MR imaging findings of glutaric aciduria type II

Glutaric aciduria type II, also known as multiple acyl coenzyme A dehydrogenase deficiency, is an autosomal recessive, mitochondrial organic acid disorder that impairs electron transfer flavoprotein (ETF) or ETF-ubiquinone oxidoreductase, and causes a defect in flavin metabolism or transport. It has a heterogeneous clinical presentation, with at least three different phenotypic appearances. Magnetic resonance (MR) imaging of the brain in this disorder shows a T2-weighted prolongation in the corpus striatum, putamen, caudate nucleus, middle cerebral peduncles and splenium of the corpus callosum. We report a seven-month-old male Caucasian child who presented at the paediatrics emergency department with a sweetish breath. He was clinically diagnosed with diabetic ketoacidosis. However, on MR imaging, brain evaluation and laboratory analysis, he was found to have glutaric aciduria type II.

High incidence of Epstein Barr virus infection in childhood acute lymphocytic leukemia: a preliminary study

INTRODUCTION

Epstein Barr virus (EBV) has a unique association with several human malignancies, especially lymphoproliferative disorders, mainly lymphomas in adults. There is paucity of data pertaining to EBV association with various cancers in India .

OBJECTIVE

The study aims to investigate the association of EBV in childhood leukemia.

MATERIAL AND METHODS

Patients attending pediatric oncology services of the referral center have been included in the study. Twenty-five consecutive pediatric patients with acute lymphocytic lukemia (ALL) were subjected to EBV studies employing sensitive polymerase chain reaction followed by hybridization for presence of Bam H1-W region of EBV genome and detection of anti Z EBV replication activator (ZEBRA) antibodies using Western blot. Positive control included a case of Burkitt's lymphoma and infectious mononucleosis each. Raji cells were used as positive control with each test.

RESULTS

The PCR for EBV was positive in 8/25 patients of ALL. Western blot test using anti ZEBRA antibodies was positive in 5/25(20%) cases of ALL. Considering PCR as the gold standard, 32% of the children with ALL had evidence of active EBV replication. The positive controls were consistently positive. None of the 30 healthy laboratory controls, 22 age matched disease controls, 12 cases of AML and 15 cases of multiple myeloma were positive either by PCR or Western blots assays (P < 0. 01). There was no statistically significant correlation between duration of therapy and EBV positivity (P > 0.05).

CONCLUSION

These studies indicate that a significant number of patients with ALL show evidence of active EBV replication.

Outcome of chronic idiopathic thrombocytopenic purpura in children

BACKGROUND

There is paucity of data on long-term probability of remission in chronic idiopathic thrombocytopenic purpura (ITP). Aim was to study the course and factors influencing remission of chronic ITP. Chronic ITP was defined as thrombocytopenia persisting >6 months following initial diagnosis.

PROCEDURES

Case-records of children with chronic ITP, aged <14 years, were reviewed in this retrospective study (1987-2006).

RESULTS

Two hundred seventy children were followed. Median age at diagnosis was 6 years. Median duration of follow up was 30 months (range 6-166). Isolated thrombocytopenia (even if <10 x 10(9)/L) in the absence of "significant" bleeds, by itself was not considered an indication for drug therapy. Sixty-seven (24.8%) children attained complete remission (CR) over a median period of 18 months (range 7-120). The probabilities of remission at 5 years for males and females were 24% and 39.6%, respectively (P = 0.01). The probability of achieving remission at 10 years in children <8 and > or =8 years was 51.2% and 34%, respectively (P = 0.02). The probability of remission at 5 years for children who received some treatment, versus no treatment was 31.4% and 27%, respectively (P = 0.8). Nine of 18 children, who underwent splenectomy, achieved CR. Intracranial hemorrhage (ICH) occurred in 11 (4%) cases. The time of occurrence of ICH from onset of symptoms varied from 6 to 55 months.

CONCLUSIONS

The predicted spontaneous remission rate with chronic ITP was 30% and 44% at 5 and 10 years, respectively. Platelet count at diagnosis and the treatment administered did not influence remission outcomes. Age <8 years and female gender were predictors of a favorable outcome.

