The predictors of outcome and progression of pediatric sepsis and septic shock: A prospective observational study from western India.

INTRODUCTION: There is a paucity of studies on the progression and outcome of Systemic Inflammatory Response Syndrome (SIRS) with its determinants. AIMS AND OBJECTIVES: To determine the predictors of the outcome and progression of pediatric sepsis and septic shock. MATERIALS AND METHODS: Prospective observational study of children fulfilling criteria of SIRS and their progression to sepsis, severe sepsis, and septic shock (clinically and biochemically) was conducted at a tertiary care center. RESULTS: Totally, 200 children were recruited over a period of 21 months (from February 2016 to October 2017). Most cases (80, 40%) were infants. Of the total, 188 (94%) cases were of an infective etiology (mostly respiratory system). Temperature and heart rate were the two commonest SIRS parameters which were deranged. Blood cultures were positive in only 25 (12.5%) cases. Out of the total 200 children, 108 progressed to sepsis, of which 26 progressed to severe sepsis, of which 22 progressed to septic shock. Abnormal leukocyte count, culture positivity and severe acute malnutrition were significantly associated with progression of SIRS patients to septic shock (P = 0.001, 0.00001 and 0.002, respectively). Factors associated with mortality were positive blood culture, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care (P values-<0.0001, <0.0001, 0.03, <0.0001 and <0.0001, respectively). CONCLUSIONS: SIRS can progress to septic shock if not identified early. The predictors of mortality were positive blood cultures, multiorgan dysfunction, late hospital admissions, severe acute malnutrition, and requirement of supportive care. The predictors of progression to septic shock were abnormal leukocyte count, culture positivity, and severe acute malnutrition.

Dental management of a child with Wiskott Aldrich syndrome prior to bone marrow transplant: A case report.

AIM: Orodental manifestations are commonly presented in Wiskott Aldrich Syndrome (WAS). The purpose of this paper is to report a case of dental management of a 5-year-old male child with WAS before Hematopoietic Stem Cell Transplantation (HSCT). Such patients are more prone to infection due to pretransplantation chemotherapy and posttransplantation immunosuppression; thus, it becomes imperative to eliminate all potential sources of infection before transplantation. MATERIALS AND METHODS: Fluctuating blood parameters before the dental procedure was an important challenge in rendering dental treatment. Dental procedures were carried out under general anesthesia by maintaining the hematological parameters with blood and platelet transfusion. The conventional dental treatment may not be applicable in such patients as failure of dental treatment can cause the failure of HSCT, and it has to be modified based on the clinical acumen and recommendations. CONCLUSIONS: This case report focuses on the measures to be taken before, during, and after the dental procedure to ensure the success of the dental therapy and prevent failure of HSCT due to residual dental foci of infection. A multidisciplinary approach involving a pedodontist, a pediatrician, and a hematologist can improve the quality of life of such patients.

A comparative clinical study to assess safety and reactogenicity of a DTwP-HepB+Hib vaccine.

Hepatitis B and Haemophilus influenzae type b (Hib) infections are major public health problems in developing countries, including India. Hence, combination vaccines containing DTwP, recombinant hepatitis B and Hib conjugate vaccines have been developed. Here, we report a Phase IV study which assessed safety and reactogenicity of a new DTwP-HepB+Hib vaccine. Three doses of DTwP-HepB+Hib vaccine (Pentavac, Serum Institute of India Ltd) or Tritanrix-HB+Hib (GlaxoSmithKline Beecham) were administered to infants at 6, 10 and 14 weeks of age in 2:1 ratio. The subjects were followed till one month after the third dose for safety assessment. Adverse events were captured in structured diaries and physical examinations were performed on each visit. The study was conducted in 1510 infants. Both vaccines caused injection site local and systemic reactions and the incidence was similar in both the groups. The incidence of local solicited reactions was: tenderness 35.9 %-33.6 %; redness 18.1 %-17.2 %; swelling 23.7 %-22.4 %; induration 12.8 % -13.7 %. The percentage of systemic solicited reactions were: diarrhea 2.2 %-2.2 %; drowsiness 3.3 %-3.4 %; fever 14.0 %-11.2 %; irritability 28.1 %-25.4 %; loss of appetite 6.6 %-5.6 %; persistent crying 17.7 %-15.7 %; vomiting 3.5 %-3.0 %. No serious adverse event was caused by the vaccines. The new DTwP-HepB+Hib combination vaccine showed similar safety profile to that of an imported vaccine in Indian infants.

