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Panda PK, Nandani R, Sharawat IK. Children with brain tumors: how do they perform in academics later? Childs Nerv Syst 2021; 37:1413-1414. [PMID: 33619592 DOI: 10.1007/s00381-021-05096-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
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Pratyusha K, Dawman L, Vinay K, Tiewsoh K, Sharawat IK. Dermatological manifestations in children with chronic kidney disease: a study from a North Indian tertiary care institute. Clin Exp Dermatol 2021; 46:1270-1276. [PMID: 33904201 DOI: 10.1111/ced.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dermatological manifestations due to impaired renal function in children with chronic kidney disease (CKD) are diverse and are an important cause of morbidity. AIM To determine the prevalence of dermatological manifestations in predialysis children with different stages of CKD and its association with various metabolic parameters. METHODS This cross-sectional observational study was conducted in 200 predialysis children with CKD stages 1-5 and 200 age- and sex-matched healthy controls (HCs). Detailed dermatological examination was performed to check for any pathological/physiological changes in the skin, mucosa, hair and nails, and changes were recorded in a predesigned proforma. RESULTS The median age of cases and HCs was 60.50 months (76.5% males) and 62 months (78.5% males) respectively. Skin manifestations were seen in 189 (94.5%) cases and 156 (78%) HCs (P < 0.001). The most common skin manifestation among cases was pallor (75.5%, P < 0.001) followed by xerosis (48.5%, P < 0.001), atopic diathesis (41.5%) and pruritus (13%, P < 0.001), while among HCs, the most common skin manifestation was atopic diathesis (46%), followed by pallor (24%) and xerosis (14%). Xerosis was found to be significantly associated with higher serum creatinine levels (P = 0.04) and hypocalcaemia (P = 0.03). There was no significant association found between pruritus and serum creatinine. CONCLUSION Xerosis was significantly associated with higher levels of creatinine and hypocalcaemia. Timely recognition of these symptoms and proper management can improve the quality of life in children with CKD.
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Panda PK, Tomar A, Pillai GR, Kumar A, Sharawat IK. Infantile tremor syndrome and laryngomalacia: A novel association? Clin Nutr ESPEN 2021; 43:235-238. [PMID: 34024520 DOI: 10.1016/j.clnesp.2021.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infantile tremor syndrome (ITS) is a rare clinical entity, predominantly characterized by coarse tremors, regression of motor and/or cognitive, and language milestones. Although the exact pathogenesis yet remains to be unknown, various micronutrient deficiencies like vitamin B12, zinc, magnesium, and vitamin C have been shown to be associated with ITS. Vitamin B12 deficiency is the most accepted etiology of this entity. Here we are describing a seemingly novel association of laryngomalacia with infantile tremor syndrome. METHODS Clinical details, laboratory investigations, demographic and socioeconomic parameters of all children<2 years of age, diagnosed with ITS between August 2019 and November 2020 was obtained by a retrospective chart review. The study population was divided into two subgroups based on the presence/absence of laryngomalacia and different variables were compared between the two subgroups. RESULTS During the study period, 22 ITS and 13 pre-ITS cases were identified, out of which 5 ITS cases had laryngomalacia, the prevalence is higher as compared to estimated prevalence in reported literature (p < 0.0001). All these 5 cases had associated gastro-esophageal reflux and swallowing dysfunction and all of them were managed conservatively, apart from standard care treatment for ITS. On follow-up, all 5 of them showed improvement in symptoms of laryngomalacia, apart from clinical and hematological improvement. Differences between various clinical and biochemical parameters in the subgroup with and without laryngomalacia were not significantly different. Seventeen out of twenty-two children with ITS and 10/13 children with pre-ITS had macrocytic anemia and the rest had dimorphic anemia on peripheral smear. There was moderate vitamin B12 deficiency in 13/22 and 8/13 children with ITS and pre-ITS respectively, and the rest had a severe vitamin B12 deficiency. CONCLUSION Clinicians need to screen cases with ITS for probable symptoms of laryngomalacia and accordingly advise management measures. Although our study showed a seemingly apparent association between ITS and laryngomalacia, large prospective controlled studies with long-term follow-up are necessary to prove this association.
