Primary neurological manifestations of HIV in children.

Human immunodeficiency virus type 1 (HIV-1) causes various diseases in different age groups. Neurological manifestations of HIV are common and add to morbidity and mortality. It was previously thought that the central nervous system (CNS) was involved only in the advanced stages of the disease. However, recent evidence supports pathological involvement of the CNS from initial viral entry. Some of the CNS manifestations in children share similarities to neurologic disorders of HIV-infected adult patients, while others are unique to the pediatric population. Many HIV-related neurologic complications seen in adults are rarely encountered in children with AIDS and vice versa. However, with recent advances in the treatment, more HIV-infected children are surviving into adulthood. A systematic review of the available literature was performed to study the manifestations, causes, outcomes, and treatment of primary neurologic disorders in children with HIV. Online databases (Ovid Medline, Embase and PubMed), websites from the World Health Organization, commercial search engines, including Google, and chapters on HIV in standard textbooks of pediatrics and medicine were reviewed. HIV-associated neurological syndromes can be classified into four types: primary HIV neurological diseases, treatment-related neurological diseases, adverse neurological effects of antiretroviral therapy and secondary/opportunistic neurological illness. These conditions are not mutually exclusive and may co-exist in a given patient. This narrative review will focus mainly on the primary neurological manifestations of HIV in children.

Causality, Severity, and Avoidability of Adverse Drug Reactions in Hospitalized Children: A Prospective Cohort Study.

BACKGROUND:  Adverse drug reactions are an important cause of morbidity and mortality in all patients. Information regarding adverse drug reactions in the pediatric age group, especially with regard to the drugs involved and the clinical presentations is scanty. The aim of our study is to determine the incidence of adverse drug reactions and to study their features in terms of causality, type, severity, avoidability, drugs implicated and their clinical presentations. METHODS:  The study was carried out on patients admitted to the pediatric ward and the pediatric intensive care unit over a one-year period (January 1, 2013 to December 31, 2013). Patients either presenting with or developing an adverse drug reaction in the hospital were included in the study. RESULTS:  The incidence rate for adverse drug reaction causing hospital admission was 1.79% (95% CI 1.48, 2.16) whereas it was 1.23% (95% CI 0.97, 1.53) for children exposed to a drug during their hospital stay. Type B (bizarre or idiosyncratic type) was seen in 114 (62.6%) of the ADRs whereas 53 (29.1%) were of type A (augmented pharmacologic effect). Severe ADRs were seen in 25 (13.7%) of the total ADRs. ADR was responsible for the death of two patients. 15.4% were rated as avoidable. Anti-microbials were the most common group responsible for ADRs (43.4%), followed by drugs acting on the immune system (15.9%) and drugs acting on the nervous system (14.3%). The most common ADRs were metabolic (29.3%) followed by neurological (17.6%). CONCLUSIONS:  Adverse drug reactions can occur in a substantial proportion of hospitalized patients with some of them being severe and potentially avoidable. Awareness among physicians should be encouraged regarding monitoring, documentation and notification of adverse drug reactions.

Prevalence and subtypes of hypertension in normal-weight and obese Indian adolescents: a cross-sectional study.

This cross-sectional study examined the prevalence, stages, subtypes of hypertension, and the associated risk factors in adolescent school children in Western India. We screened 2,644 adolescents, from 10 different private and government schools in urban and rural areas for hypertension, as defined by the 2017 Clinical Practice Guidelines. The association of stages and subtypes with age, gender, body mass index, type of school, and place of residence was analysed. 197 children (7.5%) had hypertension; 170 (6.4%) had stage I, 27 (1%) had stage II and 76 (2.9%) had elevated blood pressure (EBP). The risk of EBP was higher in children > 15 years of age (p = 0.006). Compared with normal-weight children, obese, and overweight children had a higher risk of hypertension [odds ratio (OR) 9 (5.84, 13.88) and 3.77 (2.59, 5.48) respectively], whereas underweight children had a lower risk [OR 0.39 (0.16, 0.98)]. Normal-weight hypertension was seen in 5.2% and was higher in children from government schools (9.4%). Systolic-diastolic hypertension (SDH) was the most common subtype, seen in 136 (5.1%). SDH was more common in girls, in rural children, and in those with stage II hypertension. Isolated diastolic hypertension, seen in 51 (1.9%), was more common in boys, in urban children, and in those with EBP.

