Vesiculobullous lesions of the oral cavity

Vesiculobullous lesions are a type of mucocutaneous disease that is characterized by vesicles and bullae or blisters. Both vesicles and bullae are fluid-filled lesions, and they are distinguished by size, vesicles being less than 5–10 mm and bulla being larger than 5–10 mm, In the case of vesiculobullous diseases which are also immune disorders the term immunobullous is sometimes used. This review will provide an overview of vesiculobullous lesions involving oral cavity, their characteristic features and recent developments in the diagnosis of these lesions.

Thiamine responsive megaloblastic anemia syndrome.

Thiamine responsive megaloblastic anemia syndrome (TRMA) is a clinical triad characterized by thiamine-responsive anemia, diabetes mellitus and sensorineural deafness. We report a 4-year-old girl with TRMA whose anemia improved following administration of thiamine and this case report sensitizes the early diagnosis and treatment with thiamine in children presenting with anemia, diabetes and deafness.

A profile of bacteriologically confirmed pulmonary tuberculosis in children.

OBJECTIVE: To describe the clinical profile of children with bacteriologically confirmed tuberculosis. STUDY DESIGN: A multicentric study was conducted in three hospitals in Chennai city between July 1995 and December 1997. Children aged 6 months to 12 years with signs and symptoms suggestive of tuberculosis were investigated further. Clinical examination, chest radiograph, tuberculin skin test with 1 TU PPD and, sputum or gastric lavage for mycobacterial smear and culture were done for all and, lymph node biopsy when necessary. RESULTS: A total of 2652 children were registered and tuberculosis was bacteriologically confirmed in 201. Predominant symptoms were history of an insidious illness (49%), fever and cough (47%), loss of weight (41%) and a visible glandular swelling (49%). Respiratory signs were few and 62% were undernourished. Over half the patients with confirmed TB had normal chest X-ray. Abnormal X-ray findings included parenchymal opacities in 47% and hilar or mediastinal lymphadenopathy in 26%. The prevalence of isoniazid resistance was 12.6% and MDR TB 4%. CONCLUSIONS: Children with tuberculosis present with fever and cough of insidious onset. Lymphadenopathy is a common feature even in children with pulmonary TB. A significant proportion of children have normal chest X-rays despite positive gastric aspirate cultures. Drug resistance rates in children mirror the pattern seen in adults in this geographic area.

Psychosocial problems in families of children with cancer.

OBJECTIVE: The aim of this study is to assess the effect of diagnosis of cancer on the parents, to study the coping response adopted by the child and the family and to evolve counseling strategies. METHODS: Prospective questionnaire based. Thirty-four parents of children suffering from cancer were included, of which 15 belonged to joint families and 19 to nuclear families. RESULTS: The family support played an important role in giving emotional sustenance, besides shared care of the child, the sibling and the household. Emotional and psychological impact was maximum on the mothers. Siblings of the cancer child were also affected both by way of behaviour problems and school performance. Behaviour problems in the cancer child included temper tantrums, as also verbal and physical abuse of mothers. Group therapy was useful for sharing emotional trauma and exchanging day to day problems of childcare. Positive outlook helped in better care of the cancer child. CONCLUSION: The family structure was the foundation for emotional and psychological security. Psychological support by professional tumour support group would enhance this.

Crohn's disease presenting as palatal ulcer.

Crohn's disease (CD) in children younger than 5 years of age is termed as early onset inflammatory bowel disease (EO-IBD). We report a 4 yr 6 mo-old child with EO-IBD, who presented with palatal ulcer, an extra intestinal manifestation of Crohn's disease as the dominant feature.

Benign acute childhood myositis.

OBJECTIVE: To describe the clinical and laboratory features of benign acute childhood myositis. METHODS: 40 children of BACM were seen during October 2001 to February 2002, 22 (52%) were male with mean age of 5.3 years. Duration of illness was 3.97 days. Preceding symptoms included fever, leg pain, vomiting and inability to walk. A provisional diagnosis of viral myositis was made in 26 (66%). Guillian Barre Syndrome was the most common referral diagnosis. RESULTS: 11 (27.5%) children had leucopenia with lymphocytic response and 16 (40%) had thrombocytopenia. CRP was negative in 32 (80%). CPK was markedly elevated (more than 1000 IU/l) in 18 (45%) and more than 500 IU/l in 11 (27.5%) remaining between 200 to 500 IU/l. Associated features were hepatitis (elevated SGOT & SGPT) in 28 (70%) and shock in 5 (12.5%).Serological test were indicative of dengue virus (Elisa PAN BIO) in 20 (50%) of which 8 (25%) were primary dengue and 12 (30%) were secondary dengue. The outcome of therapy mainly supportive were excellent. CONCLUSION: Benign acute myositis occurs often in association with viral infection. In the present study, Dengue virus was positive in 20 (50%) children. Benign acute myositis can be differentiated from more serious causes of walking difficulty by presence of calf and thigh muscle tenderness on stretching, normal power and deep tendon reflex and elevated CPK.