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Panda PK, Elwadhi A, Sharawat IK. Intracranial calcification and seizures in Down syndrome. BMJ Case Rep 2021; 14:14/4/e243180. [PMID: 33893139 PMCID: PMC8074555 DOI: 10.1136/bcr-2021-243180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Panda PK, Sharawat IK. Undergraduate neurology training in the inpatient and outpatient setting: How do they differ? Eur J Neurol 2021; 28:e44-e45. [PMID: 33794038 DOI: 10.1111/ene.14848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
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Panda PK, Sharawat IK. Pyruvate Dehydrogenase Complex Deficiency due to a De Novo Heterozygous Mutation in Exon 7 of PDHA 1 Gene Presenting as Isolated Severe Lactic Acidosis in an Infant: Correspondence. Indian J Pediatr 2021; 88:420-421. [PMID: 32809143 DOI: 10.1007/s12098-020-03473-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
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Panda PK, Sharawat IK. Early risk factors for encephalopathic transformation in children with benign childhood epilepsy with centrotemporal spikes. Brain Dev 2021; 43:601-602. [PMID: 33213973 DOI: 10.1016/j.braindev.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/27/2020] [Indexed: 01/15/2023]
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83
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Panda PK, Sharawat IK. Kawasaki Disease Presenting as Febrile Seizure: A Clinical Oddity. J Clin Rheumatol 2021; 27:e83. [PMID: 31895112 DOI: 10.1097/rhu.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sharawat IK, Panda PK, Dawman L. Clinical Characteristics and Genotype-Phenotype Correlation in Children with KMT2E Gene-Related Neurodevelopmental Disorders: Report of Two New Cases and Review of Published Literature. Neuropediatrics 2021; 52:98-104. [PMID: 33111303 DOI: 10.1055/s-0040-1715629] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In recent years, many new candidate genes are being identified as putative pathogenic factors in children with developmental delay and autism. Recently, heterozygous mutations in the KMT2E gene have been identified as a cause of a unique neurodevelopmental disorder with variable combination of global developmental delay or isolated speech delay, intellectual disability, autistic features, and seizures. METHODS Here, we present two new cases of KMT2E mutation-associated neurodevelopmental disorder in a 4-year-old girl and 5-year-old boy. We also performed a pooled review of the previously published cases of KMT2E-related neurodevelopmental disorder. Articles were identified through search engines using appropriate search terms. RESULTS Along with the presented 2 cases, 40 cases were analyzed. Out of them, 30, 6, and 4 children had protein-truncating mutations, missense mutations, and copy number variants, respectively. The common features were global developmental delay (97%) followed by macrocephaly (35%), seizures (30%), and autism (25%). Children with missense variants had severe phenotype, with microcephaly, profound developmental delay, and increased frequency of seizures. Neuroimaging revealed nonspecific changes, including cerebral white matter signal abnormalities. CONCLUSION KMT2E-related neurodevelopmental disorder remains one of the clinical differentials in children with global developmental delay and/or autistic features/seizure. With the reporting of more cases in the future, the already heterogeneous clinical spectrum of this disease is likely to be widened.
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Sharawat IK, Panda PK, Kasinathan A. Atypical handedness and its clinicoradiological predictors in children with focal epilepsy. Epilepsy Res 2021; 173:106622. [PMID: 33813361 DOI: 10.1016/j.eplepsyres.2021.106622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/09/2021] [Accepted: 03/20/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE Handedness has been strongly linked to cerebral lateralisation for language. Literature on atypical handedness and its association with focal epilepsy starting from early childhood is limited and needs exploration. METHODS In this cross-sectional study, the prevalence of atypical handedness (left-handedness and ambidexterity) was compared between children with left/right focal epilepsy aged 3-14 years without any definite motor deficit, between August 2019 and July 2020. Cognition, behavioral abnormalities, working memory, and executive function were also compared between the groups. Various clinical, demographic, and radiological variables were explored to determine any association with the presence of atypical handedness. RESULTS Of the total 79 children (45 boys, 57 % mean age 6.5 ± 2.3 years, 41-left focal epilepsy) with focal epilepsy enrolled for the study, the prevalence of atypical handedness was found to be 12.6 % (10/79). No association between atypical handedness and clinical/demographic variables including left/right focal epilepsy was observed in the study excepting neuroimaging abnormality (p = 0.0008 and 0.02 respectively). This increased prevalence of neuroimaging abnormality in patients with atypical handedness was significant in multivariate analysis, after adjusting for confounding variables. Similarly, intelligence quotient (full scale, verbal and non-verbal, as well as sub-domains), behavioral abnormality (internalizing and externalizing score on CBCL), scores on picture memory, simple copying, and missing scan task were not significantly different between children with left and right focal epilepsy or children with atypical handedness and right-handedness. CONCLUSION Atypical handedness is not more frequent in children with left focal epilepsy as compared to right focal epilepsy.