Peritoneal Dialysis Using a Bicarbonate-buffered Dialysate in a Child with an Inborn Error of Metabolism Presenting with Severe Acidosis.

Metabolic acidosis is observed in the pediatric intensive care unit (PICU) in several conditions including sepsis, intoxications, and severe catabolic states. It is occasionally seen due to acute decompensation in an inborn error of metabolism (IEM). Persistent acidosis results in a decrease in myocardial contractility, cardiac output, and catecholamine responsiveness. The mainstay of treatment of metabolic acidosis has been intravenous sodium bicarbonate infusion. However, the large amounts of sodium bicarbonate sometimes required can be hazardous resulting in hypernatremia, hypervolemia, and hyperosmolality. We report a 3-year child who presented with persistent lactic acidosis due to an IEM whom we treated with peritoneal dialysis (PD) using a bicarbonate-buffered dialysate. The child recovered uneventfully within 72 hours of dialysis. Peritoneal dialysis using a bicarbonate-buffered dialysate is a safe and simple method of treating persistent severe acidosis in the PICU. How to cite this article: Kalbhande A, Gajare U, Shanbag P. Peritoneal Dialysis Using a Bicarbonate-buffered Dialysate in a Child with an Inborn Error of Metabolism Presenting with Severe Acidosis. Indian J Crit Care Med 2020;24(3):200-202.

Coexisting Spinal Intramedullary and Intracranial Tuberculomas in an Immunocompetent Child.

Pediatric neurotuberculosis manifests commonly as tuberculous meningitis and intracranial tuberculomas. The ratio of occurrence of intracranial to intraspinal tuberculoma reported is 42:1. Intramedullary tuberculomas (IMTs) are rare, and the coexistence of intramedullary and intracranial tuberculoma is extremely rare. We report a case of coexisting intramedullary and intracranial tuberculoma in a 5-year-old boy who presented with fever for 12 days, progressive motor weakness in the lower limbs for 9 days, and retention of urine and constipation for 6 days. Neurological examination revealed signs of compressive myelopathy. Magnetic resonance imaging (MRI) of the spine detected IMT at D4-D5 level of the thoracic cord with perilesional edema. MRI of brain revealed a right frontal tuberculoma. Medical management with antituberculosis therapy and steroids resulted in complete neurological recovery.

Intravenous magnesium sulphate infusion as first-line therapy in the control of spasms and muscular rigidity in childhood tetanus.

Background: Reports suggest that, in tetanus, magnesium sulphate (MgSO4) alone may control muscle spasms, thereby avoiding sedation and mechanical ventilation. Aim: To study the efficacy and safety of intravenous MgSO4 in controlling spasms and rigidity in children with tetanus. Methods: All children with tetanus consecutively admitted over a 2-year period in a tertiary-care teaching hospital were recruited. In addition to human tetanus immunoglobulin and parenteral metronidazole, patients received MgSO4 100 mg/kg intravenously followed by infusion at 40 mg/kg/hr. The infusion rate was increased by 5 mg/kg/hr every 6 h until cessation of spasms or abolition of the patellar tendon reflex. Efficacy was determined by control of spasms. Time to commencement of feeds, frequency of autonomic instability, the need for ventilatory support, duration of hospitalisation and mortality were also recorded. Results: Twenty-seven children with tetanus aged between 18 months and 10 years were recruited. A contaminated wound was the most common portal of entry of tetanus spores. The incidences of severity were: grade I, 3; grade II, 7; grades IIIa and b, 17. Rigidity and spasms were controlled by magnesium therapy alone in 14 patients. Additional sedation was required for 13 patients (grade II, 1; grade III, 12). Feeding could be commenced early in five patients. Mechanical ventilation was required in eight patients. The mean (SD) duration of hospitalisation was 26.5 (12.0) days. Five patients died (18.5%). Asymptomatic hypocalcaemia was a universal finding and was treated with calcium supplements. Conclusion: MgSO4 alone is effective in mild-to-moderate tetanus but not when it is severe.