Pattern and implications of therapy abandonment in childhood acute lymphoblastic leukemia

Abandonment of therapy is cited as an important factor contributory to inferior survival outcome in developing nations. In this communication we describe the pattern of therapy abandonment and its impact on survival of childhood acute lymphoblastic leukemia at a large tertiary care center in Northern India and discuss remedial measures.

Pattern of relapsed disease in childhood all: experience from a single tertiary care center in North India

The study was designed to determine the pattern of relapsed disease and identify problem areas in management. Relapse occurred in 111 (23.9%) of the boys and 16 (13.0%) of the girls. The majority relapsed while on chemotherapy. Isolated relapse in the marrow and in the CNS was seen in 51 (40.8%) and 24 (18.9%) patients, respectively. Isolated testicular relapse was seen in 17 (15.3%) of the 111 boys who suffered a relapse. Age and TLC at initial presentation and gender in relapsers and nonrelapsers were compared. Multivariate regression analysis showed that gender (p = .03) and TLC (p = .001) were significant predictors of relapse. Relapse of disease while on chemotherapy and high incidence of CNS and testicular relapse indicate the need for reappraisal of treatment protocols.

Fulminant candida infection in an infant with Acrodermatitis Enteropathica

Acrodermatitis Enteropathica (AE) is an important nutritional disorder of children affecting both innate and cell mediated immunity. It predisposes to secondary bacterial and candida superinfections. We describe an infant with typical features of AE who had candida infection with a fulminant course. Need of early recognition and prompt initiation of therapy for fungal infection in AE is emphasized.

Cutaneous Rosai-Dorfman disease: presenting as massive bilateral eyelid swelling

Rosai-Dorfman disease is a rare, benign histiocytic proliferative disorder, which commonly affects the lymph nodes. Cutaneous Rosai-Dorfman disease is a rare form of Rosai-Dorfman disease limited to the skin. We report a case of cutaneous Rosai-Dorfman presenting with bilateral eyelid swelling in a child.

Survival outcome in childhood ALL: experience from a tertiary care centre in North India

BACKGROUND

Survival of children with ALL, in developing nations has not kept pace with cure rates in developed countries. Our study was designed to assess survival data and identify risk factors.

PROCEDURE

Data of 762 patients with ALL were analyzed. Information regarding the clinical-demographic profile, therapy and course of illness were recorded. Status and duration at last follow-up were utilized to generate Kaplan-Meier survival curves.

RESULTS

The mean age was 5.7 +/- 0.23 years (M/F, 3.2:1). Parents of 230 (30.2%) patients opted for no therapy. There were 68 and 60 deaths in induction and remission phases respectively. Besides these, 111 children either defaulted therapy or were lost to follow up. Relapsed disease was documented in 125 cases. The 5-year OS and EFS was 46% and 43% respectively. Survival analysis, using the Cox multivariate regression, for gender (P = 0.659, CI: 0.852-1.161), age (P = 0.943, CI: 0.725-1.225), symptom-diagnosis interval (P = 0.002, CI: 1.116-1.668), WCC (P < 0.001, CI: 1.353-1.814) and platelet count (P = 0.001, CI: 0.546-0.849) was performed. Bulk disease (P = 0.049, CI: 0.428-0.986), mediastinal adenopathy (P = 0.045, CI: 1.040-3.697), WCC (P = 0.016, CI: 1.395-2.691), platelet count (P = 0.031, CI: 0.431-0.967) and administration of 2 intensification blocks (P = 0.012, CI: 0.624-0.940) were found to be significant predictors of outcome by multivariate analysis.

CONCLUSIONS

The management of ALL requires financial resources and access to quality supportive care. One third of our patients opted for no therapy. The other problem areas were a high proportion of therapy defaulters, lost to follow up and infection related deaths during induction and remission phases. The introduction of remedial measures for resolving the difficulties identified would hopefully improve cure rates in ALL in developing nations.

