Role of cerebrospinal fluid tau protein levels as a biomarker of brain injury in pediatric status epilepticus.

BACKGROUND: Various biomarkers have been studied for predicting etiology and outcome in status epilepticus (SE); cerebrospinal fluid (CSF) total tau (t-tau) protein levels is foremost among them. Only handful of studies are available regarding role of t-tau in childhood SE. METHODOLOGY: This prospective study was conducted in a tertiary care center of Northern India in children 6 months -12 years of age. The Cases were patients with convulsive status epilepticus (CSE) whereas Controls were patients without SE and normal CSF. The t-tau levels were done in CSF of both the groups. The outcome was assessed by GOS-E Peds score. RESULTS: A total of 50 (62% males) cases and 15 (67% males) controls were enrolled in the study. SE was generalized in 78% cases whereas 14% had refractory SE. Most common etiology of CSE was acute symptomatic (52%), followed by prolonged febrile seizure (24%), remote symptomatic group (14%), unknown etiology (8%) and progressive disorder (2%). Case fatality rate was 10%. Poor outcome was seen in 30% cases. Median (IQR) CSF t-tau levels was significantly lower 2.6 × 103 (0.5-9.4 × 103) pg/ml in cases vs 10.6 × 103 (6.0-14.2 × 103) pg/ml in controls (p = 0.004). There was no significant correlation seen between type, duration, etiology and response to antiepileptic drugs of SE with CSF t-tau levels. Also, no significant correlation of poor sensorium, outcome of SE and critical care needs with CSF t-tau levels was noted. CONCLUSION: CSF t-tau is not a useful diagnostic or prognostic biomarker in pediatric SE.

Recurrent Intracranial Bleed in 3 Siblings: Short of a Shot of Vitamin K!

We present a family who suffered recurrent sibling losses due to vitamin K deficiency bleed. The index child was asymptomatic at presentation, had normal clinical examination, and was investigated for coagulation disorders in view of previous 3 sibling losses as a result of intracranial hemorrhage. His investigations showed deranged coagulogram and clotting factors' assay. The baby was given vitamin K1 1 mg intramuscularly following which his coagulogram and clotting factors' assay returned to normal. The genetic analysis did not identify any inherited cause of bleeding tendency. The significant family history, exclusive breastfeeding, no diarrhea, failure to thrive or drug use, no prophylaxis with vitamin K at birth, recovery of clotting factors on vitamin K administration, and a corroborative molecular analysis confirmed diagnosis of vitamin K deficiency in the index child. This case gives a strong reminder not to miss birth dose of vitamin K in any neonate.

Infantile Tremor Syndrome Followed by West Syndrome: Effect or Continuation of Spectrum?

BACKGROUND: Infantile tremor syndrome (ITS) is a nutritional deficiency syndrome, frequently reported from the Indian subcontinent caused by vitamin B12 deficiency. The West syndrome (WS), on the other hand, is a type of epileptic encephalopathy with variable etiology. CASE SERIES: We present a series of five children who presented with symptoms consistent with ITS and received standard intramuscular vitamin B12 therapy to which good response was observed. All these children were readmitted with WS with a time lag varying from 2 to 12 months. Magnetic resonance imaging brain and metabolic screen were within normal limits. Three out of five patients responded well to adrenocorticotropic hormone (ACTH), remaining two required additional drugs. We hypothesize that WS could have developed after ITS due to developmental desynchronization. CONCLUSION: In the Indian scenario, it is particularly important to be aware of appearance of WS after ITS, because of high prevalence of ITS and devastating nature of WS.

Stroke in Pediatric Diabetic Ketoacidosis: Case Series.

Diabetic ketoacidosis (DKA) can present with various neurological complications, but stroke is rare. Here, we present three children with recent-onset diabetes with DKA, two of them had deep coma not responding to standard DKA regimen and the third one had seventh nerve palsy noted after recovering from coma. Computed tomography scan of head showed hemorrhage in the area of midbrain in one patient and infarcts in two patients. In any child of DKA with severe neurological impairment, possibility of stroke should be entertained.

Bronchial asthma with ABPA presenting as PTE.

Allergic bronchopulmonary aspergillosis (ABPA), as a complication of asthma, is rare in children. The persistent and poorly-controlled asthma leading to cor pulmonale is not uncommon in adults but rarely described in the pediatric age group. Here, we report a case of asthma and ABPA complicated by pulmonary thrombo-embolism and cor pulmonale. To the best of our knowledge, such association has never been reported in the pediatric age group.

