An Observational Study on Pattern of Empirical Acyclovir Therapy in Children With Acute Encephalitis From Northern India.

OBJECTIVES: To identify the prevalence of herpes simplex encephalitis (HSE), factors influencing the duration of empirical acyclovir and frequency of acute kidney injury (AKI) in children with acute encephalitis syndrome (AES). DESIGN: Prospective observational study. SETTING: Pediatric Emergency Department and PICU of a tertiary hospital in Northern India. PATIENTS: All consecutive, eligible children between 1 month and 12 years old presenting with AES, defined as altered consciousness for greater than 24 hours (including lethargy, irritability, or a change in personality) and two or more of the following signs: 1) fever (temperature ≥ 38°C) during the current illness, 2) seizures or focal neurological signs, 3) cerebrospinal fluid (CSF) pleocytosis, 4) electroencephalogram, and/or 5) neuroimaging suggesting encephalitis, who received at least one dose of acyclovir. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 101 children screened, 83 were enrolled. The median (interquartile range [IQR]) age was 3 years (1-6 yr). Thirty-one children (37.3%) were diagnosed with AES, of which four were labeled as probable HSE (three based on MRI brain, one based on serology). Scrub typhus, dengue, Japanese encephalitis, and mumps were the other infective causes. The median (IQR) duration of acyclovir therapy was 72 hours (24-264 hr); 21 children (25.3%) received acyclovir for less than 24 hours and 11 (13.3%) for greater than or equal to 14 days. New-onset AKI was seen in 18 children (21.7%) but was mostly transient. Death ( n = 8, 9.6%) and discontinuation of care due to futility or other reasons ( n = 15, 18%) were noted in 23 children (28%). Factors associated with duration of acyclovir greater than 7 days, on univariable analysis, were lower modified Glasgow Coma Score at admission, requirement of invasive ventilation, invasive intracranial pressure monitoring, and CSF pleocytosis (5-500 cells). On multivariable analysis, only CSF pleocytosis of 5-500 cells was associated with duration of acyclovir greater than 7 days. CONCLUSIONS: Given the low prevalence of HSE, and the risk of AKI, this study sensitizes the need to review our practice on initiation and stopping of empirical acyclovir in children with acute encephalitis.

Medical Equipment Donation: An End in Itself or a Mean to an End?

Reddy M, Samprathi M, Bhatia V. Medical Equipment Donation: An End in Itself or a Mean to an End? Indian J Crit Care Med 2022;26(3):399-400.

Presepsin: Hope in the Quest for the Holy Grail.

How to cite this article: Samprathi A, Samprathi M, Reddy M. Presepsin: Hope in the Quest for the Holy Grail. Indian J Crit Care Med 2022;26(6):664-666.

Epidemiology and Outcomes of Early Morning Neuroparalytic Syndrome Following Snake Bite-A Retrospective Study.

OBJECTIVE: Snake envenomation has been poorly studied in developing countries. 'Early morning neuroparalytic syndrome' (EMNS), the classical clinical constellation caused by krait bites, refers to nighttime, indoor bites where nonspecific symptoms progress to neuroparalysis. Literature regarding EMNS in children is scarce. This study was planned to describe the clinical profile, intensive care needs and predictors of outcome in children with EMNS. METHODS: It is a retrospective study of children below 12 years admitted with a clinical diagnosis of snake envenomation to the pediatric intensive care unit (PICU) of a tertiary care hospital in North India. Patient records were reviewed from the electronic patient database manager. Comparison was made between the EMNS group and the non-EMNS group and between survivors and nonsurvivors within the EMNS group. RESULTS: Of the 111 children with snake envenomation, 76 had neuroparalysis (68%) and 51 had EMNS. In the EMNS cohort, 37 (72.5%) belonged to rural areas, 46 (90.2%) had indoor bites and 39 (76.5%) were witnessed. Patients with EMNS were more likely to have absent fang marks, hypoxemia at admission, bulbar palsy and need for PICU admission. Mortality rate was 13.7% in EMNS; predictors included younger age, presence of ptosis, cardiac arrest at admission and nonavailability of PICU bed (univariable analysis) but none of them independently predicted mortality. CONCLUSION: Younger age, presence of ptosis, cardiac arrest at admission and nonavailability of intensive care beds increase the risk of mortality in children with EMNS. Timely recognition and respiratory support may reduce mortality in these children.

Better Groundwork Can Avoid Troubled Waters: A Developing Country Perspective on Drowning.

