Comparison of gastric lavage/sputum and stool specimens in the diagnosis of pediatric pulmonary tuberculosis- A pilot study.

BACKGROUND AND OBJECTIVE: Global TB report 2021 mentions 11 % prevalence of pediatric TB, whereas 5.65% of the cases were reported from India in 2020. India features in the list of TB high burden countries, HIV-TB high burden and MDR-TB high burden countries. The diagnosis of pulmonary tuberculosis in children is difficult as they tend to swallow the sputum, invasive techniques of gastric aspirates needs to be followed and the disease itself is paucibacillary. The disease progresses rapidly in young children and hence rapid diagnosis is needed. Obtaining appropriate respiratory samples for diagnosis is difficult especially in primary care settings. Stool sample is easy to obtain and since children swallow sputum, it can be used to diagnose pulmonary tuberculosis. With this background, a pilot study was planned to evaluate the accuracy of the Xpert MTB/RIF assay for the detection of MTB in stool specimens obtained from pediatric pulmonary TB patients confirmed either by gastric lavage(GL) or sputum(SP) Xpert MTB/RIF assay. In addition, the results of microscopy of stool specimen were compared with that of gastric lavage/ sputum (GL/SP) specimen by Ziehl-Neelsen (ZN) and fluorescent light-emitting diode (LED) staining. MATERIAL AND METHODS: A prospective study was carried out on 50 GL/SP Xpert MTB/RIF assay positive children (0-14 years). Stool specimens from these children were processed for Xpert MTB/RIF assay. The GL/SP and stool specimens were processed for ZN and Auramine O fluorescent microscopy as well. RESULTS: Fluorescent staining detected acid fast bacilli (AFB) in 24 GL/SP and 16 stool specimens as compared to 20 GL/SP and 10 stool specimens by ZN staining. Stool Xpert MTB/ RIF assay was positive in 29 out of 50 children. Rifampicin resistance was detected in 13 of the 50 (26%) GL/SP specimens. Of these 13 children, rifampicin resistance was detected in 7 stool specimens, rifampicin indeterminate resistance was detected in one specimen and in the remaining 5 children, M.tuberculosis was not detected in stool. CONCLUSION: Stool is a good non-invasive specimen for the detection of pulmonary TB in children, especially in remote areas, where invasive techniques cannot be performed for sample collection.

Clinical Profile and Outcome of Pediatric Tetanus at a Tertiary Care Center.

The aims and objectives of this study were to study clinical profile and factors affecting mortality in tetanus. This was a retrospective study of 25 tetanus patients (aged 6 months-12 years) admitted to pediatric intensive care unit of a tertiary center (over 3 years). In this study, 25 tetanus cases (mean age 6.6 years) were analyzed; 16 were males and 9 were females. Incubation period ranged from 2 to 30 days (mean 8.2 days), period of onset from 11 to 120 hours (mean 42.8 hours), and duration of spasms from 4 to 26 days (mean 14 days). The commonest portal of entry was posttrauma (52%), followed by otogenic (40%). Eighteen patients had moderate and 7 had severe tetanus. Fifteen were unimmunized and 10 were partially immunized. The commonest complaints were trismus and spasms (100%), hypertonia (72%), fever (60%), dysphagia (48%), and neck stiffness (44%). Eight patients required primary tracheostomy and 11 required primary endotracheal intubation. Complications encountered were pneumonia (58%), conjunctivitis (41%), gastrointestinal bleed (37.5%), urinary infection (33%), acute kidney injury (AKI) following rhabdomyolysis (33%), sepsis (29%), disseminated intravascular coagulation (DIC) (25%), bedsores (25%), and acute respiratory distress syndrome (ARDS) (20%). Oral diazepam was most commonly used, followed by midazolam, vecuronium, and magnesium sulfate. Mortality rate was 32% (five moderate and three severe cases died). Short period of onset (less than 48 hours), AKI following rhabdomyolysis, sepsis, DIC, ARDS, and inotrope need were significantly associated with higher mortality. It is concluded that the commonest portal of entry was posttrauma. None of the patients was completely immunized. Short period of onset, AKI, sepsis, DIC, ARDS, and inotrope need predicted a higher mortality.