A Community-Based Study of Antenatal and Neonatal Risk Factors in Autism Spectrum Disorder.

Objective: To assess children in the community for autism spectrum disorder (ASD) and associated risk factors.Methods: In this 2-stage, cross-sectional study, children between 1.5 and 10 years of age were screened using the Chandigarh Autism Screening Instrument. Those with a score above the cutoff of 10 were assessed in detail using the Childhood Autism Rating Scale and the Autism Diagnostic Interview-Revised, and a detailed pediatric assessment was conducted. Risk factors were evaluated, and karyotype and fragile X genetic testing was done for those diagnosed with ASD. The study was conducted from July 2014 to December 2017.Results: Compared to the control group, mothers of ASD children had more pregnancy-induced hypertension (PIH) and bleeding per vaginum (BPV) during the antenatal period. In the multivariate analysis, there was 6.3 times higher odds of having history of PIH (P = .02) and 7.7 times higher odds of BPV (P = .011) among children with ASD. There were much higher odds of having birth asphyxia (OR = 12.6), cardiorespiratory problems (OR = 10), metabolic abnormalities (hypoglycemia/ hypocalcemia) (OR = 12), and neonatal sepsis (OR = 16) in the ASD group compared to controls.Conclusions: ASD patients experienced more antenatal and neonatal problems compared to controls.Trial Registration: Clinical Trials Registry-India (CTRI/2017/02/007935).

Neuroimaging Findings in Vitamin B12-Deficient Infants With Neurologic Features.

Background:Vitamin B12 deficiency causes serious neurologic problems among infants. However, its neuroradiologic correlate is still largely obscure. Methodology: This prospective study was conducted on patients aged 6 months to 2 years. All children with proven vitamin B12 deficiency were planned to undergo magnetic resonance imaging (MRI) and magnetic resonance spectroscopy of the brain. Results: A total of 35 patients (63% female) were enrolled. Twenty-six (74%) patients had significant findings on brain MRI scan, commonest of which were thinning of corpus callosum and prominence of extra-axial spaces in 28.6% children, cerebral atrophy in 17%, and diffuse symmetrical hyperintensity of white matter in 5.7% patients. Using logistic regression, it was found that odds of abnormal neuroimaging findings were higher in children below 12 months, in females, and in patients with developmental regression, but none of them were statistically significant. Conclusion: Most of the infants with vitamin B12 deficiency have abnormal neuroimaging findings.

Psychopathological Aspects in Children with Epilepsy and Its Contributing Factors: A Cross-Sectional Study from India.

Background Children with epilepsy (CWE) are at high risk of psychopathological problems because of neurobiological, social, and treatment factors. Objectives This study was conducted to estimate the prevalence of psychopathological problems in CWE and their contributing factors. Methods This cross-sectional study was done in pediatric neurology clinic and outpatient department of a government medical college in Northern India. Children between the ages of 4 and 14 years with intelligence quotient > 70 were enrolled; for CWE, the criteria were antiepileptic drugs therapy for more than 6 months and for controls it was being free from any chronic illness. Childhood Psychopathology Measurement Schedule (CPMS) was used for assessing psychopathological problems. Results A total of 135 CWE and 70 controls were enrolled, groups were similar in respect of age, gender, socioeconomic status, and family history. CWE group had significantly high mean ± standard deviation CPMS scores (13.68 ± 10.57) as compared with controls (9.75 ± 7.97) ( p < 0.0001). These scores were particularly high in sectors of low intelligence, conduct disorder, psychotic symptoms, and depression. Academic performance was significantly poor in CWE (39%) versus controls (6%) ( p 0.042). Age of onset, duration, type, and etiology of epilepsy had no significant relation with CPMS scores. Polytherapy and treatment with valproate were associated with high CPMS scores ( p 0.005 and 0.045). Conclusion Psychopathological problems are frequently associated with epilepsy in children and antiepileptic drug therapy might contribute to it.

Varicella vaccination in India's universal immunisation program -is it time?

We report two representative cases of complicated varicella in immunocompetent children highlighting the significant vaccine preventable varicella burden in the Indian population. A robust surveillance programme followed by incorporation of varicella vaccine in routine immunization would be the way forward to mitigate this illness.

Disability and Mortality in Convulsive Status Epilepticus in Children at 3 Months' Follow-Up: A Prospective Study from India.