OBJECTIVE: Drowning is a leading cause of unintentional injury-related death in low- and middle-income countries (LMICs). This study was undertaken to know the epidemiology, intensive care needs and predictors of outcome of children with drowning. METHODS: Records of children below 12 years admitted with drowning to the emergency room and/or paediatric intensive care unit (PICU) of a tertiary care hospital in North India were retrospectively analysed. 'Favourable outcome' was defined as normal neurological status at discharge (normal cognition and no motor deficits) and 'unfavourable outcome' as death or abnormal neurological status at discharge. Multivariable analysis was done for predictors of unfavourable outcome. RESULTS: Twenty-seven children were analyzed, 14 (51.8%) were boys. Median (IQR) age was 18 months (12-30). The median (IQR) duration of submersion was 4 min (3-9). Six children (22.2%) presented in pulseless arrest, and 7 (43.7%) had both hypoxaemia (saturation <94% on room air) and encephalopathy (GCS <13) at admission. Ten children (37%) were transferred to PICU; principal indications being hypoxic ischaemic encephalopathy (HIE) (n = 6) and ventilation (n = 4). One child died, four survived with sequalae. Predictors of unfavourable outcome on univariable analysis were hypoxaemia, or pulseless arrest at admission, HIE and need for mechanical ventilation; none of these could predict outcome on multivariable analysis. CONCLUSION: Hypoxaemia or pulseless arrest at admission, HIE and need for ventilation predict unfavourable outcome. Appropriate on-site resuscitation and early stabilization may improve outcome in children with drowning in LMIC.

Secular trends of body mass index in North Indian children with Type 1 diabetes do not support the Accelerator Hypothesis.

OBJECTIVE: The accelerator hypothesis, which proposes a link between Type 1 diabetes (T1D) and Type 2 diabetes (T2D) through weight-related insulin resistance, remains untested in developing countries with increasing rates of childhood obesity and T1D, and different ethnicities. We aimed to test the accelerator hypothesis in the context of a significant increase in T1D at our centre. DESIGN AND METHODS: Medical records of children diagnosed with T1D between January 2005 and December 2014 were retrospectively reviewed. The body mass index (BMI) standard deviation scores (SDSs) were calculated using height and weight measurements recorded 1-2 months after diagnosis of T1D and compared with age-matched anthropometric data. The rate of change in BMI SDSs over time was calculated. Analysis of BMI data was undertaken for the three age categories: <5, 5 to <10 and >10 years. RESULTS: The mean age at diagnosis of 467 children with T1D was 7·27 ± 0·32 years and showed no change over the study period. There was a yearly increase of 14·11% in patient numbers; this increase was similar in the three age categories (22·7%, 17·0%, 16·3%, respectively, P = 1·0). Comparison of patient numbers between the two time periods of 5 years each showed a marked increase during 2010-2014 (148 vs 319, % increase 115·5%). The mean BMI SDSs at diagnosis in the three age categories were similar (P = 1·0) and showed a yearly change of -0·36; the mean change in the three age categories was also similar (-0·35, -0·27, -0·46, respectively, P = 1·0). No correlation was found between age at diagnosis and BMI SDSs (correlation coefficient 0·010, P = 0·82). The mean BMI SDS in patients was significantly lower compared to controls (-0·54 vs -0·02, P = 0·001). CONCLUSION: There was no association between BMI SDS and age at diagnosis in children with new onset T1D. Further studies are needed to test whether the accelerator hypothesis is relevant in developing countries.

Multiple Lower Limb Fractures in a Child With Spinal Muscular Atrophy Type 2: A Preventable Complication.

Patients with spinal muscular atrophy (SMA) are at risk of poor bone health and fractures. We report a child with SMA type 2, presenting with acute pain and swelling of both lower limbs following physiotherapy, and found to have multiple fractures in both lower limbs. Literature on fractures in children with SMA is limited. Awareness of risk assessment and appropriate preventive measures among healthcare providers caring for children with SMA is essential.

Scrub typhus presenting with massive splenomegaly in an adolescent boy.

Scrub typhus is a serious public health problem in the Asia Pacific region. Early diagnosis and treatment can prevent complications and mortality. Splenomegaly in isolated scrub typhus is mostly mild or subclinical and rarely massive. We report an adolescent boy with scrub typhus presenting with fever, massive splenomegaly and severe anemia. Clinicians should be aware of atypical presentations of scrub typhus, which is easily treatable with minimal investigations.

Thrombocytopenia in severe iron deficiency anaemia: A report of two cases.

Iron deficiency, the commonest cause of anaemia in children, is a global public health problem. Worldwide, almost 50% of children <5 years of age are anaemic. Platelet count in iron deficiency anaemia is mostly normal or high; thrombocytopenia is rare. We describe two children with iron deficiency anaemia and severe thrombocytopenia who recovered with iron supplementation alone.

Case Report: Fulminant Infantile Beriberi: A Report of Six Cases.

Thiamine deficiency disorders are an under-recognized public health problem in low- and middle-income countries. Infantile beriberi, the most important symptom for children, is suspected to significantly contribute to infant mortality and lifelong neurodevelopmental morbidity. Lack of awareness, varied clinical presentation, and lack of a readily available diagnostic marker lead to frequent misdiagnoses. We report six thriving infants who presented with an acute fulminant illness with varied clinical manifestations mimicking common childhood illnesses like pneumonia and sepsis. Four of them presented with the severe cardiovascular form, called Shoshin beriberi, and severe pulmonary arterial hypertension. Empirical intravenous thiamine administered to four of the six infants resulted in dramatic recovery. Awareness of the clinical definition of infantile beriberi and treatment with empirical thiamine can be lifesaving.

Biomarkers in COVID-19: An Up-To-Date Review.