Branchio-oto-renal syndrome presenting with syndrome of hyporeninemic hypoaldosteronism.

Branchio-oto-renal (BOR) syndrome is an autosomal dominant, clinically heterogeneous disorder characterized by branchial arch anomalies, hearing impairment, and renal malformations. We report the case of a 10-year-old boy with BOR syndrome who presented with hyperkalemic hyperchloremic metabolic acidosis due to hyporeninemic hypoaldosteronism. The child also had mental retardation and spastic diplegia which have hitherto not been described in BOR syndrome.

Cardiac status in children with acute poststreptococcal glomerulonephritis.

Acute poststreptococcal glomerulonephritis (PSGN) is the most common type of glomerulonephritis seen in children. It can affect multiple organs with heart being frequently involved. Yet, there are very few studies on cardiac status in children with PSGN and hence this study was conducted. All consecutive children from 1 month to 12 years of age, admitted over a two-year period with a diagnosis of PSGN, were included in the study. An electrocardiogram (ECG) and two-dimensional echocardiogram were performed in all patients on admission and repeated at six and 12 weeks, if abnormal. A total of thirty patients (18 males and 12 females) were enrolled in the study. The median age was six years. Prolonged QTc interval was found in 11 patients (37 %), of whom nine had hypertension. Seven of the 30 patients had a left ventricular ejection fraction (LVEF) <60%. The same patients also had left atrium/aorta ratio >2 and E/A ratio >2. LVEF returned to normal by six weeks in all except one patient, in whom it was normal by 12 weeks. Two of seven patients with low LVEF had normal blood pressure. All the seven patients recovered completely on follow-up. ECG and echocardiographic abnormalities may be seen in the acute phase of PSGN but are usually transient, returning to normal in most patients by three months. Although hypertension is the most common cause of cardiac failure, the role of primary myocardial dysfunction should also be considered.

Hyponatremia in children with tuberculous meningitis: A hospital-based cohort study.

BACKGROUND: Hyponatremia has long been recognized as a potentially serious metabolic consequence of tuberculous meningitis (TBM) occurring in 35-65% of children with the disease. The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has for long been believed to be responsible for the majority of cases of hyponatremia in TBM. Cerebral salt wasting syndrome (CSWS) is being increasingly reported as a cause of hyponatremia in some of these children. AIM: This study was done to determine the frequency and causes of hyponatremia in children with TBM. METHODS: Children with newly diagnosed TBM admitted over a 2-year period (January 2009 to December 2010) were included. All patients received anti-tubercular therapy, mannitol for cerebral edema, and steroids. Patients were monitored for body weight, urine output, signs of dehydration, serum electrolytes, blood urea nitrogen, serum creatinine, and urinary sodium. Hyponatremia was diagnosed if the serum sodium was <135 mEq/L. CSWS was diagnosed if there was evidence of excessive urine output, volume depletion, and natriuresis in the presence of hyponatremia. The outcome in terms of survival or death was recorded. RESULTS: Twenty-nine of 75 children (38.7%) with TBM developed hyponatremia during their hospital stay. In 19 patients, hyponatremia subsided after the discontinuation of mannitol. Ten patients with persistent hyponatremia had CSWS. There were no patients with SIADH. CONCLUSIONS: CSWS is an important cause of hyponatremia in children with newly diagnosed TBM. In our patients, it was more commonly seen than SIADH.