Background Convulsive status epilepticus (CSE) is a common neurological emergency with high mortality, morbidity, and poor quality of life. There is a paucity of follow-up studies from developing nations in pediatric age group. Objectives This article looks for clinico-etiological profile of CSE and estimates the immediate and short-term mortality in children with CSE and its predictive factors. Methodology This prospective longitudinal study was done at a tertiary care institute of Northern India. The patients between the ages of 1 and 16 years with CSE were enrolled after informed consent, they were observed in the hospital, and survived patients were followed till 3 months after discharge. Results A total of 200 patients (58% males) were enrolled. Acute symptomatic (63.5%) was the most common etiology. Twenty-five (12.5%) patients died during hospital stay; at discharge, 160 (80%) had good recovery and rest had a varying range of disability. The predictive factors for poor outcome were female gender, duration of CSE > 1 hour at presentation, generalized seizures, Glasgow Coma Scale < 8 at presentation, refractory status epilepticus, need for critical care support, and acute symptomatic etiology. On follow-up, two patients died at 1-month and one at 3-month follow-up, the cause of death was probably seizures in two patients and feed aspiration in one patient. Seven patients deteriorated from good recovery scoring to moderate disability during the time interval between first and second follow-up, none of them reported apparent repeat seizures. Conclusion Pediatric CSE is associated with immediate poor outcome; risk of death and new disabilities persist after discharge thus proper follow-up is essential.

Massive cerebral air embolism on ante mortem CT head following pneumothorax in a child with pneumonia.

Cerebral air embolism (CAE) is a rarely reported complication of a common condition like pneumothorax, presenting with deterioration of sensorium and cardiovascular instability. We report a case of 3-year-old male who developed pneumothorax after positive pressure ventilation followed by deterioration of sensorium. CT head revealed massive CAE.

Infant with a parotid swelling: beware of the rare.

Salivary gland tumours are rare in children. We present the case of an infant who presented with a progressively increasing swelling of short duration in the parotid region accompanied by a small preauricular cutaneous haemangioma. Failing to comply with the commoner diagnoses like parotitis, help of imaging was taken that pointed towards the rarer diagnosis of parotid haemangioma. The child was started on oral propranolol and dramatic reduction in parotid and cutaneous swelling was seen after three months of therapy without any side effects.

Using Telemedicine During the COVID-19 Pandemic.

Telemedicine is the delivery of health care services using information or communication technology. In the current pandemic scenario, telemedicine can supplement health-care delivery in the absence of in-person visit. The Government of India has recently launched the e-sanjeevani OPD, a National teleconsultation service, which has been adopted by many state governments as mandatory for health-care providers. With Indian Medical Association issuing an advisory against the use of telemedicine except in few situations, a lot of confusion exists in the mind of a pediatrician. Despite the uncertain situation, we have to remember that other diseases shall not stall in the face of a pandemic. Since telemedicine is an evolving subject, training of medical professionals, clear guidelines and good quality internet service systems will go a long way in increasing the acceptability of telemedicine in the Indian population. We herein discuss issues related to using telemedicine during the SARS-CoV-2 pandemic.

Changing Clinicoradiologic Spectrum of Intracranial Neurotuberculosis in Children: A Cross-sectional Study.

BACKGROUND: Neurotuberculosis is among the most severe type of tuberculosis with high mortality and morbidity in all age groups. Various sociodemographic and disease-/treatment-related factors have emerged over the years that can affect clinical and radiologic features of neurotuberculosis. OBJECTIVE: To investigate various clinical and neuroradiologic presentations of neurotuberculosis. METHODOLOGY: This cross-sectional study was done in a tertiary care center of northern India. The patients between the ages of 3 months and 18 years with newly diagnosed neurotuberculosis were enrolled after taking informed consent. RESULTS: A total of 78 patients (37% males) were enrolled. Fifty-six patients (72%) had tubercular meningitis (TBM) and 22 (28%) isolated tuberculomas. Very high percentage of patients in both the groups was BCG vaccinated. In the tubercular meningitis group, fever (68%), headache (59%), and vomiting (54%) were the most common complaints whereas in the tuberculoma group, seizures (95.5%) were the main complaint and systemic symptoms were rare. In tubercular meningitis patients, cerebrospinal fluid-based studies showed cartridge-based nucleic acid amplification test (Xpert MTB/RIF) positivity for Mycobacterium tuberculosis in 17.6% cases, whereas on gastric aspirate and sputum examination, acid-fast bacilli were seen in 30.7% and cartridge-based nucleic acid amplification test was positive in 19% patients. On neuroimaging, hydrocephalus was seen in 44.6% of tubercular meningitis patients, infarcts in 32%, and basal exudates in 12% patients only; coexistent tuberculomas were seen in 53%. CONCLUSION: Compared with the available literature, the present study showed a smaller percentage of children <5 years of age, stage III tubercular meningitis cases, and typical neuroradiologic findings like hydrocephalus and basal exudates and more tuberculomas associated with tubercular meningitis.