The ongoing pandemic of coronavirus disease 2019 (COVID-19) poses several challenges to clinicians. Timely diagnosis and hospitalization, risk stratification, effective utilization of intensive care services, selection of appropriate therapies, monitoring and timely discharge are essential to save the maximum number of lives. Clinical assessment is indispensable, but laboratory markers, or biomarkers, can provide additional, objective information which can significantly impact these components of patient care. COVID-19 is not a localized respiratory infection but a multisystem disease caused by a diffuse systemic process involving a complex interplay of the immunological, inflammatory and coagulative cascades. The understanding of what the virus does to the body and how the body reacts to it has uncovered a gamut of potential biomarkers. This review discusses the different classes of biomarkers - immunological, inflammatory, coagulation, hematological, cardiac, biochemical and miscellaneous - in terms of their pathophysiological basis followed by the current evidence. Differences between children and adults are highlighted. The role of biomarkers in the diagnosis and management of Multisystem Inflammatory Syndrome in Children (MIS-C) is reviewed. The correlation of biomarkers with clinical and radiological features and the viral load, temporal evolution and the effect of treatment remain to be studied in detail. Which biomarker needs to be evaluated when and in whom, and how best this information can contribute to patient care are questions which currently lack convincing answers. With the evidence currently available broad guidelines on the rational use of available biomarkers are presented. Integrating clinical and laboratory data, monitoring trends rather than a single value, correlating with the natural course of the disease and tailoring guidelines to the individual patient and healthcare setting are essential.

Pre-extubation ultrasonographic measurement of intracricoid peritubal free space: A pilot study to predict post-extubation airway obstruction in children.

OBJECTIVE: Post-extubation airway obstruction (PEAO) is common and difficult to predict in children. We hypothesized that Intracricoid Peritubal Free Space (IPFS) obtained by deducting the outer diameter of the endotracheal tube in situ (ODTT - provided by the manufacturer) from the ultrasonographically measured internal transverse cricoid diameter (ICDt) is likely to be inversely proportional to the risk of developing PEAO. This prospective observational study was planned to evaluate this hypothesis. METHODS: This study was conducted in a Pediatric Intensive Care Unit of a tertiary care teaching hospital in a low-middle income economy. Laryngotracheal ultrasound was performed just prior to the first elective extubation in 93 patients (3mo-12yrs) intubated for ≥ 48 h, to calculate the IPFS. Patients with pre-existent upper airway conditions, chronic respiratory diseases and poor airway reflexes were excluded. Patients with Westley's Croup Score (WCS) ≥4 were classified as PEAO, and those with WCS ≥7, as extubation failure (EF). RESULTS: Thirty-two (34%) patients developed PEAO, while seventeen (18%) developed EF. Baseline clinical characteristics were similar in patients with and without PEAO. IPFS was lesser in patients who developed PEAO (4.16 ± 1.18 mm vs. 5.28 ± 1.51 mm, p < 0.001) and EF (4.13 ± 1.44 mm vs. 5.07 ± 1.46 mm, p = 0.019) compared to those who did not. IPFS <5.16 mm predicted PEAO [sensitivity, 84%; positive predictive value (PPV), 87%; AUC, 0.714), while IPFS <3.77 mm predicted EF (specificity, 80%; PPV, 88%; AUC, 0.679). Combining clinical risk factors (presence of clinical edema, prolonged ventilation and younger age) and lesser IPFS helped develop a clinico-sonographic prediction model with improved predictability for PEAO and EF (AUC, 0.820 for both). CONCLUSIONS: Lesser IPFS is reasonably sensitive and specific to predict PEAO and EF respectively with high PPV. Combining clinical risk factors and IPFS improved the PPV further. Further studies with larger samples stratified for different age groups in different clinical settings are required to confirm these observations.

Clinical Profile of Critical Pertussis in Children at a Pediatric Intensive Care Unit in Northern India.

OBJECTIVE: To delineate the clinical profile, complications, intensive care needs, and predictors of mortality in children with critical pertussis. METHODS: Retrospective analysis of case records of children in the pediatric intensive care unit of a tertiary-care hospital, with a diagnosis of critical pertussis over 3 years. Diagnostic criteria included CDC case definition and confirmation by polymerase chain reaction (PCR), when available. Survivors and non-survivors were compared to identify predictors of mortality. RESULTS: 36 records were analysed, most cases were infants (31, 86.1%). 10 (27.7%) were (below 6 weeks of age). In the rest, 16 (61.5%) were partially immunized or unimmunized against pertussis. Rapid breathing (88.9%), paroxysmal cough (86.1%) and apnea (41.7%) were common presenting complaints. Hypoxemia (97.2%), hyperleukocytosis (61.1%) and encephalopathy (52.8%) were common complications. Intensive care needs were mechanical ventilation in 11 (30.6%), vasoactive support in 7 (19.4%) and exchange transfusion in 3 (8.3%). Female gender, apnea, hyperleukocytosis, encephalopathy, need for vasoactive support, and mechanical ventilation predicted mortality. CONCLUSIONS: Pertussis demands attention due to its varied presentation, increased complications and higher mortality.