsy without epilepsy 05 [20%], developmental delay 10 [40%]. Mortality in the study was 12 [12.5%]. Clonic seizures are commonest in neonates apart from infants and children who have GTCS. The most common etiology of seizures in neonates is birth asphyxia. Phenobarbitone is still the most commonly prescribed antiepileptic. Quick assessment, timely diagnosis and aggressive management according to the etiology are necessary to prevent the morbidity and mortality associated with neonatal seizures. Long term neurodevelopmental outcome is worse in patients with birth asphyxia especially with low Apgar score at 5 minutes. Normal delivery and birth asphyxia were the major risk factors for cerebral palsy

five years old girl child with takayasu arteritis

Takayasu arteritis is a systemic vasulitis of large vessels that mainly involves the aorta and its branches. It normally presents in third decade of life and has rarely been reported in children under 10 years of age. We report here a case of Takayasu arteritis in a 5 years old girl who presented with headache, generalized body swelling, severe hypertension, proteinuria and minimal functioning kidneys. Conventional angiography demonstrated narrowing of descending aorta, right subclavian artery and right common iliac artery. She responded steroids, diuretics, antiplatelets and digoxin and discharged home on maintenance therapy.

Diagnostic value of C-reactive protein and haematological parameters in neonatal sepsis

To analyse various parameters of sepsis screen singly and in combination to formulate a guideline for the diagnosis of neonatal sepsis. Design: A cross-sectional analytical study. Place and Duration of Study: The neonatal intensive care unit at the Paediatric Department, Military Hospital, Rawalpindi, over a period of seven months from 1st June to 31st December 2003. Subjects and One hundred neonates having clinical features of sepsis and 100 normal asymptomatic neonates were evaluated with a set of investigations. C-reactive protein [CRP], erythrocyte sedimentation rate, total leukocyte count, absolute neutrophil count [ANC], immature neutrophils to total neutrophil count ratio [I/T ratio], thrombocytopenia, degenerative changes in the neutrophils and gastric aspirate cytology [GAC] for polymorphs were used for diagnosis of neonatal sepsis. CRP was positive in 24/28 [85.7%] of group-A [proven sepsis] and 58/72 [80.5%] of group-B [probable sepsis] and had a specificity of 95%. ANC was the second most sensitive test having sensitivity of 71.4% for group- A and 63.9% for group-B and 88% specificity. For group-A, sensitivity of GAC for polymorphs and platelet count was 71.4% and 64.3% respectively. The sensitivity, specificity and predictive values [PV] of the individual tests and different tests combination was also calculated for group-A and B. A set of investigations including CRP, TLC, ANC, thrombocytopenia, cytoplasmic vacuolization in the neutrophils and GAC for polymorphs are highly sensitive in detection of culture negative cases of neonatal sepsis. Moreover, a combination of three tests enhances the sensitivity of these tests

Incidence of respiratory distress syndrome

To determine the incidence of respiratory distress syndrome [RDS] in hospital born babies. Design: A prospective study. Place and Duration of Study: The study was conducted in the neonatal intensive care unit [NICU] at the Pediatric department, in collaboration with the Obstetrics and Gynecology Department, Military Hospital, Rawalpindi, over a period of one year from January to December 2000. Subjects and All live born infants delivered at the hospital and who fulfilled the diagnostic criteria of respiratory distress syndrome [RDS] were included in the study. Ninety-four neonates developed RDS. Out of these, 88 [93.61%] were preterm and 06 [6.38%] were term infants. There was a male preponderance [65.95%]. RDS was documented in 1.72% of total live births, 37.28% of preterm and 0.11% of term neonates born at the hospital. The incidence of RDS was 100% at 26 or less weeks of gestation, 57.14% at 32 weeks, and 3.70% at 36 weeks. The mortality with RDS was 41 [43.61%]. RDS is the commonest cause of respiratory distress in the newborn, particularly, in preterm infants. It carries a high mortality rate and the incidence is more than that documented in the Western world