A longitudinal study of antibody responses to selected host antigens in rheumatic fever and rheumatic heart disease.

Introduction. Group A streptococci can trigger autoimmune responses that lead to acute rheumatic fever (ARF) and rheumatic heart disease (RHD).Gap Statement. Some autoantibodies generated in ARF/RHD target antigens in the S2 subfragment region of cardiac myosin. However, little is known about the kinetics of these antibodies during the disease process.Aim. To determine the antibody responses over time in patients and healthy controls against host tissue proteins - cardiac myosin and peptides from its S2 subfragment, tropomyosin, laminin and keratin.Methodology. We used enzyme-linked immunosorbent assays (ELISA) to determine antibody responses in: (1) healthy controls; (2) patients with streptococcal pharyngitis; (3) patients with ARF with carditis and (4) patients with RHD on penicillin prophylaxis.Results. We observed significantly higher antibody responses against extracellular proteins - laminin and keratin in pharyngitis group, patients with ARF and patients with RHD when compared to healthy controls. The antibody responses against intracellular proteins - cardiac myosin and tropomyosin were elevated only in the group of patients with ARF with active carditis. While the reactivity to S2 peptides S2-1-3, 8-11, 14, 16-18, 21-22 and 32 was higher in patients with ARF, the reactivity in the RHD group was high only against S2-1, 9, 11, 12 when compared to healthy controls. The reactivity against S2 peptides reduced as the disease condition stabilized in the ARF group whereas the reactivity remained unaltered in the RHD group. By contrast antibodies against laminin and keratin persisted in patients with RHD.Conclusion. Our findings of antibody responses against host proteins support the multistep hypothesis in the development of rheumatic carditis. The differential kinetics of serum antibody responses against S2 peptides may have potential use as markers of ongoing cardiac damage that can be used to monitor patients with ARF/RHD.

Clinical Profile and Outcome of Guillain-Barre Syndrome in Pediatric Patients Admitted to a Tertiary Care Centre: A Retrospective Study.

AIMS AND OBJECTIVES: To study clinical profile and outcome in Pediatric Guillain Barre Syndrome (GBS). MATERIALS AND METHODS: Retrospective study of 30 patients (age 1 month to 12 years) admitted with GBS enrolled over a period of 2 years (August 2016-July 2018) from Department of Pediatrics of tertiary centre. RESULTS: Mean age was 5.4 years (21 males; 9 females). Most common presenting complaints- symmetrical lower limb weakness (26 cases; 86.67% cases), respiratory complaints (6 cases; 20% cases), quadriparesis (4 cases; 13.33% cases) and facial palsy (2 cases; 6.67%). Antecedent illnesses- gastrointestinal (6 cases) and respiratory (3 cases). Two patients had varicella (in preceding one week) and one had mumps (one month prior to presentation). MRI-spine done in 12 patients; of whom 9 had features of GBS (thickening and contrast enhancement of the intrathecal and cauda equina nerve roots on T1 weighted MRI). Nerve conduction studies done in 16 patients, of which Acute Motor Axonal Neuropathy was seen in 10 cases. Intravenous immunoglobulin was given to 27 patients while 3 received methylprednisolone in addition. 90% patients receiving IVIG showed improvement. Sixteen patients were admitted to the intensive care unit and 7 required mechanical ventilation. Average hospital stay was 13 days. Two patients had recurrent episodes. Common complications included- pneumonia (6 cases; 2 aspiration and 4 ventilator associated) and autonomic disturbances (6 cases). Two patients died due to autonomic disturbances and presence of autonomic disturbances predicted higher mortality (P = 0.034). CONCLUSIONS: Gastrointestinal illness was common antecedent illness for GBS. Symmetrical lower limb weakness was commonest complaint. Pneumonia and autonomic disturbances were commonest complications. Presence of autonomic disturbances predicted higher mortality.

