An Interesting Case of Refractory Kawasaki Disease With Co-infection.

Kawasaki disease (KD), formerly called mucocutaneous lymph node syndrome, is one of the common vasculitides of childhood. KD most commonly occurs in children over six months up to five years of age, although it can occur in young infants, older children, and adults. Early diagnosis is critical to achieving optimal treatment. We present a case of a three-year-old female child who was admitted with a fever for five days and fulfilled the diagnostic clinical criteria for KD. She was given intravenous immunoglobulin (IVIG) and aspirin. However, the fever persisted, and a urine culture showed the growth of Klebsiella pneumoniae. We started an antibiotic based on her sensitivity. Since fever spikes were not subsiding, she was given a repeat dose of IVIG along with an oral corticosteroid for refractory KD, after which she showed clinical improvement. This case highlighted that refractory KD can coexist with infection.

Gamma-Tubulin 1 (TUBG1) Mutation-Associated Lissencephaly and Microcephaly in an Indian Child: A Rare Case.

Malformations of cortical development (MCD) are a group of disorders affecting the normal development of the human cortex and are significant causes of delay in psychomotor development and epilepsy in children. Lissencephaly (smooth brain) forms a major group of brain malformations. Microtubules help in the migration of neuronal cells. Defect in tubulin gene alpha-tubulin (TUBA), beta-tubulin (TUBB), and gamma-tubulin (TUBG) leads to defective neuronal migration. This group of disorders is termed as "tubulinopathies." The important genes implicated in causing lissencephaly are LIS1, XLIS, and TUBA1A gene. Recently, a mutation in the TUBG1 gene is associated with it. Here, we report a one-and-a-half-year-old girl with global developmental delay, microcephaly, infantile-onset epilepsy, epileptic spasms, dysmorphism, and motor signs. There was no significant birth history. Neuroimaging (MRI) showed a broad thick gyri and a decreased number of sulci suggestive of lissencephaly/pachygyria spectrum. There was dilatation of the ventricles, and no grey matter heterotopia was noted. Sleep EEG showed multifocal epileptiform discharges. The child was treated with multiple anti-seizure medicines (ASMs). A genetic test, whole exome sequencing, was done to determine the etiology of MCD. A heterozygous missense variation in exon 6 of the TUBG1 gene was identified and reported as a "variant of unknown significance." Still, because the genotype matched with the clinical phenotype of the patient, it was considered clinically significant. Therefore, a complete diagnosis of TUBG1 mutation-associated cortical malformation (lissencephaly/pachygyria) with microcephaly and early-onset epilepsy was established. TUBG1 mutation is de novo in most cases, but parental testing is recommended. The parents of such patients need to be counseled about the need for prenatal testing and the risk of the disease to siblings. The overall prognosis in such cases is poor because of refractory seizures, physical limitations, and intellectual disability.

Study of the Vertical Transmission of COVID-19 by Using the World Health Organisation Protocol in a Tertiary Care Hospital in Eastern India.

BACKGROUND: The World Health Organisation (WHO) has established criteria to diagnose vertical transmission in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study aimed to determine the incidence of vertical transmission of SARS-CoV-2 using WHO criteria in a tertiary care centre in eastern India. METHODS: A hospital-based prospective observational study was conducted from June 2021 to February 2022 on women admitted for delivery with a positive nasopharyngeal (NP) swab and a SARS-CoV-2 real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test. Following the delivery, the amniotic fluid (AF) and swab from the placenta were tested for SARS-CoV-2 by the Truenat test. The umbilical cord and maternal blood were analyzed to detect immunoglobulin M (IgM) and immunoglobulin G (IgG). The nasopharyngeal swabs of the newborns were tested for SARS-CoV-2 by RT-PCR. RESULTS: Forty-eight SARS-CoV-2-positive asymptomatic women were included in the study. Twenty-eight (58.3%) were delivered via cesarean section. Preterm delivery occurred in 13 (27.1%) cases. In only one case, vertical transmission was confirmed as the neonate had a positive nasopharyngeal SARS-CoV-2 RT-PCR test and the cord blood was IgM positive (suggesting an immune response in the neonate). The placenta was positive in three cases, and amniotic fluid was positive in two. However, vertical transmission was deemed unlikely in these cases as there was no evidence of immune response or viral persistence according to the WHO criteria. There was one stillbirth, and it tested negative for SARS-CoV-2. CONCLUSION: This study strengthens the evidence of vertical transmission in COVID-19-positive asymptomatic mothers. The data suggest a low transmission rate.

Calvarial Tuberculosis With Skin Tuberculosis in a Child: A Rare Case Report.

