Case Report: Extensive Gangrene: A Rare Presentation of Multisystem Inflammatory Syndrome in Children.

A wide spectrum of cutaneous manifestations are reported in multisystem inflammatory syndrome in children (MIS-C). However, gangrenous changes are less frequently reported. A 3-year old boy, with a known case of unoperated tetralogy of Fallot, presented with a short history of fever, rash, and melena. The rash was black and diffuse, with a rapid progression. The patient was stable hemodynamically at admission, with pallor, grade II clubbing, edema, and oral ulcers. Inflammatory markers were raised. He developed gangrenous changes over the ears and acral areas. He had very high levels of antibodies to severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) infection and was diagnosed as having MIS-C. Skin biopsy revealed near total epidermal necrosis with dermal vascular thrombi and negative immunofluorescence. Skin biopsy was positive for IgG antibodies to SARS-CoV-2. He was treated with antibiotics, immunomodulation with steroids, intravenous immunoglobulin, and plasmapheresis. He had features of both micro- and macroangiopathy. Gradually the child improved, with residual deformity.

Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES).

OBJECTIVE: To study if protocolized monitoring of endotracheal tube (ETT) cuff pressure every 6 hours is better than adjusting endotracheal tube cuff inflation by the only bedside clinical assessment. MATERIALS AND METHODS: This was a single-center prospective randomized controlled study done between July 1, 2017 and March 31, 2019. Children between 1 month and 18 years, intubated with cuffed ETT by our trained doctors were included. After obtaining consent, patients were randomized into two groups, standard group (SG) and cuff pressure monitoring group (MG). Sample size was calculated with 80 patients in each group with a power of 80%, significance level (alpha 0.05 and beta 0.2). In the SG, ETT cuff inflation was adjusted by clinical assessment (bedside minimal leak technique and monitoring the percentage of leak displayed on ventilator display) at 6 hours interval. In the MG, cuff pressures were monitored by the device every 6 hours to maintain between 20 and 25 mm Hg. RESULTS: Out of 543 mechanically ventilated children during the study period, 266 were eligible and randomized for study. During the study, 89 patients died and 17 were left against medical advice, leaving 80 patients in each group. Incidence of post-extubation stridor (PES), re-intubation rate, ventilator-associated pneumonia (VAP) rate, ventilator days, and length of pediatric intensive care unit (PICU) stay were analyzed and found no advantage of protocolized monitoring of cuff pressures in the reduction of any of the above variables. CONCLUSION: Our findings if confirmed by large multicentric studies can bring an end to routine ETT cuff pressure measurements and emphasize more on clinical assessment. Clinical trial registry (CTRI/2019/05/019098).Indian Journal of Critical Care Medicine (2021): 10.5005/jp-journals-10071-23737. HOW TO CITE THIS ARTICLE: Shaikh F, Janaapureddy YR, Mohanty S, Reddy PK, Sachane K, Dekate PS, et al. Utility of Endotracheal Tube Cuff Pressure Monitoring in Mechanically Ventilated (MV) Children in Preventing Post-extubation Stridor (PES). Indian J Crit Care Med 2021;25(2):181-184.

An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report.

Mid aortic syndrome is rare cause of hypertensive urgency in children with poor outcome if left untreated, high index of suspicion with prompt management is the key to survival with good outcome. A 12-year-old boy was presented with fever, puffiness of face, and breathing difficulty. Clinically, he had hypertension with differential pulsation and BP in upper and lower limbs. He had peak systolic gradient of 80 mm Hg between upper and lower limb. His echocardiography and CT angiography was suggestive of significant isolated 80% narrowing of abdominal aorta without involvement any other large vessels. Percutaneous balloon dilatation of aorta was done considering multiple parameters. Post procedure, there was significant improvement in BP and we could wean his multiple anti-hypertensive drugs to keep his blood pressures below 95th centile. His BP remained control with minimum upper and lower limb gradient on follow up of almost 1 year. HOW TO CITE THIS ARTICLE: Dekate PS, Reddy S, Prasad VSV, Boda S, Saini L, Patil P. An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report. Indian J Crit Care Med 2019;23(7):339-341. KEY MESSAGE: Mid aortic syndrome is most uncommon amongst them. With prompt diagnosis and proper selection of therapeutic options like balloon dilatation or surgical correction, it has good prognosis. Aortic narrowing because of different diseases is an uncommon cause of HT urgency in children.