Unilateral pulmonary venous atresia: A rare cause of recurrent hemoptysis.

Hemoptysis is a rare but distressing complaint in children. Pulmonary venous atresia (PVA) is a rare cause of recurrent hemoptysis in children. We report a 3-year-old boy with recurrent hemoptysis for 2 years. The child had tachycardia, tachypnea, tender hepatomegaly, and left-sided decreased air entry with crepitations. Coagulation and Koch's workup was negative. X-ray of the chest showed a small left hemithorax. Computed tomography with angiography showed left unilateral PVA with pulmonary artery hypoplasia and dysplastic left lung. The child has been posted for left pneumonectomy. Although uncommon, PVA should be diagnosed early to prevent life-threatening complications such as hemoptysis and pulmonary hypertension. The patient can be managed conservatively or surgically depending on the severity. Early diagnosis and intervention helps in reducing morbidity and mortality.

Device-handling study of a novel breath-actuated inhaler, Synchrobreathe®, versus a pMDI.

INTRODUCTION: Synchrobreathe®, a new-generation, novel breath-actuated inhaler (BAI) can address the key issues arising during the use of both pressurised metered dose inhalers ([pMDIs]; hand-breath coordination) and dry powder inhalers ([DPIs]; high inspiratory flow required) with respect to optimal drug deposition. MATERIALS AND METHODS: This was an open-label, prospective, 2-week, multicentre study that assessed device handling, ease of use, errors and participant perception regarding the use of Synchrobreathe® versus a pMDI in patients with chronic obstructive pulmonary disease (COPD) (n = 162) or asthma (n = 239) and inhaler-naïve healthy volunteers (n = 59). Ability to use the device without errors at the first attempt, total number of errors before and after training, time taken to use the device correctly and total number of training sessions, and number of attempts to perform the correct technique on Day 1 and Day 14 were evaluated. Device handling and preference questionnaires were also administered on Day 14. RESULTS: Of 460 participants, 421 completed the study. The number of participants using Synchrobreathe without any error after reading the patient information leaflet (PIL) was significantly low (p < 0.05) on Day 1. On Day 14, significantly more number of participants used Synchrobreathe without any error (p < 0.001). The total number of errors before and after training with Synchrobreathe was significantly less (p < 0.001). The average time required to perform the inhalation technique correctly (p < 0.01) and the total number of attempts (P < 0.001) with Synchrobreathe were significantly lower. The average number of attempts to inhale correctly was significantly (p < 0.001) less with Synchrobreathe on Day1 and Day 14. Most participants rated Synchrobreathe as their choice of inhaler. CONCLUSION: Synchrobreathe is an easy-to-use and easy-to-handle device with significantly less number of errors, which may have positive implications for disease control in asthma and COPD.

Myxedema Coma in a Pediatric Patient with Down Syndrome.

Myxedema coma due to severe/long standing hypothyroidism is a known fatal endocrine emergency but is rare in children and unreported in pediatric Down syndrome. It mimics other conditions in the emergency room, making the diagnosis challenging. We present a 10-year-old-male child with global developmental delay and Down syndrome phenotype, admitted for altered sensorium subsequent to a febrile illness. The presence of myxedematous changes on clinical examination, on a background of altered sensorium and hypothermia, led to suspicion of myxedema coma, confirmed by laboratory testing. Due to nonavailability of triiodothyronine (T3), thyroxine (T4) was administered through nasogastric tube after an endocrine consult. Despite initial recovery in terms of improved consciousness, the child ultimately succumbed to refractory shock and terminal ventricular tachycardia. Our case highlights the need to consider myxedema coma as a differential diagnosis for altered mental status in the emergency room and use of screening tools for effective selection of patients.

Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center.