Establishment of prenatal diagnosis for β-thalassaemia: A step towards its control in a developing country

Beta-thalassaemia constitutes a major health burden on the limited health resources of India and prenatal diagnosis is seen as an important preventive measure to reduce the burden of the disease. Prenatal diagnosis has been offered to 99 women in 112 pregnancies by fetal DNA analysis, using a PCR-based Amplification Refractory Mutation System (ARMS) for the common and uncommon Indian mutations. Restriction fragment length polymorphism (RFLP) for the beta-globin gene was used when the mutation remained unidentified in one of the parents or to complement the ARMS result. In 53 cases the fetus tested had beta-thalassaemia trait (betaTT) (47.3%), 22 were normal (19.6%) and 31 had thalassaemia major (27.6%). In five cases (4.5%), a definitive report could not be given due to maternal contamination. In one case (0.9%), there was a misdiagnosis. Pitfalls encountered in the diagnosis were maternal contamination and occasional non-amplification of the primers. Having established a regional centre for the prenatal diagnosis for thalassaemia, the screening programmes will be enlarged both to identify carriers and prevent the birth of further homozygous children, even during the first pregnancy.

Ascariasis-associated worm encephalopathy in a young child

Infestation with Ascaris lumbricoides in children has a varied manifestation, but encephalopathy is a very rare presentation. This report describes a case of ascariasis-associated encephalopathy in a child. An 18-month-old boy was admitted with altered sensorium. He had a history of vomiting and was passing Ascaris worms in the vomitus. The cerebrospinal fluid analysis did not reveal any abnormality. The patient was treated with an antihelminthic drug and he recovered completely. Worm encephalopathy should be considered as a differential diagnosis for unexplained encephalopathy in tropical areas.

Vitamin D nutritional status of exclusively breast fed infants and their mothers

BACKGROUND

Vitamin D nutrition has a profound effect on the development of an infant. Vitamin D status of mothers and their infants are closely correlated. While hypovitaminosis D has emerged as a significant public health problem across all age groups, there is limited information of this condition in lactating mothers and their breast fed infants.

AIM

To evaluate the vitamin D status of lactating mothers and their breast fed infants.

SUBJECTS AND METHODS

180 healthy lactating mothers and exclusively breast fed infants, 2-24 weeks old, were recruited for the study. The mother-infant pairs underwent concurrent clinical, biochemical and hormonal evaluation for calcium-vitamin D-PTH axis.

RESULTS

The mean serum 25(OH)D values in lactating mothers was 27.2 +/- 14.6 nmol/l (10.9 +/- 5.8 ng/ml), while that of their infants was 28.9 +/- 20.8 nmol/l (11.6 +/- 8.3 ng/ml). Serum 25(OH)D levels <25 nmol/l (10 ng/ml) were found in 47.8% of the mothers and 43.2% of the infants. Among these, elevated PTH levels (>54 pg/ml) were seen in 59.3% of the mothers and 69.6% of the infants. A highly significant negative correlation was found between serum 25(OH)D and PTH in mothers (r = -0.480, p = 0.01) and their infants (r = -0.431, p = 0.01). A strong positive correlation was seen of 25(OH)D levels in mother-infant pairs (r = 0.324, p = 0.001).

CONCLUSIONS

A high prevalence of vitamin D deficiency was found in lactating mothers and their exclusively breast fed infants. Infants born to mothers with hypovitaminosis D had 3.8 times higher risk of developing hypovitaminosis D as compared to those born to mothers with normal vitamin D levels.

Changes in bone mineral density during therapy in childhood acute lymphoblastic leukemia

Quantitative computed tomography was performed to determine bone mineral density (BMD) at initial presentation and following 6-months of therapy in children with acute lymphoblastic leukemia (ALL). Of 46 children enrolled, the complete set of observations was available in 32. The combined mean BMD of three lumbar vertebrae at diagnosis and during treatment were 167.1+/-27.4 and 148.8+/-31.4 mg/ cm3, respectively (P=0.001). Twenty six children (81.2%) had a decrease in BMD on treatment. The mean BMD for each of 3 vertebrae declined as well. The mean T-scores at diagnosis and during therapy were -0.15+/-0.9 and -0.86+/-1.0, respectively (P=0.001). Conventional radiographs revealed metaphyseal lucencies which were replaced with metaphyseal dense bands with therapy. To conclude, there was a significant reduction of BMD in children with ALL following 6- months of treatment.

