Subconjunctival cysticercosis - Is surgery always indicated? Role of medical management-literature review and report of two cases.

Ocular cysticercosis is caused by the larval form of pork tapeworm for which humans and pigs are the intermediate hosts. Intense inflammation secondary to immunological reaction is the hallmark feature of the infection, which can affect almost any tissue of the host. Orbital imaging yields specific features suggestive of the diagnosis. Although medical management is the recommended treatment for extra-ocular and retro-orbital cysticercosis, surgical removal has also been suggested by several authors. Here, we report two cases of subconjunctival cysticercosis, successfully managed with medical treatment alone using oral steroid and albendazole. Surgical excision for subconjunctival cysticercosis is associated with complications which can be observed even with the most experienced hands. Through these two cases, we wish to sensitize the practicing physicians regarding the most common ocular infestation seen in the developing countries along with brief literature review on the management protocols to be followed before any surgical reference.

Subcutaneous fat necrosis in an infant with hypoxic ischaemic encephalopathy stage 3: an uncommon association.

Subcutaneous fat necrosis (SCFN) is inflammation and necrosis of adipose tissue associated with hypoxia and hypothermia. It leads to various metabolic abnormalities, of which the most dreaded is hypercalcaemia. We report a case of a 7-week-old boy with history of birth asphyxia (hypoxic ischaemic encephalopathy stage 3) who presented to us with features suggestive of hypercalcaemia with bilateral nephrocalcinosis. On examination, there were multiple subcutaneous nodules on both arms. Evaluation revealed suppressed parathyroid activity along with low levels of 25(OH)vitamin D3 and elevated 1,25-dihydroxyvitamin D3 Skin biopsy confirmed the diagnosis of SCFN. He was managed with intravenous fluids, single dose of intravenous furosemide and oral prednisolone. Hypercalcaemia responded within 14 days of admission, prednisolone was tapered and stopped in a month. SCFN, in our case, can be attributed to the underlying perinatal asphyxia along with use of therapeutic hypothermia. Through this case, we wish to sensitise practicing neonatologists for the need of screening and early identification of these abnormalities, which if missed can be fatal.

Isoniazid induced palmoplantar hyperhidrosis.

Secondary focal hyperhidrosis is usually due to peripheral or central neuronal defects and is a complex dysfunction of the parasympathetic and sympathetic nervous system. Palmoplantar hyperhidrosis has been described with various types of polyneuropathies such as diabetic but has not previously been described with isoniazid. We report a 15-year-old boy, being followed for neurotuberculosis, who presented with burning sensation and hyperhidrosis of both palms and soles five months after starting antitubercular therapy. With oral pyridoxine supplementation, the paraesthesia and hyperhidrosis reduced to minimal severity over the next four months. Before commencing antiperspirants, simple pyridoxine supplementation can lead to the reversal of symptoms in such cases.

Anti-N-methyl-d-aspartate Receptor Encephalitis Presenting as New-onset Refractory Status Epilepticus Responding to Rituximab in an Adolescent Girl.

New-onset refractory status epilepticus (NORSE) is defined as a refractory status epilepticus (SE) in a patient, without a clear acute or active structural, toxic, or metabolic cause, previous active epilepsy, or preexisting relevant neurological disorder. Cryptogenic NORSE cases, often immunotherapy is considered empirically as a favorable response, have been documented in anecdotal case reports. More than half of children with the anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis develop seizures and SE may also occur during the clinical course. But NORSE as a presenting feature of anti-NMDAR encephalitis is extremely rare, as most children present with subacute onset neuropsychiatric and extrapyramidal features. We are describing one such case in an adolescent girl with anti-NMDAR encephalitis, in whom even intravenous anesthetic infusion and first-line immunotherapy including corticosteroid and IVIG were insufficient to achieve seizure control. Super refractory left focal SE in this child resolved after 96 h of injection rituximab, following which intravenous anesthetics could be tapered and child survived with only mild functional limitation on follow-up at 6 months. In children with cryptogenic NORSE, the clinicians need to rule out the cerebrospinal fluid anti-NMDAR antibody. Rituximab is one of the most promising second-line immunotherapy options in children with anti-NMDAR encephalitis for achieving seizure control and inducing long-term remission.