Meningitis related ventriculitis--experience from a tertiary care centre in northern India.

OBJECTIVE: To assess clinical profile and short term outcome of patients with meningitis related ventriculitis. METHODS: Case records of 47 patients admitted with a diagnosis of ventriculitis (complicating meningitis) over 3 y were analysed retrospectively. RESULTS: The mean age of patients was 4.96 mo (20 d - 42 mo). The common symptoms were fever (27/47), enlarging head (23/47) and seizures (12/47) with signs of raised intracranial pressure (29/47). Ventricular cerebro-spinal fluid (CSF) showed mean cells - 237 cells/µL, sugar - 36 mg/dL and protein - 568 mg/dL. Gram stain and/or culture were positive in 5 patients. Ultrasonography of the head (done in 32 of 47 patients) showed hydrocephalus in 29 and internal echoes, debris or septations in ventricles in 5 patients. Computed tomography (CT) of brain (done in 42 of 47 patients) showed hydrocephalus in 36, abscesses in 7, ependymal enhancement in 4, infarcts in 4 and subdural empyema in 3 patients. MRI brain (done in 13 patients) showed hydrocephalus in all, 6 had cysts and 3 had ependymal enhancement. Thirty seven patients were started on ceftriaxone combined with vancomycin/cloxacillin with/without amikacin, and 10 patients received vancomycin and meropenem. Mean duration of antibiotics treatment was 4.17 wk (range; 0.8-12 wk). External ventricular drainage (EVD) was done in 22/47 patients. Cure rate (improvement in clinical and CSF parameters) in patients with external ventricular drainage was 59% as against 50% in patients who received antibiotics alone. At least 19 patients required ventriculoperitoneal (VP) shunt for unresolved significant hydrocephalus by discharge. There were 10 deaths, four of them occurred within first 2 wk of admission, one in 3rd wk and 5 within few months of discharge from hospital. CONCLUSIONS: Ventriculitis associated with meningitis is a difficult to treat infection with significant mortality and morbidity. It requires prolonged administration of antibiotics. External ventricular drainage may improve cure rate and hasten clearing of CSF infection.

Management of acute diarrhea in emergency room.

Acute diarrhea is the second leading cause of under-five mortality in India. It is defined as the passage of frequent watery stools (>3/24 h). Recent change in consistency of stools is more important than frequency. Acute diarrhea is caused by variety of viral, bacterial and parasitic agents. The common ones are: Rotavirus, E. coli, Shigella, Cholera, and Salmonella. Campylobacter jejuni, Giardia and E. histolytica are also not uncommon. The most important concern in management of acute diarrhea in Emergency room (ER) is fluid and electrolyte imbalances and treatment of underlying infection, wherever applicable. It includes, initial stabilization (identification and treatment of shock), assessment of hydration and rehydration therapy, recognition and treatment of electrolyte imbalance, and use of appropriate antimicrobials wherever indicated. For assessment of hydration clinical signs are generally reliable; however, in severely malnourished children sunken eyes and skin turgor are unreliable. Oral Rehydration Therapy is the cornerstone of management of dehydration. Intravenous fluids are not routinely recommended except in cases of persistent vomiting and/or shock. Majority of cases can be managed in ER and at home. Hospitalization is indicated in infants <3 mo, children with severe dehydration, severe malnutrition, toxic look, persistent vomiting and suspected surgical abdomen. Supplementations with zinc and probiotics have been shown to reduce severity and duration of diarrhea; however evidence does not support the use of antisecretary, antimotility and binding agents. Education of parents about hand hygiene, safe weaning and safe drinking water etc., can help in reducing incidence of this important health problem in the country.

An Indian girl with Fanconi-Bickel syndrome without SLC2A2 gene mutation.

Fanconi-Bickel syndrome is a rare autosomal-recessive disorder caused by defects in the facilitative glucose transporter 2 (GLUT2) gene. It is characterized by hepatorenal glycogen accumulation, tubular nephropathy and impaired utilization of glucose and galactose. In this communication, we present the case of a 5-year-old girl who presented with deforming rickets and massive hepatomegaly. Liver biopsy confirmed the diagnosis of glycogen storage disorder. However, the mutation of the SLC2A2 (GLUT2) gene was not found. Mutation negative patients with characteristic Fanconi-Bickel syndrome phenotype suggest additional underlying mechanisms that need exploration.

Acute community acquired pneumonia in emergency room.

Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO's classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.