Pediatric presentations of leptospirosis.

OBJECTIVE: Leptospirosis in children is an often under diagnosed condition due to the non specificity of the presentations except for the classical Weil's disease. METHODS: Children presenting with symptoms and signs suggestive of Leptospirosis were included in the study. Diagnostic criteria were fever, myalgia, conjunctival suffusion, Jaundice, headache, altered sensorium, seizures, bleeding manifestation and oliguria. Their clinical profile, lab parameters (general and specific), response to treatment and outcome were analysed. RESULT: One hundred and thirty nine cases were diagnosed during a 4-year period. The commonest symptoms were fever 133 (96%), headache and myalgia 34 (24%). Jaundice was present in only 25 (18%) of cases with renal failure in 2 cases. The frequently encountered clinical signs were hepatomegaly in 100 (72%), myalgia in 34 (24%) with icterus in 25 (18%), 12 (9%) of children presented with shock and 10 (7%) had meningitis. CPK estimated was a useful index of myositis. The diagnosis was confirmed by Dark field microscopy and paired or single high serological tests (MAT, ELISA IgM). Overlapping infections such as culture positive Salmonella typhi with leptospirosis (Serology positive) or Dengue Hemorrhagic fever with Leptospirosis presented with complications such as a myocarditis, shock and ARDS. CONCLUSION: Presentation of non-icteric forms of Leptospirosis are often non-specific and may be missed unless there is a high index of suspicion. This study emphasizes the myositis and meningitis forms of leptospirosis. Delayed diagnosis leads to increased mortality and morbidity.

Importance of screening the peripheral smear.

A 5-year-old boy presented with history of failure to thrive from infancy. There was a history of one sibling death due to similar problems and history of severe abortions in the mother. Routine examination of peripheral smear revealed more than 50% acanthocytes. Based on this tests were streamlined to doing lipid profile and Lipo protein electrophoresis which revealed hypolipidemia and absent beta hypo protein band. Jejunal mucosal biopsy confirmed the diagnosis of A Beta Lipo proteinemia which revealed lipid laden enterocytes. This case illustrates the importance of simple tests like peripheral smear examination in streamlining further tests in the diagnosis of major diseases.

Tuberculin and BCG tests.

The tuberculin test is widely used for the diagnosis of tuberculosis in children as it is the only one that provides evidence of infection with M. tuberculosis. Of the tuberculins that are available, the most widely used are PPDS and PPDRT 23, in various strengths. A positive test indicates prior infection with the tubercle bacillus but not necessarily active disease. A positive test may also result from BCG vaccination though the response is usually less than 10 mm and tends to wane with time. In areas with a high prevalence of atypical mycobacteria in the environment, positive reactions may also be due to cross-reactivity. BCG has been recommended by some workers as a diagnostic test but suffers from the disadvantages of low specificity.

Sino-bronchial syndrome in children with asthma.

Thirty children in the age group of 2 to 12 years were brought with a history of recurrent non-seasonal moderate to severe wheezy episodes associated with symptoms of nasal congestion, sneezing and occasional headache. All of them had maxillary or pan sinusitis with 26 having associated right, left or bilateral lower lobe pneumonitis or bronchiectasis. Serum immunoglobulins were normal in 22 and was not done in eight. There was positive (2 to 4+ above negative control) skin test response to dust and dust mite in 15 of the 22 children tested. Throat swabs/sputum or nasal secretions grew B-hemolytic streptococcus or streptococcus pneumoniae in twenty-seven. All the children were put on bactericidal drugs for 6 to 8 weeks and bronchodilators were used when needed. At the end of 6 to 8 weeks follow-up X-ray of sinuses and chest showed significant clearing of the lesions which coincided with marked clinical improvement. Sinus X-ray should be considered in bronchial asthma resistant to medical management since untreated bacterial sinusitis can be an underlying cause of chronic poorly controlled asthma.