A rare case of nephrotic syndrome: 'nailed' the diagnosis.

An 18-month-old female child presented to us with clinical features suggestive of nephrotic syndrome. Her physical examination and detailed family history highlighted the familial occurrence of abnormal nails, suggesting a diagnosis of the Nail-Patella syndrome. Nail-Patella syndrome is a rare cause of nephrotic syndrome in children. This case highlights the importance of a detailed history, including pedigree and a thorough examination of the patient.

Arterial bicarbonate may be a useful indicator of inadequate cortisol response in children with catecholamine resistant septic shock.

OBJECTIVE: To study the clinical and biochemical parameters that can predict cortisol insufficiency in children with septic shock. DESIGN: prospective, observational study. SETTING: Tertiary health-care center. PATIENTS/SUBJECTS: Fifty children admitted with the catecholamine resistant septic shock to a tertiary health-care center. MATERIALS AND METHODS: At the time of hospitalization all patients underwent detailed clinical evaluation including, history and physical examination, evaluation with the complete blood count, serum cortisol, renal function tests, liver function tests, prothrombin time activated partial thromboplastin time, arterial blood gas analysis, urine analysis, chest roentgenogram, ultrasonography of the abdomen and chest, urine, and blood culture for bacteria and fungi. RESULTS: Out of 50 children with the catecholamine resistant septic shock, seven had adrenal insufficiency (serum cortisol <18 µg/dl). Of all parameters studied, only arterial bicarbonate at the time of admission to intensive care predicted adrenal insufficiency. On Receptor operative characteristic curve analysis, a bicarbonate level of 10.9 mEq/L had the best accuracy to predict adrenal insufficiency. CONCLUSION: Arterial bicarbonate may be used as a rapid test for provisional identification of adrenal insufficiency among children with the catecholamine resistant septic shock.

Minimizing side effects of systemic corticosteroids in children.

Corticosteroids are potent drugs used in management of various inflammatory and autoimmune disorders. The antiinflammatory effects of corticosteroids cannot however be separated from their metabolic effects. Children are more vulnerable to their side effects, particularly the effects on growth, immunity and adrenal suppression. It is essential for the treating physician to be aware of the side effects and the measures to be taken to minimize them. A side effect that is unique to children is growth suppression, which is helped by alternate day treatment. Administration of small doses of prednisolone (10-15 mg/day or velocity significantly. The potency of dexamethasone and betamethasone in suppressing growth is nearly 18 times higher than that of prednisolone. There is some evidence that the administration of growth hormone can reverse these changes.

Moebius syndrome with total anomalous pulmonary venous connection.

Moebius syndrome is characterized by congenital complete or partial facial nerve palsy with or without paralysis of cranial nerves and often associated with other malformations. Cardiac anomalies though known are very rare and till date only 4 cases have been reported. We present a case of Moebius syndrome with supracardiac total anomalous pulmonary venous connection which has not yet been reported in literature.

Insulin resistance and beta cell function in chronically transfused patients of thalassemia major.

