Rare presentation of a common disease of tropics

A 19 years male presented with fever, oliguria and purpuric lesions involving both hands. The patient was diagnosed as a case of purpura fulminans with disseminated intravascular coagulation due to complicated falciparum malaria. The case is presented to sensitize the physicians to keep malaria as a differential in cases of fever with purpura fulminans.

Complete resolution of stage IIIB juvenile nasopharyngeal angiofibroma with radiation therapy

Juvenile nasopharyngeal angiofibroma is a benign, locally aggressive, vascular tumour of adolescent males. Extension to intracranial cavity is not uncommon and presents difficulties in management. Here we report a patient who had Radkowsky stage IIIB lesion, with blood supply from internal carotid artery. In view of anticipated problems with surgery, the patient was treated with 30 Gy in 15# external beam radiotherapy. On follow up, tumour was noted to disappear gradually overtime and at 3 years complete disappearance was noted with normal return of vision. Hence we are re-affirming the earlier studies than angiofibroma mass regresses gradually after completion of radiotherapy. Radiotherapy is a useful way of treating angiofibroma with significant intracranial extension.

Myelodysplastic syndrome

Pediatric myelodysplastic syndrome (MDS), though rare, constitutes a distinct entity quite different from adult MDS. They have unique clinical features, aggressive clinical course with an overall mean survival of only 9.9 months. A pediatric approach to the WHO classification has become necessary since the WHO classification of MDS has failed to address the uniqueness of pediatric MDS. A new prognostic system also needs to be evolved since the international prognostic system has limited prognostic impact in children. Intensive chemotherapy such as the one used in de novo-acute myeloid leukemia (AML) leads to complete remission in some children and this may be the treatment of choice in pediatric MDS.

Disseminated intravascular coagulation: current concepts

Disseminated intravascular coagulation (DIC) is an acquired disorder in which normal hemostatic balance is disturbed. There is excessive thrombin formation leading to fibrin deposition in microcirculation and consequent ischemic organ damage. The etiology is multifactorial. A number of medical, surgical, oncological and obstetrical conditions can cause DIC. The diagnosis is essentially clinical supported by laboratory parameters and a scoring system based on these. The mainstay of treatment is correction of underlying cause and hemostatic support with replacement of coagulation factors. The role of heparin therapy and other therapeutic options including activated protein C, antithrombin III etc. have also been discussed.

Immune thrombocytopenic purpura

Immune thrombocytopenic purpura (ITP) is the commonest cause of sudden onset thrombocytopenia in a healthy child. The condition is frequently preceded by a viral infection. The hematological parameters are essentially normal except a low platelet count. Bone marrow examination is not routinely indicated except in specific situations. The pros and cons of drug treatment have been discussed as the disease is benign with excellent prognosis in majority of the cases. The various treatment options including low and high dose steroids, intravenous immunoglobulins and anti D have been discussed at length with other modalities of treatment and role of splenectomy. Current therapeutic options with rituximab and other drugs for stimulating platelet production in chronic cases have also been included in discussion.

Vascularised joint transfer in the management of recurrent giant cell tumour of the second metacarpal

This paper presents the medium-term follow-up results (34 and 40 months, respectively) of two cases of recurrent giant cell tumour of the head of the second metacarpal, treated by marginal excision and reconstruction with a vascularised toe joint transfer. Both patients had painless, stable joints with excellent ranges of motion at the metacarpophalangeal joint of 80 degrees and 70 degrees , respectively, no degenerative changes and no recurrence of the tumours.

Purpura fulminans in a complicated Falciparum malaria

A 19-year-old male presented with fever, oliguria and purpuric lesions involving both hands. The patient was diagnosed as a case of purpura fulminans with disseminated intravascular coagulation due to complicated Falciparum malaria. The case is presented to sensitize the physicians to keep malaria as a differential in cases of fever with purpura fulminans.

Autoimmune hemolytic anemia

OBJECTIVE

To study the clinico-hematological profile and treatment outcome in children suffering from auto immune hemolytic anemia (AIHA).

METHODS

Twelve children were diagnosed with auto immune hemolytic anemia over a period of four years. Direct antiglobulin test was positive in all the cases. Other causes of hemolytic anemia like thalassemia syndromes, hereditary spherocytosis, G6PD deficiency were excluded by appropriate tests. The children were followed up for 6 months to 4 years.

RESULTS

The age ranged from 7 mth to 9 yr with a mean age of 4.51 yr. All patients had pallor as the presenting complaint followed by splenomegaly (83.3%), jaundice (66.7%), fever (50%) and bleeding manifestations (16.7%). 9 patients had primary disease and 3 had secondary disease. Tubercular infection was seen in 2 patients with secondary disease. Jaundice was seen equally in both the groups. Oral prednisolone produced remission in 83.3% cases. 4 patients (3 in primary and one in secondary group) had relapse after initial response. All responded to a second course of steroids but had subsequent relapses and developed a chronic course.

CONCLUSION

Autoimmune hemolytic anemia is an uncommon cause of hemolytic anemia in children. Tubercular infection is an underlying pathology in cases of secondary autoimmune hemolytic anemia. Although oral steroids induce remission in most of the cases, relapses are common.

Factors influencing varicella zoster virus infection after allogeneic peripheral blood stem cell transplantation: low-dose acyclovir prophylaxis and pre-transplant diagnosis of lymphoproliferative disorders

Varicella zoster virus (VZV) infection is one of the frequent opportunistic infections after allogeneic bone marrow transplantation, with a high incidence of 30-50%. However, no data have been reported on VZV infection after allogeneic peripheral blood stem cell transplantation (PBSCT).