Calvarial tuberculosis (TB) is an uncommon form of skeletal TB. Early diagnosis can be challenging as they may exhibit diagnostic dilemmas. Another rare kind of skin TB is called TB verrucosa cutis. In this case, both of these uncommon forms were observed simultaneously and were effectively treated with first-line antitubercular therapy.

Reduction in the incidence of infusion-related phlebitis in a pediatric critical care unit of Eastern India: A quality improvement initiative.

Background: Phlebitis is one of the most common complications of the peripheral venous catheter (PVC) and adversely impacts future venous access, and bacterial phlebitis may lead to bloodstream infection. The objective of the study was to reduce the to reduce the incidence of infusion-related phlebitis in children admitted to the pediatric critical care unit. Methods: This Quality Initiative was implemented in the pediatric critical care unit of a tertiary care hospital between November 2019 and April 2020. Five interventions were identified (hand hygiene, use of transparent dressing, use of extension lines with PVCs, use of hard cardboard splints for joint immobilization, use of heparinized flush after medication administration) and were introduced sequentially. Over the next five weeks, a new intervention was introduced weekly while continuing the previous ones, if found to be working well as per improvement parameter, the phlebitis rate. From the sixth week onwards, all five interventions were applied together as a bundle. Results: Total seven hundred eighteen PVCs were sited in 284 (Male: female 1.58:1) patients during study period and a total of 56 incidences of phlebitis were observed. Mean baseline phlebitis rate was 48.5%. In the next 5 weeks when interventions were implemented as planned, phlebitis rate was 35.7% (n = 10), 16.6% (n = 03), 21.6% (n = 8), 10% (n = 05), and 13.3% (n = 2) respectively. Implementation of all five interventions together as a bundle led to reduction in phlebitis rate below 5 % consistently over the next 18 weeks (n = 8). Conclusion: A consistent reduction in PVC-related phlebitis can be achieved by the implementation of evidence-based interventions for the prevention of phlebitis, as a bundle.

Thermal hydrolysis of sewage sludge: Improvement in biogas generation and prediction of global warming potential.

Anaerobic digestion (AD) is a prominent treatment method for the sludge produced from sewage treatment plants. Poor solid reduction and longer retention time are the main drawbacks of AD. Thermal hydrolysis (TH) is a potential pretreatment method for solubilization of sewage sludge (SS) solids thereby improving biogas production during AD post-treatment. In this study, the SS sample (total solids = 1.75 wt% and total chemical oxygen demand (COD) = 15,450 mg L-1) was subjected to TH pretreatment (temperature = 140-180°C and reaction time = 60 minutes) in a 0.7-L capacity stainless-steel high-pressure reactor. At a reaction temperature of 180°C, the maximum solid solubilization (total dissolved solids = 4652 mg L-1) and improved dewaterability (time to filter = 4.7 s.L g-1) were observed. The biochemical methane potential test results showed almost doubling of methane generation from 145 to 284 mL gCOD-1 after TH pretreatment at 180°C. The life cycle assessment approach was used to compare various SS treatment and disposal scenarios, two of which included hydrothermal pretreatment. The scenarios involving hydrothermal pretreatments showed the least global warming potential.

Acute hepatitis with non-alcoholic fatty liver disease-expanding clinical spectrum in COVID-19 exposed children: case report and review of literature.

Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can adversely affect extra-pulmonary organs, such as the liver, heart and gastrointestinal tract apart from lungs. Although studies are showing that serum glutamic-oxaloacetic transaminase and serum glutamic-pyruvic transaminase are mildly elevated along with serum bilirubin in adult patients with mild to severe cases of COVID-19 disease, data are limited regarding liver injury in children infected with COVID virus. We report the case of a 9-year-old female patient who developed signs and symptoms of upper respiratory tract infection due to COVID-19 virus infection and subsequently developed fatty liver disease on follow-up. To our knowledge, this is the second case report in children showing an association between non-alcoholic fatty liver disease and SARS-CoV-2 virus infection.

A Case Report of Rare and Lethal Methicillin-Resistant Staphylococcus aureus (MRSA) Peritonitis in Infancy.

Peritoneal inflammation without a discernible intraperitoneal source is referred to as primary peritonitis. Only 2% of pediatric acute abdominal crises are diagnosed preoperatively. Association with other infections is uncommon and is often limited to hepatic and urinary pathogens. Here, we describe a case of primary peritonitis in a one-month-old child who had laparotomy and appendicectomy as per the recommended treatment plan. There were no accompanying hepatic and urinary diseases. In this instance, methicillin-resistant Staphylococcus aureus (MRSA) was the responsible bacteria. The use of linezolid, as per the culture sensitivity report of intraperitoneal pus, ensured a smooth recovery in this case.

