Impact of Air Pollution on Allergic Rhinitis and Asthma: Consensus Statement by Indian Academy of Pediatrics.

JUSTIFICATION: Rising air pollution is an ever-growing threat to many human diseases. Poor air quality has been directly correlated with respiratory allergies with a disproportionate affection among the pediatric age group. A clear understanding of common air pollutants and their potential contribution in allergic rhinitis and asthma is lacking. OBJECTIVE: To formulate a consensus statement for appropriate understanding among pediatricians and general practitioners about the effects of air pollution on respiratory allergies and their prevention. PROCESS: A group of experts (Pediatric pulmonologists and allergy specialists) from across India were appointed by the Indian Academy of Pediatrics (IAP) to formulate a consensus statement on 'Allergy and Air pollution'. A virtual meeting was conducted on 6th April 2020 to discuss in detail regarding various issues related to the subject and a writing committee was formed with broad consensus. After extensive literature review and multiple virtual sessions, the current document was prepared and circulated via email to the representatives from central IAP and IAP environment chapter. All the experts approved the consensus with minor modifications after a detailed discussion on 29th September 2020 on a virtual platform. RECOMMENDATIONS: Air pollution is the emerging contributor to respiratory allergies due to various mechanisms including oxidative stress and compromised mucociliary clearance. Children are more vulnerable to both outdoor and indoor pollution, due to their unique physiological characteristics. Knowledge about pollutant particle size and air quality index will help in demarcating level and extent of airway involvement. Relevant environmental history in difficult allergic rhinitis and asthma cases, along with conventional pharmacological measures, is warranted. Multipronged approach, targeted at community, physician and individual levels, needs to be emphasized to improve air quality and reduce economic and psychological burden of respiratory allergies.

Invasive meningococcal infection: analysis of 110 cases from a tertiary care centre in North East India.

OBJECTIVES: To report an outbreak of invasive meningococcal disease from Meghalaya, in the north east India, from January 2008 through June 2009. METHODS: Retrospective review of case sheets was done. One hundred ten patients with invasive meningococcal disease were included for the study. RESULTS: Of the total patients, 61.8 % were boys and 38.2 % were girls (boy to girl ratio = 1.62:1). The average age of presentation was 8.48 ± 5.09 y. Meningococcal meningitis was seen in 61.8 % of cases, meningococcemia in 20 % and 18.2 % had both. Fever was the most common manifestation (100 %) followed by meningeal signs (78.2 %), headache (56.4 %), vomiting (53.6 %), shock (38.2 %), low Glasgow coma scale (GCS) (25.5 %), purpura and rashes (23.6 %), seizures (9.1 %), abdominal symptoms (4.5 %), irritability and excessive crying (4.5 %) and bulging anterior fontanalle (23 %) in those below 18 mo of age. Raised intracranial pressure (ICP) was the most common complication (28.2 %) followed by coagulopathy (16.4 %), hepatopathy (10 %), herpes labialis (9.1 %), syndrome of inappropriate ADH secretion (SIADH) (8 %), pneumonia (7 %), arthritis (6 %), purpura fulminans, respiratory failure, sixth nerve palsy and diabetes insipidus in 4.5 % each, subdural empyema, optic neuritis, ARDS and ARF in 1.8 % each, cerebral salt wasting syndrome, third nerve palsy, cerebritis and hearing impairment in 0.9 % each. Culture was positive in 35.5 %. Patients were treated initially with ceftriaxone and dexamethasone but later on with chloramphenicol due to clinical drug resistance. Mortality was 6.4 %. CONCLUSIONS: This is the first epidemic report of invasive meningococcal disease from the north east India. Chloramphenicol acts well in areas with penicillin or cephalosporin resistance. Mortality reduces significantly with early diagnosis and prompt intervention.

Immune complex reaction after successful treatment of meningococcal disease: an excellent response to IVIG.

The convalescence phase of severe meningococcal sepsis is complicated by immune complex reactions with arthritis being the commonest. No standard guidelines exist for management of such complications, but non-steroidal anti-inflammatory drugs and steroids have been used with varying success. We report excellent response to intravenous immunoglobulin in a child with immune complex reaction following meningococcal sepsis.

Characteristics of pediatric scrub typhus during an outbreak in the North Eastern region of India: peculiarities in clinical presentation, laboratory findings and complications.