Vitamin B12 status and neurodevelopmental delay in Indian infants: a hospital-based cross-sectional study.

Background: Vitamin B12 deficiency owing to a vegetarian diet is common in India and is associated with neurodevelopmental disorders.Objective: To investigate the prevalence of vitamin B12 deficiency in infants aged 1-12 months and to correlate the results with neurodevelopment.Methods: A cross-sectional study of 200 infants aged 1-12 months presenting to the emergency department or ward and requiring blood sampling or intravenous cannulation was undertaken in a tertiary-care centre of Northern India. Patients' serum vitamin B12 levels were correlated with Denver development screening test II (DDST II).Results: Of 200 infants recruited, 43 (22%) were vitamin B12-deficient (<211 pg/ml). After excluding 16 (8%) infants who were unsuitable for DDST screening, 21/39 (54%) and 22/145 (15%) were DDST-suspect in the vitamin B12-deficient and sufficient groups, respectively (p = 0.0001). There was a statistically significant correlation between B12 deficiency and an abnormal DDST (p < 0.0001).Conclusion: In India, vitamin B12 deficiency is prevalent in infancy and is associated with neurodevelopmental delay.

Predictors of health related quality of life in childhood epilepsy and comparison with healthy children: findings from an Indian study.

BACKGROUND/AIM: Children with epilepsy have reduced health-related quality of life (HRQOL) due to disease and medications. We aimed to assess child-reported HRQOL in Indian children with epilepsy and compare it with that in healthy children. MATERIALS AND METHODS: A cross-sectional study of 256 children with epilepsy aged between 5 and 18 years on antiepileptic drug (AED) treatment for at least 3 months was performed and 125 age and sex matched healthy children were included. A generic version of the Pediatric Quality of Life (PedsQL version 4) scale was used to assess HRQOL. RESULTS: Children with epilepsy had diminished scores in total score and all subdomains of PedsQL as compared to healthy children. Children with epilepsy on polytherapy had diminished HRQOL compared with those on monotherapy. Children with generalized seizures or with symptomatic epilepsy had diminished HRQOL. Significant predictors of poor HRQOL were adverse drug reactions (ADRs) to AED, polytherapy, longer duration of epilepsy, shorter seizure-free interval, and seizure frequency. CONCLUSION: Children with epilepsy have diminished HRQOL than healthy children in all subdomains of PedsQL. Significant predictors are ADRs to AED, polytherapy, longer duration of epilepsy, shorter seizure-free interval, and seizure frequency. Comprehensive management of children with epilepsy must go beyond seizure control.

An atypical case of parotid gland swelling and arthritis in a child.

BACKGROUND: Early onset sarcoidosis is a rarely reported disease in children. CASE CHARACTERISTICS: 2½-year-old girl with chronic enlargement of bilateral parotid glands and polyarthritis. OBSERVATION: Biopsy of salivary gland revealed non-caseating granuloma. OUTCOME: Polyarthritis and salivary gland swelling resolved completely after starting oral corticosteroids. MESSAGE: Sarcoidosis is an important differential diagnosis in young children with joint and salivary gland involvement.

Modifiable factors for prevention of childhood mortality.

OBJECTIVE: To know the disease-related causes of child mortality and identify socially modifiable factors affecting child mortality among hospitalized children aged >1 month-18 years in a referral hospital of North India. METHODS: Causes of death (ICD-10 based) were extracted retrospectively from hospital files (n=487) from 17 March 2003 to 30 June 2012. Modifiable factors were prospectively studied in 107 consecutive deaths from 6 October 2011 to 30 June 2012. RESULTS: Pneumonia, CNS infections and diarrhea were the most common disease-related causes of child mortality. CONCLUSIONS: Amongst modifiable factors, administrative issues were most common followed by family-related reasons and medical-personnel related problems.

Locked-in syndrome as a presentation of snakebite.

Snake bite is a common condition in tropical countries. Neurotoxic features of snake bite vary from early morning neuroparalytic syndrome to various cranial nerve palsies. Locked in syndrome (LIS) is a rare presentation. We present four children that had LIS; three patients had total and one had incomplete LIS. All patients made successful recovery with polyvalent anti-snake venom and supportive management. This case series highlights the importance of early diagnosis of LIS in snake bite.