Langerhans' cell histiocytosis: experience from a single center

Clinical profile, disease-distribution and outcome of Langerhans cell histiocytosis (LCH) is presented in this retrospective analysis. There were 69 children with LCH from January 1986 to December 2004. Diagnosis was presumptive in the majority. The age ranged from 2 months to 12 years. Multisystem disease was documented in 48 (69.6%) children. Evidence of hepatic dysfunction was detected in 25 (36.2%). An elevated serum alkaline phosphatase was a prominent observation in patients with hepatic involvement. Children with localized disease received oral steroids, while cases with disseminated/multi-system disease were treated with prednisolone and, vinblastine or etoposide. 20 (54%) children with disseminated disease and organ dysfunction died. A favorable outcome was documented in all but one case with localized disease. Portal hypertension developed in 3 cases, all of whom had a fatal outcome. Twelve (17.4%) patients had diabetes insipidus. Disseminated disease with organ dysfunction was observed to be a predictor of fatal outcome.

Marfanoid hypermobility syndrome and skeletal abnormalities in a rare case of torsion of wandering spleen

Wandering spleen is a rare clinical entity characterized by splenic hypermobility resulting from laxity or maldevelopment of supporting splenic ligaments. Its major complication is splenic torsion, which is a potentially fatal surgical emergency. We present a rare case of wandering spleen with torsion and splenic infarction in a patient with marfanoid hypermobility syndrome and vertebral abnormalities.

Evaluation of the role of ultrasonography in diagnosis of autoimmune thyroiditis in goitrous children

OBJECTIVES

To evaluate the role of thyroid ultrasound in children with autoimmune thyroiditis diagnosed either on cytopathology or by the presence of thyroid peroxidase antibodies.

DESIGN AND SETTINGS

Children presenting for the first time to the Thyroid Clinic at the Institute of Nuclear Medicine and Allied Sciences for the complaint of goiter over a two year period (January 2005-December 2006) were studied.

SUBJECTS

695 school children (244 boys and 451 girls) aged 5-18 year were studied.

METHODS

Children were subjected to thyroid ultrasound, cytopathology, thyroid peroxidase antibody and thyroid function tests.

RESULTS

Overall, 16% of goitrous children had hypoechogenicity on ultrasound, 15.2% had cytopathological evidence of thyroiditis, 10.6% had positive thyroid peroxidase antibodies and 25.2% had abnormal thyroid function tests. Subjects with hypoechogenicity had higher percentage of thyroiditis on cytopathology (41.4% vs. 10.3%; P<0.01), thyroid peroxidase antibody positivity (30.6% vs. 6.8%; P<0.01) and thyroid dysfunction (46.8% vs. 21.2%; P<0.01) than those with normal echogenicity.

CONCLUSION

Thyroid USG has a useful, though limited, role in excluding thyroid disease in children. The sensitivity of echogenicity for the diagnosis of autoimmune thyroiditis in children is less than that reported in adults.

Reference range of thyroid hormones in normal Indian school-age children

OBJECTIVE

There is an ongoing debate on narrowing the TSH reference range in adults. In view of the scarce data on normal values of thyroid function tests in children from India, we planned to establish a reference range for thyroid hormones in school-age children.

DESIGN AND SUBJECTS

All children (N = 9527; 6-19 years) from six schools representing various zones of Delhi were evaluated for clinical evidence of goitre, thyroid ultrasound, serum free T3 (FT3), free T4 (FT4) and TSH and anti-thyroid peroxidase (anti-TPO) antibodies. From this sample, a reference population (N = 5122) was obtained by excluding those with a personal or family history of thyroid disease, use of thyroid medications, goitre, hypoechogenicity/nodularity on ultrasound or serum anti-TPO antibodies.

MEASUREMENTS

Thyroid hormone (FT3, FT4 and TSH) reference ranges were established for each year of life for the total and reference populations.

RESULTS

In the reference population, mean serum FT3 was in the range 4.19-4.84 pm/l for boys and 4.03-4.47 pm/l for girls, mean serum FT4 14.69-17.36 pm/l for boys and 14.32-15.88 pm/l for girls, and mean serum TSH 2.57-3.6 mIU/l for boys and 1.83-3.58 mIU/l for girls. For TSH, the 97th percentile was in the range 6.01-8.4 mIU/l for boys and 5.28-8.04 mIU/l for girls, suggesting that at least in children there may not be a need to reduce the upper limit of normal for serum TSH.

