Secondary Hemophagocytic Lymphohistiocytosis - A Common Ramification of Different Diseases.

Hemophagocytic lymphohistiocytosis is a rare and potentially fatal disorder caused by immune dysregulation. It can occur as a primary genetic disease or secondarily due to various causes including infections, malignancies or autoimmune diseases. In this case report, we present two cases of Hemophagocytic lymphohistiocytosis which were secondary to typhoid and dengue fever. While primary disease occurs predominantly in infants, secondary hemophagocytic lymphohistiocytosis can occur in any age group. Both primary and secondary hemophagocytic lymphohistiocytosis are characterised by fever, hepatosplenomegaly, pancytopenia and multiorgan dysfunction. But unusual persistence of fever and other organ involvement should need further workup for hemophagocytic lymphohistiocytosis. Secondary hemophagocytic lymphohistiocytosis may resolve on treating the underlying disorder. But severe cases need treatment with immunosuppressive/immunomodulation therapy to prevent morbidity. Early clinical suspicion, prompt diagnosis and treatment of hemophagocytic lymphohistiocytosis are essential to prevent deleterious effects to health.

Renal Manifestations in Children with Dengue Fever Hospitalized in Pediatric Intensive Care Unit.

OBJECTIVE: To study the pattern of acute kidney injury in children with dengue infection hospitalized in an intensive care unit. METHODS: This is a retrospective study from January 2019 through December 2019. Various renal manifestations of dengue were studied and compared between the severity of dengue fever. RESULTS: Three hundred nineteen children with dengue fever were hospitalized and 127 needed intensive care admission. Among the 127 patients, 26 (20.5%) children developed acute kidney injury (AKI). Children with severe dengue developed a higher number of AKI (n = 20; 28.6%), as compared to dengue with warning sign group (n = 6; 11.8%). Colloid infusion, inotropic support, ventilatory requirement and presence of secondary hemophagocytic lymphohistiocytosis were the risk factors for AKI. Nine children underwent dialysis. Among the AKI group, 23 recovered and 3 died and all three had multi organ dysfunction syndrome. CONCLUSIONS: It is essential to recognize the various renal manifestations of dengue AKI which is associated with increased mortality and morbidity.

Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters.

OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains. DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017. SETTING: Multicenter study conducted in 33 PICUs across eight countries. SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation. INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions. MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008). CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Achromobacter xylosoxidans Sepsis Unveiling X-linked Agammaglobulinemia Masquerading as Systemic-onset Juvenile Idiopathic Arthritis.

BACKGROUND: X-linked agammaglobulinemia, a primary immunodeficiency, can present with musculoskeletal manifestations. CASE CHARACTERISTICS: A 4-year-old boy, diagnosed as systemic juvenile idiopathic arthritis at the age of 3 years and treated with biological agents, presented with fever, dyspnea and chest pain. Blood culture and pericardial fluid culture revealed Achromobacter xylosoxidans. OUTCOME: Investigation revealed normal serum ferritin but low levels of serum immunoglobulins. Further immunological work-up revealed diagnosis of X-linked agammaglobulinemia. Child improved on antibiotic therapy; treatment with steroids and biological was discontinued. MESSAGE: Underlying immunodeficiency disease must be looked for in children suspected to have juvenile arthritis, more so if they develop unusual serious infection in response to immunomodulatory therapy.

Severe hypercalcemia: A rare and unusual presentation of acute lymphoblastic leukemia.

Hypercalcemia is a rare and unusual complication of childhood malignancies. Acute lymphoblastic leukemia (ALL) presenting with hypercalcemia and lytic bone lesions is very rare in children. Here, we report a case of a 4-year-old girl with ALL who presented with severe hypercalcemia and radiological evidence of osteolytic lesions. Malignancies are the most common parathyroid hormone-independent cause of hypercalcemia. Severe hypercalcemia is a life-threatening emergency that should be addressed immediately. Effective treatment includes intense hydration, frusemide, calcitonin, and bisphosphonate in addition to the treatment of underlying cause.