Human Adenovirus Infection Causing Hyperinflammatory Syndrome Mimicking Multisystem Inflammatory Syndrome in Children (MIS-C): A Case Report.

Transmission of human adenovirus (HAdV) infection and the associated clinical disease can be sporadic or epidemic and manifestations may range from mild infection to severe disease. HAdV has been seen to behave as a proinflammatory virus that can trigger the release of high levels of inflammatory cytokines and chemokines in children. Here, we report an unusual case of an infant with HAdV infection who presented with respiratory illness, with a protracted course, complicated with hyperinflammation and multi-system involvement with clinical characteristics mimicking multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease. The patient was an 11-month-old male infant with a background of infantile epilepsy, epileptic encephalopathy, hemimegaloencephaly, and global developmental delay, diagnosed as Ohtahara syndrome. He was admitted with a three-day history of cough, cold, fever, and respiratory distress. Management was initiated with a heated humidified high-flow nasal cannula and given ceftriaxone and hypertonic saline nebulization. Additionally, he developed loose motion on the fifth day of admission. The reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal swab was positive for HAdV. Due to persistent fever, elevated inflammatory markers, multisystem involvement (diarrhea, coagulopathy), an absence of a clear microbial etiology, and an epidemiologic link to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, MIS-C was diagnosed. The first dose of intravenous immunoglobulins (IVIG) was administered over the course of 48 hours and the baby required a second dose of IVIG as the fever failed to settle after the first dose. Within 24 hours of the second IVIG dose, defervescence occurred. His platelet count started to rise, and the baby developed thrombocytosis in the third week of illness. Echocardiography was suggestive of dilatation of mild left main coronary artery. He was weaned off oxygen support by day 14 and discharged on day 17. To our knowledge, this is the first reported case of HAdV infection with hyperinflammatory syndrome and vasculitis akin to MIS-C and Kawasaki disease.

Congenital Diaphragmatic Hernia With Intra Thoracic Gastric Volvulus: A Rare, Life-Threatening Combination.

Congenital diaphragmatic hernia (CDH) is a known cause of secondary gastric volvulus (GV). Both entities are life-threatening, either alone or in exceedingly rare instances when they occur in combination. Here, we describe one such rare combination of CDH and secondary GV in a nine-year-old boy, who presented to us with recurrent episodes of abdominal pain. Urgent laparotomy was done after radiological evaluation (X-ray of chest and abdomen and contrast-enhanced CT chest and abdomen), which revealed mesenterico-axial volvulus of the stomach, secondary to an underlying diaphragmatic defect in the left hemidiaphragm, thus establishing the cause (diaphragmatic defect) and effect (GV), and resulting in a favourable outcome.

Acute-on-Chronic Subdural Hemorrhage Due to Late Vitamin K Deficiency.

Vitamin K deficiency bleeding (VKDB) is closely associated with the hemorrhagic disease of the newborn (HDN) and can have a late onset, after one week of birth up to six months of age. It is a major concern in developing countries where vitamin K prophylaxis is not often given to newborns and can lead to significant mortality and morbidity. We report a case of a three-month-old child who was exclusively breastfed. He presented with repeated vomiting and was eventually diagnosed as a case of acute-on-chronic subdural hemorrhage. Timely diagnosis and surgical intervention played a key role in ensuring a favorable outcome for the child.

Six-month outcome of multisystem inflammatory syndrome with persistent neutropenia in neonate: A case report and review of literature.

Multisystem inflammatory syndrome in Children (MIS-C) is a postinfectious immune mediated complications seen in children and develop after 4-6 weeks of severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) infection, however, it is rare in neonates. The index case was admitted at day 19 of life with complaints of fever, loose stools and rash. Baby was discharged after 1 weeks with diagnosis of Multisystem inflammatory syndrome with persistent neutropenia. We follow up the case at 6 weeks, 12 weeks and 6 months of life. Growth, neurodevelopment and hematological parameters were monitored over time. We are reporting this follow up of MIS-N with persistent neutropenia because it is very rare, organ specific manifestations, effect on growth & development is unknown and needs to be reported. Improvement in hematological parameters and markers of coagulopathy & systemic inflammation required months before they return to baseline. There are no long-term sequelae on growth and neurodevelopment.

Clinical study to determine the predictability of significant rebound hyperbilirubinemia in neonates after phototherapy and conditions likely to be associated with it: Prospective observational study in a teaching hospital in Eastern India.