OBJECTIVE: To identify and report a recent outbreak of scrub typhus cases recorded from October 2009 to January 2010 in the state of Meghalaya, India. METHODS: The case sheets of all the children were retrieved and reviewed retrospectively. Twenty four (24) patients, who were both clinically and serologically confirmed as scrub typhus cases were included in the study. RESULTS: Fever for more than 1 wk duration was the most common manifestation (100%) followed by splenomegaly (45.8%), eschar (41.7%), cough (37.5%), hepatomegaly (33.3%), headache and body ache (25%), pain abdomen (25%), vomiting (20.8%), altered sensorium (16.6%), seizures (12.5%) lymphadenopathy (12.5%), and loose stools (8.3%). Meningoencephalitis was the most common complication (29.2%) followed by pneumonia (16.3%) and subconjunctival hemorrhage (8.3%).Cortical blindness, septic shock, peritonitis, myocarditis with CCF, pancytopenia, acute renal failure, coagulopathy, prolonged oxygen dependency and urinary tract infection (UTI) were found in one of each case. Hyponatremia (66.7%), elevated liver enzymes without significant rise of bilirubin (58.3%), hypoalbuminemia (52.2%) and thrombocytopenia (26%) were the other significant laboratory findings. Patients were treated with chloramphenicol, doxycycline and azithromycin. There was no mortality. CONCLUSIONS: This is the first outbreak report from the north eastern region of India with varied clinical presentations, laboratory investigations and complications. Weil Felix test still remains fruitful for diagnosing this disease in a resource limited set up.

Empyema thoracis: analysis of 150 cases from a tertiary care centre in North East India.

OBJECTIVES: To analyze the clinical characteristics, microbiological profile, management, complications and outcome of cases with empyema thoracis. METHODS: All cases diagnosed as 'empyema thoracis' over a period from January 2006 through June 2010 were identified from the inpatient records and discharge summaries. Of the 160 cases identified, 150 cases were taken up for analysis and the rest 10 cases, of which two had significant predisposing co-morbidity and eight cases diagnosed as tubercular empyema thoracis were excluded from the analysis. RESULTS: Mean age of presentation was 4.74 ± 3.53 years and two thirds of the children were under 5 years with male to female ratio of 1.42:1. Pus culture was positive in 32% (48 cases) with Streptococcus pneumoniae being the commonest organism isolated (31 cases, 64.6%) followed by Staphylococcus aureus (11 cases, 22.9%), Klebsiella pneumoniae (3 cases, 6.3%), Haemophilus influenzae type b (2 cases, 4.2%) and Enterococcus (1 case, 2%). Clustering was seen in the hot and humid months from April to July (63.3%). Fever was the commonest presentation (96.7%) followed by cough (90%), breathing difficulty (66.7%), chest pain (26.7%) and pain abdomen (10.7%). Ampicillin and cloxacillin was used as the first line antibiotic in 57.3% cases. Average duration of intercostal water seal drainage (ICWSD) in situ was 13.5 ± 8.05 days and 59 patients (39.3%) received fibrinolytic therapy. The commonest complications were collapse (18%), thickened pleura (16.7%), pericardial effusion (8%), cardiac tamponade (3.3%) and bronchopleural fistula (3.3%). Surgical procedures involved in this case series were decortication (14 cases, 9.3%), pericardiocentesis (5.3%), pericardiostomy (2.7%) and pericardiectomy (1.6%). Mortality was 3.3%. CONCLUSIONS: This is the first report of empyema thoracis from the north eastern region of India. Streptococcus pneumoniae was found to be the leading cause of empyema thoracis in this case series. Conservative management with ICWSD and antibiotics or early use of fibrinolytic therapy if indicated are effective modalities of treatment.

Unusual presentations of malaria in children: an experience from a tertiary care center in North East India.

OBJECTIVE: To identify cases of malaria with unusual presentations. METHODS: The medical record of all the cases of malaria admitted to PICU and pediatric general ward from Oct 2006 to Sep 2009, were reviewed and cases with unusual presentations were identified. The study design was retrospective descriptive study. RESULTS: Sixteen (10%) out of 162 malaria cases had unusual presentations - three had hemiplegia, two each with viral hepatitis-like presentation, acute abdomen, gastrointestinal bleed, generalized edema and hyperglycemia and one each with ptosis, severe headache and subacute intestinal obstruction-like presentation. Eleven cases had mixed parasitemia and two each with P. vivax and P. falciparum. One case was diagnosed on clinical grounds. CONCLUSION: Malaria is a common disease, but both typical and atypical presentations deserve attention for early diagnosis and management.

Macrophage activation syndrome in malaria.

Macrophage activation syndrome (MAS) is a clinical syndrome caused by an excessive proliferation of T lymphocytes and well-differentiated macrophages; an entity distinct from malignant histiocytosis. Although rheumatologic conditions are the common cause of MAS, a wide range of infections are also seen to cause MAS. We report an adolescent with severe Plasmodium falciparum malaria and MAS. He fulfilled six out of eight criteria required to diagnose hemophagocytic lymphohistiocytosis.