Varied manifestations of viral myocarditis.

Nine children in the age group of new born to 10 years were seen during the period October 1989 to January 1993 with varying manifestations of Myocarditis. This ranged from cardiogenic shock due to fulminant cardiac failure, recurrent wheezy episodes (mistakenly treated as bronchial asthma) bronchiolitis and rhythm disturbances. Clinical picture was collaborated by radiological evidence of cardiomegaly, ECG changes of low voltage QRS complexes with ST depression, T wave inversion or signs of left ventricular dilatation. SGOT, SGPT, CPK, LDH were elevated significantly in 7 cases. Echocardiographic changes ranged from left ventricular dilatation to global hypokinesia and mild mitral incompetence. Viral studies suggested infection with Coxsackie B1 in 4 cases, B4 in 2, B5 in 2 and Dengue 3 in 1 case. All the children recovered well with routine anti failure measures and treatment of arrhythmias and 2 children needed steroid therapy. At the end of follow up of 6 months to 1 year there has been complete reversal of ECHO changes to normal. Viral Myocarditis can manifest in varied ways in children and if treated adequately may lead to complete recovery.

Maternal fetal immunological relationship particularly mycobacterial immunity.

Thirty-nine paired maternal and cord blood from normal full term deliveries were tested for lymphocyte function by proliferative response to mitogens-Phytohemagglutinin-P (PHA) and Poke week mitogens (PWM). Monocyte function was assessed by the ability of the monocytes to release hydrogen peroxide (H2O2) in response to standard stimulus (PMA). Mycobacterial immunity was assessed by lymphocyte proliferative response to purified proteins derivative (PPD) and IgM and IgG antibody response to H37Rv and 5 atypical mycobacteria. Lymphocyte functions were significantly lower in cord blood (PHA 20.6, PWM 21.2) as compared with maternal blood (PHA 65.8, PWM 37.8). The capacity of fetal monocytes to release H2O2 was comparable to maternal monocytes. The mean proliferative response of fetal lymphocytes to tubercular protein (PPD) was 0.67 as compared (P less than 0.01) to maternal lymphocytes (3.79). Nearly 86% of the cord blood did not show any response to PPD. None of the cord blood showed IgM antibody response to H37Rv nor to any of the range of 5 atypical mycobacteria though maternal IgM and IgG response was present. There was only passive transfer of IgG antibody from mother to fetus. Hence, though this is a highly endemic area for atypical mycobacteria and M. tuberculosis, there was apparently no transplacental transfer of antigen in normal sensitized mothers.

Post-streptococcal acute glomerulonephritis: a clinical, bacteriological and serological study.

Eight hundred and sixty four children were admitted with Acute post-streptococcal glomerulonephritis (APSGN) at the Institute for Child Health, Madras, during the period January 1981 to January 1983. Majority of the cases followed infected scabies or impetigo. 135 children were investigated and followed up for a period of 1-2 years. The disease had an excellent prognosis in these children. None of those examined 2 years after discharge had proteinuria or hypertension. Group A beta hemolytic streptococcus (BHS) was isolated in 13.4% of patients and 11.25% of skin infection controls. Eight different T types were identified in patients and 6 T types in pyoderma cases. All patients and 87% of skin infection controls had elevated anti-D Nase B titres, while ASO titres were not significantly raised.

Cell mediated immunity in childhood malaria.

Children with malarial infection, due to P. Vivax and P. falciparum, were tested for cell mediated immunity (CMI) by lymphocyte proliferative response to mitogens PHA (phytohaemagglutinin) and PWM (poke weed mitogen) and antigen PPD (purified protein derivative). This was done during the period of parasitemia and after treatment, and compared to 19 normal matched controls. There was no significant difference between the patients and the control group with regard to PHA (patients 57.4 +/- 50.5; controls 61.3 +/- 54.9); PWM (patients 27.4 +/- 19.9, controls 29.9 +/- 24.5); PPD (patients 2.2 +/- 1.2, controls 1.9 +/- 1.4). There was also no significant difference in the lymphocyte responses during the period of parasitemia and after treatment. Hence, there does not seem to be any depression of CMI as shown by lymphocyte proliferative responses during childhood malaria.