Aim: Neonatal hyperbilirubinemia is defined as yellowish discoloration of the skin, conjunctive, and sclera from the elevated serum or plasma bilirubin in the newborn. The standard of care for the management of neonatal hyperbilirubinemia is phototherapy to prevent long-term neurological sequelae. The aim of this study was to ascertain the predictability of significant rebound hyperbilirubinemia (SRH) in neonates after phototherapy and the factors associated with it. Materials and Methods: Neonates ≥ 35 weeks of gestation, who received treatment for hyperbilirubinemia and admitted in our hospital from 15th of March 2019 to 15th of September 2020 were enrolled after taking parental consent. SRH was defined as bilirubin levels crossing the treatment threshold within 72 hours of phototherapy termination. Logistic regression analysis was used to identify the predictability of SRH. Results: Out of 400 neonates treated with phototherapy, 10% developed SRH. Prematurity (Gestational age < 37 weeks), low birth weight (Birth weight < 2000 gram), ABO and Rh incompatibility, Glucose-6-phophate dehydrogenase deficiency (G6PD) deficiency, sepsis, and longer duration of primary phototherapy were found to be significantly associated with rebound hyperbilirubinemia. The probability of SRH increases for all American Academy of Paediatrics (AAP) risk categories as the gestational age decreases and total serum bilirubin at the stoppage of phototherapy increases. Conclusions: The presence of risk factors should be taken into account while planning discharge and follow-up of neonates admitted for neonatal hyperbilirubinemia to prevent long-term complication of bilirubin neurotoxicity.

Traumatic Intramural Jejunal Hematoma: A Case Report and Review of Literature.

We report a case of a jejunal hematoma in a six-year-old boy with an antecedent history of trauma. The development of duodenal hematoma post blunt abdominal trauma is well known; however, the jejunal hematoma is very rare. A six-year-old boy was brought to Tata Main Hospital (TMH), Jamshedpur, with pain abdomen, associated with a history of trauma to the abdomen. There were no signs of peritonitis on clinical examination. Initial ultrasonology revealed mild free fluid in the abdomen. CT abdomen was suggestive of intramural hematoma in the jejunum. Exploratory laparotomy findings were in concordance with CT abdomen findings. Resection-anastomosis of the jejunum was done. The patient was discharged uneventfully on postoperative day 7. Blunt trauma to the abdomen is the principal cause of jejunal hematoma. The trauma in the majority of cases is trivial and usually the patients present late. The symptoms range from mild abdominal pain to intestinal obstruction with acute abdomen. A trial of conservative management is justifiable in a stable patient. If no clinical improvement is seen, surgical intervention is indicated. Surgical exploration was necessary because of signs and symptoms of intestinal obstruction due to jejunal hematoma. In pediatric cases, loss of functional bowel length and sudden decompensation due to expanding hematoma favor early exploration.

Higher Termination of Brachial Artery in Cadavers in the Department of Anatomy of a Medical College: A Descriptive Cross-sectional Study.

INTRODUCTION: The main blood supply for arm is provided by the brachial artery. It shows variation in branching and termination patterns in some individuals. Variation in brachial artery may cause difficulties during various clinical and surgical procedures. The present study aims to find out the prevalence of higher termination of brachial artery in cadavers in the department of anatomy of a medical college. METHODS: A descriptive cross-sectional study was carried out from 10th January 2020 to 20th April 2021 after the ethical approval was taken from the Institutional Review Committee of Nobel Medical College (reference number: IRC-NMCTH 280/2020). The study was done in 58 upper limbs of 29 properly embalmed cadavers. Convenient sampling was done. They were carefully dissected. The level of termination of brachial artery was noted. The length of the brachial artery and the distance between its termination and the intercondylar line of humerus was recorded. RESULTS: Higher termination of brachial artery was observed in 3 (5.17%) extremities; one (1.72%) at middle third of arm and two (3.45%) at lower third of arm. In 52 (89.66%) extremities, the site of termination was at the level of neck of radius. The brachial artery terminated a few centimeters below its usual site at the level of upper part of shaft of the radius in 3 (5.17%) extremities. CONCLUSIONS: The prevalence of higher termination of brachial artery in cadavers is slightly lower than the studies performed in similar settings. It is not an uncommon finding. It may have impact on clinical and surgical procedures.

Pes Planus Foot among the First and Second Year Medical Students of a Medical College: A Descriptive Cross-sectional Study.