Unveiling Uncommon Manifestations in a Pediatric Patient With Systemic Lupus Erythematosus: A Case Report.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with multi-organ involvement. It may involve skin, kidneys, joints, central nervous system (CNS), and cardiopulmonary system. Marked variations in clinical presentations are seen in SLE patients, ranging from subclinical to life-threatening manifestations. SLE and antiphospholipid syndrome (APS) may be associated with Libman-Sacks endocarditis. Visceral vasculitis usually manifests with disease flares and can affect almost any organ. APS can have arterial or venous thrombosis and the presence of persistently positive antiphospholipid antibodies (aPL), including lupus anticoagulants (LA), anticardiolipin antibodies (aCL), and/or anti-ß2-glycoprotein-I antibodies (aß2GPI). Peripheral neuropathy is unusual in pediatric patients. We present a case of an adolescent girl with juvenile SLE (JSLE) in whom endocarditis and digital gangrene at first presentation were actually masquerading underlying life-threatening secondary APS with extensive medium vessel thrombosis. Additionally, there was cutaneous and visceral vasculitis and a rare peripheral nervous system (PNS) manifestation, mononeuritis multiplex (MNM).

Vitamin B12 deficiency in children from Northern India: Time to reconsider nutritional handicaps.

BACKGROUND AND AIMS: Subclinical Vitamin B12 deficiency is a very common entity in the Indian subcontinent with devastating clinical and socio-economic consequences. The objective of this study was to estimate the proportion of vitamin B12 deficient children and to evaluate their clinical profile. SETTING AND DESIGN: This prospective analytical study was conducted in a tertiary level care institute in Northern India. MATERIALS AND METHODS: Children with clinical pallor, were included in this study. Detailed history, height, weight percentiles and characteristic features of vitamin B12 deficiency were recorded and complete blood counts, mean corpuscular volume and vitamin B12 levels were done. STATISTICS: For Qualitative data was analyzed using Pearson Chi square tests and quantitative data was analyzed using two sided independent samples t tests. RESULTS: A total of 111 children were included. 64.8% (n = 72) had vitamin B12 deficiency. Lethargy (63.9%) and weight loss (62.1%), Knuckle pigmentation were common features. One-fourth of the children were on vegetarian diet. Neurological manifestations were significantly associated with fragile hair (p 0.056) and knuckle pigmentation (p 0.027). Younger children had more weight loss (p 0.001), knuckle pigmentation (p 0.019) and hypotonia (p 0.045). One fifth of children presented with neurological manifestations. CONCLUSIONS: Two-thirds of the anemic children had vitamin B12 deficiency. There was a bimodal age distribution with regard to B12 deficiency. Neurological manifestations were predominant in younger children [<6] and hematological abnormalities were more frequent in older children [≥6 years]. Estimation of vitamin B12 levels forms an essential component while evaluating children with anemia, despite mixed dietary habits and normal MCV.

Pig Bite Injury Mimicking as Battered Baby Syndrome Leading to Bilateral Foot Amputation in a Toddler: A Diagnostic Dilemma and a Rare Case Report.

INTRODUCTION: Animal bites are a less common cause of pediatric injury. They are rarely associated with fractures in toddlers. Child abuse is the most closely related differential diagnosis in a child presenting with animal bite and it is a serious threat to both mental health and physical well-being of pediatric population. In all such cases with diagnostic dilemma, battered child syndrome (BCS) needs to be ruled out and reported. To the best of our knowledge, there has been no case report of bilateral femur fracture after a pig bite injury in a toddler with gangrene of bilateral foot. Hence, we report this case to highlight the importance of differentiating animal bite injuries to BCS. CASE REPORT: We report a rare case of pig bite injury with bilateral femur fracture and bilateral foot gangrene in a case of an 11-month-old female child suffering from BCS. CONCLUSION: Apart from the medical and surgical management of pediatric injuries, it is essential to determine the cause of pediatric fractures and differentiate between abuse and accidental trauma. Identification of the etiology is significant to make sure that proper multidisciplinary intervention is initiated for the safety of the child.