OBJECTIVE: To assess the glycometabolic function in chronically transfused patients of beta- thalassemia major in terms of glucose tolerance, insulin secretion, insulin resistance index, and beta cell function index and to determine their relationship with clinical and biochemical profile. METHODS: 30 homozygous thalassemia major children (aged 8-15 years) receiving regular blood transfusion and 10 age and sex matched normal children attending a tertiary level hospital were subjected to glucose tolerance test, estimation of fasting plasma insulin level, insulin resistance index and beta cell function index. Liver enzymes, liver size and indicators of iron overload (serum ferritin, total units of blood transfused, splenic size) were recorded. RESULTS: There was no diabetes mellitus or impaired glucose tolerance test in either the cases or the controls. Fasting plasma insulin levels were significantly higher in cases than controls (P = 0.004), and correlated well with indicators of iron overload like total units of blood transfused (r = 0.41, P = 0.03), serum ferritin (r = 0.38, P = 0.038) and splenic size (r = 0.43, P = 0.03). Insulin resistance was higher in cases compared to controls (P = 0.01). It correlated well with age (r = 0.56, P = 0.006), fasting blood glucose (r = 0.8, P = 0.003), fasting plasma insulin (r = 0.95, P = 0.00001), total units of blood transfused (r = 0.52, P = 0.005), serum ferritin (r = 0.4, P = 0.02) and splenomegaly (r = 0.51, P = 0.004). Insulin resistance was higher in patients not on chelation therapy compared with those on chelation therapy (P = 0.003). The beta cell function index was higher in cases compared to the controls, but not of statistic significance (P = 0.077). It did not correlate well with total amount of blood transfused (r = -0.32, P = 0.08), serum ferritin (r = -0.138, P = 0.46), spleen size (r = 0.16, P = 0.36), or chelation therapy (P = 0.98). CONCLUSION: Diabetes mellitus or impaired glucose was not seen in chronically transfused patients of thalassemia major (between 8 and 15 years of age), in our study. Insulin resistance, compensated by hyperinsulinemia, sets in early even before the onset of frank diabetes mellitus and correlated well with age, chelation therapy and indicators of iron overload like total units of blood transfused, splenomegaly and serum ferritin.

Pseudomonas sepsis with Noma: an association?

We report here a 2.5-year-old male child with community-acquired Pseudomonal sepsis showing the characteristic lesions of ecthyma gangrenosum. The child had development of gangrenous changes of the nose and face - the 'cancrum oris' or 'Noma'. We highlight the possible association of Pseudomonas sepsis and Noma, with malnutrition playing a central role in causing both the diseases.

Intramuscular midazolam vs intravenous diazepam for acute seizures.

OBJECTIVE: To determine effectiveness of intramuscular midazolam to control acute seizures in children as compared to intravenous diazepam. METHODS: 115 children in the age group of 1 month to 12 years who presented with acute convulsions were enrolled in the study. Patients who already had an intravenous access present were treated intravenous diazepam. Patients without an i.v. access at the time of convulsions were randomised into 2 groups and treated with either intramuscular midazolam or intravenous diazepam for control of seizures. Time interval from administration of drug to cessation of seizures was compared. Effectiveness of i.m. midazolam in various age groups, types of convulsions and etiology of convulsions was analyzed. Side effects of both drugs were evaluated. RESULTS: The mean interval to cessation of convulsions with i.m. midazolam was 97.22 seconds whereas in diazepam group without prior i.v. access it was 250.35 seconds and in diazepam group with prior i.v. access it was 119.4 seconds. i.m. midazolam acted faster in all age groups and in patients with febrile convulsions, which was statistically significant. i.m. midazolam was equally effective in various types of convulsions be it GTC or focal convulsions. 7 patients (10.8%) had thrombophlebitis associated with i.v. diazepam administration whereas none of the patients in the midazolam group had any side effects, which was statistically significant. CONCLUSION: i.m. midazolam is an effective agent for controlling acute convulsions in children especially in children with febrile convulsions. It has relatively no side effects as compared to Intravenous diazepam and can be used as a first line agent for treatment of acute convulsions in patients with difficult intravenous access.

A bedside dipstick method to detect Plasmodium falciparum.