INTRODUCTION: Foot is a complex segmented structure formed by the articulation of 26 different bones which are held together by multiple ligaments, extrinsic tendons and the intrinsic muscles of the feet. The assessment of median longitudinal arch serves as an important reference in determining the degree of pes planus or pes cavus. This study aims to find the prevalence of pes planus among the undergraduate medical students of a medical college. METHODS: A descriptive cross-sectional study was carried out in the first- and second-year undergraduate medical students of a teaching hospital after taking ethical approval from Institutional Review Committee. The study was conducted from 15th November 2019 to 14th November 2020. Eighty-seven participants were involved in study using the random sampling technique. Foot prints were collected from the participants in the A4 size paper after applying ink over plantar surface of the foot. Measurements were done using the Autodesk Autocad software. Statistical Package for the Social Sciences was used. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Out of the total subjects, 14 (8.04%) (5.14-10.94 at 95% Confidence Interval) presented with flat foot. Similarly, high arched foot was seen in 29 (16.67%) of subjects whereas normal arched foot was seen in 131 (75.29%) subjects. CONCLUSIONS: From the current study we conclude that the prevalence of pes planus was slightly higher than that compared with the similar studies.

Prevalence of Retrocaecal Appendix among Patients with Appendicitis in A Tertiary Care Hospital of Nepal.

INTRODUCTION: Appendicitis is one of the most common causes of acute abdomen. The clinical presentation of appendicitis and its susceptibility to acute inflammation may be affected by the length and position of vermiform appendix. Length and position of appendix are variable. The aim of the study was to find the prevalence of retrocaecal appendix among patients undergoing appendectomy for appendicitis. METHODS: A descriptive cross-sectional study was performed in 264 patients undergoing appendectomy in Department of Surgery, Nobel Medical College, Biratnagar, Nepal from 1st May, 2018 to 15th May, 2019. Ethical approval was taken. Simple random sampling was done. The position of appendix was noted before appendectomy. Subgroup analysis was done on the basis of gender and length of appendix recorded in centimeters with a measuring scale immediately after removal of appendix. Data was collected in excel and was analyzed in SPSS version 16. RESULTS: Prevalence of retrocaecal appendix among patients with appendicitis was 95 (35.98%). Similarly, other positions noted were pelvic in 67 (25.37%), post-ileal in 61 (23.10%), pre-ileal in 11 (4.16%) and subcaecal in 30 (11.36%) individuals. The length of appendix ranged from 1.7 cm to 14.7 cm. The mean length was 8.67±2.44 cm. CONCLUSIONS: The most common position of appendix in patients with appendicitis is retrocaecal position followed by pelvic position in both males and females.

Concomitant Guillain Barre Syndrome and Transverse Myelitis as Initial Neuropsychiatric Manifestation in a Case of Lupus: A Diagnostic Quandary.

Neuropsychiatric manifestations of systemic lupus erythematosus are varied. Presently nineteen in number, they are classified as whether affecting the central or the peripheral compartments of the nervous system. Its diagnosis however remains difficult, more so when two or more of the syndromes are found concomitantly in the same patient and when they occur in absence of the more classical rash, serositis, and haematological manifestations. We present a case of lupus where myelopathy as well as demyelination existed simultaneously as the initial neurologic manifestation.

Characterization of M. tuberculosis SerB2, an essential HAD-family phosphatase, reveals novel properties.

M. tuberculosis harbors an essential phosphoserine phosphatase (MtSerB2, Rv3042c) that contains two small- molecule binding ACT-domains (Pfam 01842) at the N-terminus followed by the phosphoserine phosphatase (PSP) domain. We found that exogenously added MtSerB2 elicits microtubule rearrangements in THP-1 cells. Mutational analysis demonstrates that phosphatase activity is co-related to the elicited rearrangements, while addition of the ACT-domains alone elicits no rearrangements. The enzyme is dimeric, exhibits divalent metal- ion dependency, and is more specific for l- phosphoserine unlike other classical PSPases. Binding of a variety of amino acids to the ACT-domains influences MtSerB2 activity by either acting as activators/inhibitors/have no effects. Additionally, reduced activity of the PSP domain can be enhanced by equimolar addition of the ACT domains. Further, we identified that G18 and G108 of the respective ACT-domains are necessary for ligand-binding and their mutations to G18A and G108A abolish the binding of ligands like l- serine. A specific transition to higher order oligomers is observed upon the addition of l- serine at ∼0.8 molar ratio as supported by Isothermal calorimetry and Size exclusion chromatography experiments. Mutational analysis shows that the transition is dependent on binding of l- serine to the ACT-domains. Furthermore, the higher-order oligomeric form of MtSerB2 is inactive, suggesting that its formation is a mechanism for feedback control of enzyme activity. Inhibition studies involving over eight inhibitors, MtSerB2, and the PSP domain respectively, suggests that targeting the ACT-domains can be an effective strategy for the development of inhibitors.