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Panda PK, Natarajan V, Sharawat IK. Neurocognitive profile of children with ESES, generalized, and focal epilepsy: Is there any difference? Epilepsy Res 2021; 172:106451. [PMID: 33711708 DOI: 10.1016/j.eplepsyres.2020.106451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 08/19/2020] [Accepted: 08/21/2020] [Indexed: 11/24/2022]
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Dawman L, Tiewsoh K, Barman P, Pratyusha K, Chaakchhuak L, Sharawat IK. Phenotype and Genotype Profile of Children with Primary Distal Renal Tubular Acidosis: A 10-Year Experience from a North Indian Teaching Institute. J Pediatr Genet 2021; 11:221-226. [DOI: 10.1055/s-0041-1724114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
AbstractPrimary distal renal tubular acidosis (dRTA) or Type 1 RTA in children is caused by a genetic defect (involved genes ATP6V0A4, ATP6V1B1, SLC4A1, FOXI1, or WDR72), which causes tubular transport defects characterized by an inability to appropriately acidify urine with resultant persistent hyperchloremic metabolic acidosis. Retrospective analysis of 28 children (14 males) under the age of 14 years with dRTA seen from 2010 to 2019 was reviewed, and detailed clinic records were analyzed. The clinical features, investigations, and response to treatment were recorded. The median age of the children at presentation was 30 months (range: 9.25–72 months), and the median age at onset of symptoms was 2 months. All the children had growth failure, polyuria, and polydipsia at presentation. Mean serum potassium, pH, bicarbonate, and anion gap at presentation was 2.3 ± 0.5 mmol/L, 7.22 ± 0.09, 13.28 ± 4.37 mmol/L, and 9.3 ± 2.18, respectively. Mean serum potassium, pH, bicarbonate at follow-up was 3.88 ± 0.6 mmol/L, 7.35 ± 0.06, and 20.13 ± 4.17 mmol/L, respectively. The median z-score for the weight for age and height for age at initial presentation was −4.77 (–7.68 to –3.74) and –4.21 (–5.42 to –2.37) and at follow-up was –3.35 (–5.29 to –1.55) and –3.84 (–5.36 to –1.63), respectively. Twenty-two (78.6%) children had medullary nephrocalcinosis. Four children had sensorineural hearing loss. Seven children had genetic testing done, and six had pathogenic or likely pathogenic variants in ATP6V1B1 and ATP6V0A4 gene. Children with dRTA have a guarded prognosis and ATP6V1B1 and ATP6V0A4 mutations are the most common implicated genetic defect in Indian children with distal RTA.
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Panda PK, Sharawat IK. Impact of carbamazepine and lacosamide on serum lipid levels. Epilepsia 2021; 62:1034-1035. [PMID: 33651399 DOI: 10.1111/epi.16859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/12/2021] [Indexed: 11/27/2022]
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Sharawat IK, Panda PK. Caregiver Satisfaction and Effectiveness of Teleconsultation in Children and Adolescents With Migraine During the Ongoing COVID-19 Pandemic. J Child Neurol 2021; 36:296-303. [PMID: 33170754 DOI: 10.1177/0883073820968653] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The ongoing COVID-19 pandemic and the lockdown measures have forced clinicians across the world to look on telemedicine. Although migraine as such seems an ideal option for telemedicine, a systematic study reviewing feasibility, efficacy, and advantages of current advanced telecommunication technologies in children with migraine is lacking. METHODS Clinical details of telephonic consultations performed between March 25 and June 4, 2020, including migraine characteristics, analgesic/prophylactic drug regimens, headache frequency/severity/disability, compliance, drug-related/unrelated adverse effects and unavailability of drugs were recorded. Suitable change in the dose/commercial brand of drug regimen and the addition of new drugs were done as required. Voice call, text messages, picture/video messages, and all other possible measures were used to accumulate maximum clinical information in real time. Unless contacted for trivial reasons, most children were later followed up telephonically to ensure health care concern was resolved and to fill up one 6-item trichotomous quality control questionnaire. RESULTS A total of 146 telephone consultations were performed in 51 participants. Thirty-six patients were identified to have 42 significant clinical events (worsening clinical status/partial response to medications [18; 44%], drug-related adverse effects [10; 19%], unrelated systemic complaints [7; 13%], and worsening of headache due to stress/triggers [7; 13%]). In the rest of the patients, the query of the caregiver included concern regarding COVID-19-related symptoms. Twenty-nine children required increment in drug dose or addition of new drug or commercial brand. Around 90% of caregivers were satisfied with the quality of teleconsultation. CONCLUSION Teleconsultation is a feasible and efficacious option, with excellent caregiver satisfaction for children with migraine.