Infantile nephropathic cystinosis with incomplete fanconi syndrome, hypothyroidism, hydro-uretero-nephrosis, and megacystis.

Cystinosis is an autosomal recessive lysosomal storage disorder characterized by the accumulation of the amino-acid cysteine in various organs and tissues. Infantile nephropathic cystinosis is the most severe form of the disorder. We describe the clinical features in a four and a half-year-old Indian boy with infantile nephropathic cystinosis that presented with the incomplete Fanconi syndrome, hydro-uretero-nephrosis with megacystis, and hypothyroidism.

Pulmonary and ileal tuberculosis presenting as Fever of undetermined origin.

A 12-year-old girl presented with prolonged fever with no obvious focus on either history or clinical examination. High-resolution computerized tomography of the chest revealed the 'tree-in-bud' sign in the right lung and necrotic mediastinal lymph nodes. Barium meal showed multiple ileal strictures. The child was treated with anti-tuberculous therapy for six months. At follow-up six months later, the child had gained weight and had no signs of intestinal obstruction. Tuberculosis is a common cause of fever of undetermined origin and should be investigated for especially in countries with a high prevalence.

Unusual presentation of poststreptococcal glomerulonephritis as posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a rare clinicoradiologic condition manifesting with headache, seizures, altered sensorium, visual disturbances, and characteristic lesions on neuroimaging predominantly affecting the posterior regions of the brain. We report a case of an 8-year-old boy with poststreptococcal glomerulonephritis, presenting as PRES. A magnetic resonance imaging showed hyperintense lesions in bilateral frontal and parietooccipital parenchyma on fluid-attenuated inversion recovery and T2-weighted images, suggestive of "PRES." Patient made a complete neurological recovery without any deficit.

Caroli's syndrome with autosomal recessive polycystic kidney disease.

Caroli's syndrome (CS) is a rare congenital disorder characterized by multiple segmental cystic or saccular dilatations of the intrahepatic bile ducts and congenital hepatic fibrosis. We report a 9-year-old boy who was diagnosed with CS and autosomal recessive poly-cystic kidney disease. On screening, his 5-month-old asymptomatic sister had multiple dilated biliary radicals with multiple bilateral renal cystic lesions. Both the patient and the affected sibling have been advised regular follow-up for monitoring the progression of the disease. In conclusion, patients with CS should be screened for renal cystic lesions and vice versa even if they are asymptomatic. Also, as the disease is inherited in an autosomal recessive manner, it is important to screen family members for early diagnosis and management.

Measurement of Intra-abdominal Pressure in Critically-ill Children.

INTRODUCTION: It is being increasingly recognized that intra-abdominal hypertension is an important cause of organ dysfunction. This pilot study was done to determine the feasibility of measuring intra-abdominal pressures (IAP) in critically-ill children using simple inexpensive equipment available in the PICU. MATERIALS AND METHODS: This was a prospective study done in the paediatric intensive care unit (PICU) of a tertiary care general hospital. Thirty-two consecutive patients admitted to the PICU, staying for more than 24 h and requiring a urinary catheter were studied. IAP was measured by the intravesical method, using a disposable manometer, twice a day for seven days or till discharge/death, Risk factors associated with IAH were recorded. RESULTS: The majority of the patients had an IAP less than 5 mm Hg. Three patients had grade 1 intra-abdominal hypertension (IAP>12 mm Hg). CONCLUSION: It is feasible to measure IAP in paediatric patients without the use of sophisticated equipment.

Ofloxacin-induced hallucinations.

Drug-induced hallucinations are not uncommon, and may be misdiagnosed as psychiatric illness leading to unnecessary treatment with antipsychotics. If a temporal association of use of a drug having the potential to cause hallucinations is present, mere withdrawal of the drug causes complete improvement in the symptoms. There are reports of various untoward central nervous system adverse events following administration of fluoroquinolones, including delirium, hallucinations and psychosis, even after a single dose. We describe a 5-year-old girl who suffered visual hallucinations following ofloxacin use.