PATIENTS AND METHODS

We report a retrospective analysis of VZV infection in 192 allogeneic PBSCT recipients. Twenty-seven patients (14%) received long-term prophylaxis of low-dose acyclovir (200 mg twice daily orally > or =3 months) for recurrent oral (n=21) or genital herpes simplex virus infection (n=5) or for a previous history of recurrent VZV infection (n=1).

RESULTS

Forty-two patients (22%) developed VZV infections: localized (n=37) and disseminated infection (n=5). The incidence of VZV infection at 1 and 3 years was 19.3+/-3.3% and 36.8+/-5.2%, respectively. Complications included post-herpetic neuralgia (n=18, 43%), secondary bacterial infections (n=3), and intracranial hemorrhage (n=1) with 2 deaths. A higher risk factor for VZV infection was pre-transplant diagnosis of a lymphoproliferative disorder (LPD): chronic lymphocytic leukemia, Hodgkin's disease, or non-Hodgkin's lymphoma (P=0.021, 52.5% in LPD vs. 32.6% in non-LPD group). The use of low-dose acyclovir prophylaxis (P=0.043, 14.7% in acyclovir vs. 41.6% in nonacyclovir group) was found to be protective. Although no VZV infection episodes were noted during the period of acyclovir prophylaxis, 3 episodes of VZV infection were noted after acyclovir cessation.

CONCLUSION

The incidence of VZV infection after PBSCT was high at 36.8%, with patients transplanted for LPDs at higher risk. The long-term use of low-dose acyclovir may be protective for VZV infection, although it does not completely prevent rebound of late VZV infection.

Correlation between clinical features and degree of immunosuppression in HIV infected children

We conducted this study to find out correlation of CD4% with clinical status in 102 HIV infected antiretroviral naive children. Mean age of presentation was 4.8 years. Perinatal transmission was the commonest mode of transmission (94%). Fever (53%), chronic diarrhea (36%), and cough (29%) were the commonest presenting symptoms. Protein energy malnutrition was seen in 56.7% of children. 33.3% children were asymptomatic, whereas 45.1% were in WHO clinical stages III and IV at the time of presentation. The most common opportunistic infection was tuberculosis. CD4% correlated significantly with the deterioration of the WHO clinical stages (P<0.01) and increasing grades of protein energy malnutrition (P< 0.05).

A study of bone marrow failure syndrome in children

BACKGROUND

Bone marrow failure syndrome (BMFS), or aplastic anemia, includes peripheral blood single cytopenias, as well as pancytopenia due to inability of the marrow to effectively produce blood cells.

AIM

To study the clinico-hematological profile and etiological factors of bone marrow failure syndrome in children.

SETTING AND DESIGN

This prospective study was carried out in the Department of Pediatrics of a university teaching hospital over 36 months.

MATERIALS AND METHODS

Children with pancytopenia (Hb 9 /L, platelet count<100x10(9)/L) and bone marrow cellularity<25% were included in the study. History of exposure to drugs, socioeconomic status, ethnicity and occupation of father were noted. Bone marrow aspiration; trephine biopsy; Ham test; viral studies for hepatitis A, B and C; and cytogenetic investigations were carried out.

STATISTICAL ANALYSIS

Relative risk was estimated by odds ratio (OR) with 95% confidence interval (CI) in matched cases and controls.

RESULTS

Of the 53 children studied, 6 (11.3%) were diagnosed as Fanconi anemia. Two cases had features of myelodysplastic syndrome. Forty-five children were labeled as acquired aplastic anemia, of whom one had evidence of hepatitis B infection and two patients (5.8%) had paroxysmal nocturnal hemoglobinuria. Aplastic anemia was more common in children from family with lower socioeconomic status; in Muslims; and where the father's occupation was weaving, dyeing and painting. However, the number was small to make statistically significant conclusions. No correlation could be established with exposure to drugs.

CONCLUSION

Fanconi anemia was responsible for approximately one-tenth of the cases of bone marrow failure syndrome. Majority of the patients had acquired aplastic anemia. Hepatitis B infection was an uncommon cause of acquired aplastic anemia.

QTL analysis reveals context-dependent loci for seed glucosinolate trait in the oilseed Brassica juncea: importance of recurrent selection backcross scheme for the identification of 'true' QTL

Seed glucosinolate content in Brassica juncea is a complex quantitative trait. A recurrent selection backcross (RSB) method with a doubled haploid (DH) generation interspersing backcross generations was used for the introgression of low glucosinolate alleles from an east European gene pool B. juncea line, Heera into an Indian gene pool variety, Varuna. Phenotypic comparisons among the DH populations derived from early to advanced backcrosses revealed a shift in the mean values for various glucosinolates with the advancement of backcrossing, indicating a change in the selective values of the alleles with change in the genetic background due to the existence of epistasis and context dependencies. QTL mapping for various seed glucosinolates from early (F(1)DH) and advanced generation (BC(4)DH) populations confirmed the presence of epistasis and context dependency. The common QTL detected in both F(1)DH and BC(4)DH changed their R (2) values from the former to the later generation. Some of the QTL detected in the F(1)DH became irrelevant in the BC(4)DH population. Further, new QTL were detected in the BC(4)DH population for various glucosinolates. A validation study on a population of low glucosinolate DH lines derived from all the backcross generations of the RSB breeding programme revealed that the QTL detected in BC(4)DH were the 'true' QTL. Using glucosinolate as an example, the study provides strong evidence for the importance of the RSB method for the identification of the 'true' QTL which would be significant for marker assisted introgression of a complex quantitative trait whose expression is influenced by epistatic interactions.