CONCLUSIONS

This study provides mean reference intervals for FT3, FT4 and TSH for each year of life for both the sexes separately using strict exclusion criteria.

Vitamin D & bone mineral density of healthy school children in northern India

Studies on bone mineral health in children have been primarily based on clinical, biochemical and radiological evidence. Measurement of vitamin D levels and bone mass by non invasive imaging techniques like dual energy X-ray absorptiometry (DEXA), have led to a plethora of data regarding various factors responsible for bone mineral health from various countries including India. We reviewed the currently available evidence on status of calcium-vitamin D-parathormone (PTH) relationship and bone mineral density (BMD) in apparently healthy children. High prevalence of clinical and biochemical hypovitaminosis D exists in apparently healthy school children from north India. Also, children from upper socio-economic strata (USES) from Delhi had significantly higher mean BMD values at distal forearm (BMDdf) and calcameum (BMDca) than those from lower socio-economic strata (LSES). Age, nutrition, height and weight were seen to be significantly associated with BMD at peripheral sites.

Ultrasound evaluation of thyroid size: a large nationwide study of schoolchildren in India

BACKGROUND

Ultrasound assessment of thyroid volume is considered a more objective method than clinical palpation for the diagnosis of goitre. We used ultrasonography to establish normal reference cut-off points of thyroid volume in schoolchildren of different socioecomonic groups in India and compared the results with international norms.

METHODS

In a cross-sectional study, we clinically examined 27,250 children from the lower and higher socioeconomic strata (SES) from all over India to determine their goitre staging. A single sonologist, using ultrasonography, assessed the thyroid volume in a subset of 15,986 children (8463 from the lower and 7523 from the higher SES). Students were recruited from at least one school each representing the higher and the lower SES, from cities located in 5 zones of India. Children with known thyroid disorders were excluded from the study.

RESULTS

Clinical evaluation revealed a mean goitre prevalence of 19.9% (23.2% in girls; 16.5% in boys; 17.1% in the higher SES; 23.5% in the lower SES). The thyroid volume as assessed by ultrasonography was significantly higher in children from the lower SES (mean 5.65 ml, SE 0.02) compared with those from the higher SES (mean 5.02 ml, SE 0.02) after adjusting for the imbalance in body surface area (p < 0.001). Using international norms (WHO 2004), the prevalence of goitre in various body surface area categories among children who had no goitre on clinical examination ranged from 48.2% to 75.1% for boys and 23.2% to 67.4% for girls.

CONCLUSION

The striking discrepancy in the prevalence of goitre assessed by using clinical examination and ultrasound techniques suggests that the norms recommended by WHO based on ultrasound techniques are not appropriate for India.

Profile and outcome of neuroblastoma with convertional chemotherapy in children older than one year: a 15-years experience

The clinical profile and outcome of neuroblastoma in 103 children, older than one-year is presented. 74 had Stage IV, 27 Stage III and one patient each had Stage I or II disease. Treatment included chemotherapy followed by surgical resection/debulking. Radiotherapy was administered to those with residual tumor. Chemotherapy consisted of OPEC (vincristine, cyclophosphamide, cisplatin and etoposide). The caretakers of 54 (52.4%) children either did not opt for or defaulted therapy, whilst 3 patients died before chemotherapy could be initiated. Of the remaining 46 patients, the tumor progressed during therapy in 19 (41.3%). Relapse of disease was documented in 22 (47.8%) cases. Merely 4 (8.7%) children are disease free for a period of 16.5+/-6.7 months. Majority of children presented with advanced disease and the outcome was dismal with conventional non-myloablative chemotherapy.

Intracranial calcification in beta-thalassemia major

A 13-year-old boy with thalassemia major presented with generalized seizures. He was non-chelated and had hypoparathyroidism with extensive intracranial calcification, an association that is rarely reported.

Immune mediated hemolysis in visceral leishmaniasis

Anemia in visceral leishmaniasis is a usual manifestation; however, Coombs positive hemolytic anemia has been infrequently reported. In this brief communication, we report occurrence of immune hemolytic anemia in a young child with visceral leishmaniasis. She was successfully treated with liposomal amphotericin.