Renal tubular acidosis preceding systemic lupus erythematosus

A 10-year-old girl with distal renal tubular acidosis (RTA) for 4 years (adequately treated for 3 years) developed clinical features suggesting systemic lupus erythematosus (SLE) with supportive laboratory evidence. She had heavy proteinuria and a decreased creatinine clearance (CCr). Renal biopsy showed diffuse proliferative and sclerosing glomerulonephritis with severe tubulointerstitial changes. Following treatment with corticosteroids and cyclophosphamide, she had a clinical remission, an increase in CCr and recovery from systemic acidosis. It is likely that distal RTA in this patient was a manifestation of SLE.

Neuropsychological abnormalities following CNS prophylaxis in children with acute lymphatic leukemia

The pattern and prevalence of neuropsychological abnormalities in children receiving combination CNS prophylaxis (2000 rads cranial irradiation and intrathecal methotrexate) during therapy for acute lymphoblastic leukemia (ALL) were studied. Thirty five children (25 boys) in the age group 5-15 years (mean 9.3) with no evidence of CNS leukemia were included and 20 age matched normal siblings served as controls. Neuropsychological parameters of general intelligence (Malin's modification of WISC test); attention and concentration (colour cancellation test); memory (modified PGI memory test) and visuomotor perception (Bender Gestalt test) were evaluated at least 6 months after CNS prophylaxis. Six (17.1%) patients had mean intelligence quotients (IQ) less than 85, while all controls had IQ > 85 (p < 0.05). The mean IQ of the patient population (93.4 +/- 11.9) was significantly lower than the control group (107 +/- 8.4) (p < 0.001). Scores on the colour cancellation test were lower in the patients as compared to controls (148.7 +/- 27.7 versus 184.9 +/- 23.9; p < 0.01). The mean memory quotient in the patient population was also lower than in controls (74.5 +/- 12 versus 93.6 +/- 9.2; p < 0.001). Scores on the Bender-Gestalt test did not show a significant difference. The presence of significant neuropsychological abnormalities in patients of ALL indicates the need for modification of the schedule of CNS prophylaxis. A comprehensive psychometric evaluation at regular intervals is essential for longterm rehabilitation.

Serum concentrations of rifampicin and isoniazid in tuberculosis

Ninety-four patients, 1-13 years of age suffering from different types of tuberculosis were investigated for serum rifampicin (RIF) and isoniazid (INH) concentrations using microbiological and fluorimetric methods, respectively. Of these, 64 (68.1%) had pulmonary primary complex (PPC); 20 (21.3%) progressive primary disease (PPD) and 10 (10.6%) tuberculous meningitis (TBM). Patients with PPC, PPD and TBM were given two-drug (6HR), three drug (2HRZ, 4HR) and four drug (2SHRZ, 4HRE, 3HE) regimens, respectively. RIF and INH were administered in a dose of 12 and 10 mg/kg/day, respectively. After 10-12 days of continuous therapy, their serum concentrations were estimated at 0, 2, 4, 6, 8 hours for RIF and 0, 1, 3, 5, 7 hours for INH. For RIF, the time to achieve maximum concentrations (Tmax) was 2 hours, range of mean of maximum concentration (Cmax) 3.38 to 3.88 micrograms/ml, terminal half life elimination (T1/2) 3.03 to 3.81 hours and area under serum concentration curve (AUC) 0-8 hours 24.7 to 28.3 micrograms/ml hours in different forms of tuberculosis. INH had a Tmax of 1 h, Cmax 4.38 to 8.17 micrograms/ml, T1/2 4.0 to 4.98 hours and AUC 0-7 hours 34.1 to 57.5 micrograms/ml hours. The concentrations achieved at 7-8 hours with these dosages were much above those required for therapeutic efficacy (minimum inhibitory concentration), being 50 to 250 times for RIF and 35-60 times for INH. We recommend pharmacokinetic studies with lower doses of RIF and INH for less toxic, equally effective and cheaper antitubercular chemotherapy.

Three-year experience with neonatal ventilation from a tertiary care hospital in Delhi

Ninety neonates were ventilated over a period of 33 months of whom 50 (55.5%) survived. Fifty seven babies received IPPV while 33 CPAP. IPPV mode was being used more frequently recently and survival rates have steadily improved over past 3 years. Survival was cent per cent in babies above 1.5 kg on CPAP mode while 16/26 (57.7%) survived on IPPV mode. Of 22 extremely VLBW (< 1 kg) babies, six survived. HMD was the commonest indication of ventilation (50%), of which 53% (24/45) survived. The other important indications of ventilation were apnea in 13 and transient tachypnea in 11 babies. All babies requiring ventilation for transient tachypnea survived. Nosocomial infections were common in association with ventilation 34/90 (37.7%), out of which in 14 was responsible for about a third of deaths. Pulmonary air leaks developed in 12 babies of which 6 died. Two babies developed BPD and one ROP. Neonatal ventilation should be ventured in centres where basic facilities for level II care already exist. It may not be cost effective to ventilate extremely low birth weight neonates.

Childhood tuberculosis in a referral centre: clinical profile and risk factors

One hundred and ninety six children (age group 6 months to 12 years) attending the Pediatric Tuberculosis Clinic at AIIMS, New Delhi, over a period from January 1988 to December 1989 were analysed. Nearly 61% of children were malnourished (Grades III and IV). A positive family history was noted in nearly one third (33.7%) of cases while 41.3% of children had received BCG. A positive Mantoux test was noted in 77% of cases. The most prominent lesion on radiology was parenchymal (51.4%). In nearly two third of cases, both Mantoux test and X-ray chest was positive. A family history of tuberculosis and BCG vaccination was significantly associated with positive Mantoux test (p < 0.01). Fever and cough in older children (> 6 years) while weight loss in younger children (< 3 years) were the predominant symptoms. Most of the cases (82.1%) had pulmonary primary complex, the proportion being higher in older age group. The severe form of tuberculosis, i.e., progressive primary disease, military tuberculosis, etc., were significantly more in younger children. The various risk factors significantly associated with severe form of tuberculosis were very young children (< 3 years), no BCG vaccination, a negative family history and a negative Mantoux test.

Dengue haemorrhagic fever in children in Delhi

An epidemic of dengue haemorrhagic fever occurred in Delhi during 1988. A total of 21 paediatric patients with dengue haemorrhagic fever/dengue shock syndrome were evaluated from September to November 1988. All the patients had fever, restlessness, ecchymotic spots and ascites. Pleural effusion occurred in 19 patients (90%), and 18 (86%) exhibited each of the following: vomiting, thrombocytopenia, and haemoconcentration. Hepatomegaly was observed in 15 patients (71%) and splenomegaly in three (14%). Titres of haemagglutination inhibition (HI) antibodies against dengue virus type 2 were raised in all the 15 cases from whom sera were collected during the acute stage. Convalescent sera from five patients had increased titres of HI antibodies to dengue virus type 2. The remaining 10 cases exhibited raised IgM antibody levels against dengue virus type 2. The fatality rate for serologically proven cases was 13% (2 of 15 patients), while for all patients (including those diagnosed clinically (6) and serologically (15)) it was 33.3% (7 of 21). Patients who survived had no sequelae, except one who had transient hypertension that lasted for two weeks.