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Kumar Panda P, Sharawat IK. Correspondence on "Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study". J Child Neurol 2021; 36:243-244. [PMID: 32985304 DOI: 10.1177/0883073820960986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Sharawat IK, Suthar R, Saini AG, Sankhyan N. Pyridoxine Trial in Early Infantile Epileptic Encephalopathy: Never Forget! Ann Indian Acad Neurol 2021; 23:727-729. [PMID: 33623288 PMCID: PMC7887496 DOI: 10.4103/aian.aian_204_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/10/2020] [Indexed: 11/21/2022] Open
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Abstract
Palmar erythema in children can be due to various reasons, such as chronic liver disease, rheumatological disorders, medications, irritant contact dermatitis and atopic dermatitis. Recently, there are few reports about contact dermatitis caused by frequent, daily use of hand sanitizers during this COVID-19 pandemic. A 3-year-old toddler brought with the concern of waxing-waning bilateral palmar erythema for the past 2 weeks. The parents revealed that the child liked the bright color of a recently bought hand sanitizer bottle so much he used to wash his hands every 20-30 min throughout the day. The atypical presentation of contact dermatitis might be because the child was using the sanitizer more frequently during the daytime. The dermatitis resolved with stopping excessive use of the hand sanitizer by the toddler. Clinicians should be aware of contact dermatitis during these pandemic times. Instead of investigating them extensively, careful history taking and merely advising them to judicially utilize the sanitizer can lead to complete reversal of symptoms.
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Biswal S, Parida P, Dubbudu A, Sharawat IK, Panda PK. Chromosome 1p31.1 Deletion Syndrome: Limited Expression. Ann Indian Acad Neurol 2021; 24:78-80. [PMID: 33911383 PMCID: PMC8061518 DOI: 10.4103/aian.aian_258_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/20/2020] [Accepted: 05/03/2020] [Indexed: 12/01/2022] Open
Abstract
Chromosomal microdeletion syndromes usually present with neurological abnormalities, developmental delays, and various systemic abnormalities. 1p31 microdeletion syndrome is one of the novel microdeletion syndromes that usually presents with developmental delay, intellectual disability, various craniofacial abnormalities, and other systemic abnormalities in a proportion of cases. NEGR1 and NFIA are few of the genes present in this locus responsible for these symptoms. However, none of the reported cases had only isolated intellectual disability. Here, we are reporting a case of 1p31 microdeletion syndrome with isolated moderate intellectual disability and hyperactivity in an 11-year-old boy. It is essential for clinicians to be aware of such an atypical presentation of 1p31.1 microdeletion syndrome, to maintain reasonable clinical suspicion in cases with unexplained intellectual disability.
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Sharawat IK, Panda PK, Kasinathan A, Panda P, Dawman L, Joshi K. Efficacy and tolerability of fenfluramine in patients with Dravet syndrome: A systematic review and meta-analysis. Seizure 2021; 85:119-126. [DOI: 10.1016/j.seizure.2020.12.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/13/2022] Open
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Panda PK, Sharawat IK. Paracetamol versus Ibuprofen for the Acute Treatment of Migraine Headache in Children: A Blinded Randomized Controlled Trial - Correspondence. Indian J Pediatr 2021; 88:207-208. [PMID: 32651867 DOI: 10.1007/s12098-020-03437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
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Sharawat IK, Panda PK. Echolalia: Presentation of Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis. Indian J Pediatr 2021; 88:186-187. [PMID: 32607670 DOI: 10.1007/s12098-020-03427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/18/2020] [Indexed: 10/23/2022]
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Panda PK, Sharawat IK. Impact of drug-resistant epilepsy on sleep in children: How do they behave? Epilepsy Behav 2021; 115:107717. [PMID: 33431350 DOI: 10.1016/j.yebeh.2020.107717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022]
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Panda PK, Sharawat IK. Effect of varenicline for smoking cessation in adolescents. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:e3. [PMID: 33484668 DOI: 10.1016/s2352-4642(20)30396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 06/12/2023]
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Panda PK, Sharawat IK. Seropositive Anti-NMDAR Mediated Autoimmune Encephalitis: Correspondence. Indian J Pediatr 2021; 88:204-206. [PMID: 32643052 DOI: 10.1007/s12098-020-03397-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
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Abstract
Primary neuroleptospirosis although rare but has been reported in the literature in the form of case reports and case series. However, there are no reports of autoimmune encephalitis triggered by leptospirosis in the literature, although four cases of acute disseminated encephalomyelitis, which is also considered to have autoimmune etiology have been reported. We are reporting an adolescent girl, who developed anti-N-methyl-d-aspartate receptor encephalitis after the resolution of systemic symptoms of leptospirosis. Her symptoms including neuropsychiatric and extrapyramidal features and sleep disturbances resolved completely after immunotherapy. As recently autoimmune encephalitis triggered by various infections are getting reported more frequently around the world, the clinicians need to consider this clinical possibility, even in patients with leptospirosis, who develop neurological symptoms while systemic clinical features are subsiding. Early recognition and timely administration of immunotherapy have the potential to completely reverse the neurological symptoms.
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