AIMS AND OBJECTIVES: Vancomycin is a drug of choice for various gram-positive bacterial (GPB) infections and is largely prescribed to pediatric intensive care unit (PICU) patients. Despite the different pathophysiology of these patients, limited data are available on pharmacokinetics of vancomycin. There are lack of data for critically ill Indian children; hence, study was conducted to assess the steady-state pharmacokinetics in children admitted to PICU. MATERIALS AND METHODS: Twelve subjects (seven males, five females) aged 1-12 years were enrolled. Vancomycin (dose of 20 mg/kg per 8 hours) was infused for over 1 hour and steady-state pharmacokinetics was performed on day 3. Vancomycin concentrations were measured by the validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). RESULTS: The steady-state mean C ssmax was 40.94 µg/mL (±15.07), and mean AUC0-8 hours was 124.15 µg/mL (±51.27). The mean t 1/2 was 4.82 hours (±2.71), Vd was 12.48 L (±4.43), and Cl was 2.08 mL/minute (±0.89). The mean AUC0-24 among 12 subjects was 372.44 µg/mL (±153.82). Among 35 measured trough concentrations, 23 (65.71%) were below, 11 (31.43%) were within, and 1 (2.86%) was above the recommended range. CONCLUSION: The pharmacokinetic parameters of vancomycin were comparable with previously reported studies. However, recommended trough levels (10-20 µg/mL) were not achievable with current recommended dosing of 60 mg/kg/day. HOW TO CITE THIS ARTICLE: Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, et al. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. IJCCM 2019;23(11):497-502.

A Prospective Antibacterial Utilization Study in Pediatric Intensive Care Unit of a Tertiary Referral Center.

PURPOSE: Antibacterials are commonly prescribed to Pediatric Intensive Care Unit (PICU) patients. However, inappropriate antibacterial prescriptions lead to increases in antibacterial resistance, treatment cost, duration of treatment, and poor clinical outcome. The antibacterial utilization study assesses the prescription patterns and if necessary recommends the interventions to improve antibacterial prescriptions. Hence, the present prospective groundwork was conducted. MATERIALS AND METHODS: The study was conducted over the period of 6 months (April 18 to October 20, 2014). The demographics and drug use details were captured daily from patients admitted to PICU to assess World Health Organization indicators. RESULTS: A total of 200 patients enrolled, among them 119 males and 81 females. There were 12.46 (±6.16) drugs prescribed per patient, of which 2.38 (±1.48) were antibacterials. Among the total drug prescribed, 18.49% were antibacterials and 97% patients received at least one antibacterial. Ceftriaxone (49.48%) was the most commonly prescribed antibacterial, while imipenem (2.58%) and colistin (2.06%) use was very low. A total of 80.95% antibacterials were prescribed by generic name, 94.88% were administered intravenously, and 80.76% were prescribed from hospital pharmacy. The average length of PICU stay was 6.15 days (±6.20), the average length of antibacterial treatment was 6.08 days (±6.27), and the average length of empirical antibacterial treatment was 5.50 days (±5.40). The cost of antibacterial therapy per patient was Indian rupees 824.64 (±235.35). In 27 patients, bacterial culture test was positive and of whom 21 received antibacterials as per sensitivity pattern. CONCLUSIONS: The use of antibacterials was not indiscriminately high but more prescriptions per sensitivity pattern are required.

Local anaesthetic systemic toxicity following oral ingestion in a child: Revisiting dibucaine.

Dibucaine, a potent and toxic local anaesthetic, although currently withdrawn by the United States Food and Drug Administration for use as a spinal anaesthetic, continues to remain available in many over-the-counter topical formulations. Systemic toxicity following oral ingestion of local anaesthetics is rare. We report a case of accidental ingestion of dibucaine (ear drops) in a 7-year-old child who developed diplopia, giddiness, ventricular premature contractions and a right bundle branch block. We also present a brief discussion on the pharmacologic and toxicity profile of dibucaine, the Naranjo algorithm for assessing causality in case of adverse drug reactions and a review of current guidelines on the management of local anaesthetic systemic toxicity.

Acute intermittent porphyria: A critical diagnosis for favorable outcome.