We conducted this study to determine efficacy of Parasight-F (an HRP-II antigen dipstick method to detect P. Falciparum) in children. A total of 30 children were enrolled in the age group of 2 months to 12 years whose peripheral smear showed asexual forms of Plasmodium falciparum. All patients were tested for presence of HRP-II antigen of Plasmodium falciparum in their blood by the Parasight-F dipstick test by either an EDTA sample or a finger prick blood sample. The sensitivity of Parasight-F was 83.3 % However, the sensitivity of Parasight-F to detect Plasmodium Falciparum in case of mixed Plasmodium (Vivax + Falciparum) infection was only 25 %. Also, all patients less than 6 months of age had a negative Parasight-F test. Parasitic index, prior treatment with antimalarials or severity of Falciparum malaria have no effect on the sensitivity of Parasight-F test. We conclude that Parasight-F is an effective tool for diagnosis of Plasmoduim falciparum malaria in children.

A study of Vitamin K status in children on prolonged antibiotic therapy.

Vitamin K deficiency is known to cause coagulopathy and bleeding in patients on prolonged antibiotic therapy. This study was conducted to evaluate the status of vitamin K deficiency in hospitalized children on prolonged antibiotic therapy and its role in reversing the coagulopathy. A prospective non-randomized study was conducted on children on antibiotic therapy at a tertiary care hospital. Children in the 1 month-1 year age group developed significant coagulopathy as compared to other age groups. Coagulation abnormalities were also seen to be more in children with greater grades of malnutrition, on a more prolonged course of antibiotics and in children who were critically ill in intensive care. Hypoprothrombinemia previously reported to be due to B-lactam antibiotics containing the N-Methyl Thio Tetrazole (NMTT) group also resulted from antibiotics without this side chain. Inhibition of intestinal microorganisms by antibiotics was thought to be a likely explanation of this phenomenon. We suggest Vitamin K prophylaxis in severely ill patients, on extended periods of antibiotics and inadequate diet to prevent morbidity and mortality.

Colloid cyst of the third ventricle: a cause of sudden death in a child.

Colloid cyst is a rare benign intracranial neoplasm, commonly located in the third ventricle. Though headache and visual symptoms are classical, the patients may present with sudden neurological deterioration. We present a ten-year-old male child who presented with sudden neurological deterioration due to colloid cyst of the third ventricle resulting in death. The child had intermittent headache for three months, for which medical attention was not sought. This report details the case and a short review of the condition is presented (with emphasis on the clinical features and importance of early diagnosis). Management (including surgical methods and conservative treatment) of third ventricle colloid cysts is briefly reviewed.

Pulmonary arteriovenous malformations.

Pulmonary arteriovenous malformations rarely present in childhood. Two cases are presented in this report. Both the cases presented clinically with cyanosis and clubbing without a cardiac murmur. The second case had cerebral abscess in addition. Both the cases underwent a contrast-enhanced echocardiography which suggested the presence of pulmonary arteriovenous malformations. The first case also underwent 99mTc radionuclide scan and pulmonary angiography. The cases are being reported for their characteristic clinical features and for emphasizing the role of non-invasive modalities like contrast-enhanced echocardiography and radionuclide scan in reaching the diagnosis.

Non-invasive respiratory monitoring in paediatric intensive care unit.

Monitoring respiratory function is important in a Paediatrics Intensive Care Unit (PICU), as majority of patients have cardio-respiratory problems. Non-invasive monitoring is convenient, accurate, and has minimal complications. Along with clinical monitoring, oxygen saturation using pulse oximetry, transcutaneous oxygenation (PtcO2) and transcutaneous PCO2 (PtcCO2) using transcutaneous monitors and end-tidal CO2 using capnography are important and routine measurements done in most PICUs. Considering the financial and maintenance constraints pulse oximetry with end tidal CO2 monitoring can be considered as most feasible.