Acute intermittent porphyria (AIP) is an inherited metabolic disorder characterized by the accumulation of toxic metabolites of the heme pathway. It rarely presents in the prepubertal age group. AIP often presents with nonspecific and nonlocalizing symptoms. Moreover, several commonly used medications and stress states are known to precipitate an attack. We present the case of a previously healthy 5 years female who was diagnosed as acute central nervous system infection/inflammation at admission. It was the presence of red flags that led to a correct diagnosis. Besides supportive management, a dedicated search for intravenous hemin (chemically heme arginate, aminolevulinic acid synthase inhibitor, and drug of choice) was attempted. Unexpected help was rendered by doctors from a medical college in Gujarat, and two ampoules could be obtained. The patient received three doses of intravenous hemin; however, she succumbed later. This case is presented for the diagnostic and therapeutic challenges faced in developing countries.

Acute Respiratory Distress Syndrome Caused by Mercury Inhalation: A Case Report.

Inhalation of mercury vapor is an uncommon cause of acute respiratory distress syndrome. It may go unnoticed if appropriate environmental/occupational history is not taken. A 2-year-old child presented with severe respiratory distress and progressed to develop acute respiratory distress syndrome, necessitating high-pressure mechanical ventilation. On detailed enquiry, history of exposure to mercury fumes was obtained (at home), during gold extraction by the father. Diagnosis of mercury poisoning was confirmed by blood levels, and despite treatment with dimercaprol (mercury chelator) and high-frequency ventilation, the child subsequently succumbed within 26 hours. This case reiterates the need for awareness regarding unusual environmental toxic exposures and need for stricter regulations for sale or use of toxic products.

Rare treatment option for a common pediatric airway problem.

Laryngomalacia is a common cause of respiratory obstruction with stridor in infants. Although most cases resolve spontaneously, severe laryngomalacia needs surgical intervention. Tracheostomies have been the mainstay of treatment. However, this procedure was associated with high morbidity. At present, newer modalities of treatment are being tried. We discuss successful management of an infant having severe laryngomalacia (who had three failed extubation trials) with glossoepiglottopexy.

Left ventricular noncompaction: a cardiomyopathy often mistaken.

Left ventricular noncompaction (LVNC) is a rare genetic cardiomyopathy postulated to be a defect in endomyocardial morphogenesis due to the embryonic arrest of the compaction of myocardial fibers. It could be isolated, without other structural heart defects; or associated with congenital heart defects. It is characterized by prominent ventricular myocardial trabeculations and deep intertrabecular recesses. The clinical manifestations, i.e., heart failure, arrhythmias or thromboembolism, overlap with those of other cardiac disorders. It is often misdiagnosed as restrictive or dilated cardiomyopathy. The high mortality and morbidity associated with it and familial occurrence make diagnosis important. Only 3 pediatric cases have been reported from India. We present 2 cases, that of an 11-year-old girl (familial case) with embolism (documented but rare in children) and atrial flutter (not yet reported), with mother having asymptomatic LVNC; and that of a 4-month-old girl. Both presented with heart failure. The 11-year-old child had sudden death, known to occur in LVNC.

Cutaneous mastocytosis. Getting beneath the skin of the issue: a case report.

An eleven month old girl presented with chronic urticaria since three months of age. There was a generalised hyperpigmented maculo-papular rash. Darier sign was positive. The skin biopsy showed plenty of spindle shaped mast cells with eosinophilic cytoplasm infiltrating the dermis and the appendiceal structures. The diagnosis of cutaneous mastocytosis (urticaria pigmentosa) was made. The child received symptomatic relief with chronic oral hydroxyzine and ranitidine therapy. Automated epinephrine self-injectors usually prescribed in this condition for self-management of anaphylactic episodes were not available. Intramuscular administration of (1:1000) diluted adrenaline via a disposable tuberculin syringe was taught to the mother. A medical bracelet containing her diagnosis and instructions in emergency was custom-made for her.