Persistent jaundice in an infant with homozygous beta thalassemia due to co-inherited Crigler-Najjar syndrome

Clinically apparent jaundice is unusual in patients with beta-thalassemia major. Co-inheritance of Gilbert syndrome has been reported to cause hyperbilirubinemia in these subjects. Crigler-Najjar syndrome is another rare disorder of bilirubin metabolism caused by mutation in the gene coding the enzyme UGT1A1. We report a patient of beta-thalassemia major who presented with persistent jaundice due to co-inherited Crigler-Najjar syndrome type 2 secondary to a novel mutation in UGT1A1 gene [homozygous base substitution at position 362 (GGT>AGT) in exon 3].

Chronic idiopathic myelofibrosis with myeloid metaplasia presenting as refractory ascites

Chronic idiopathic myelofibrosis (CIM) with myeloid metaplasia is a myeloproliferative disorder characterized by leukoerythroblastosis, tear drop erythrocytes, extra-medullary hematopoesis (EMH), and varying degree of myelofibrosis. CIM, presenting as refractory ascites secondary to peritoneal hematopoesis, is extremely rare with only six adult cases reported in literature. This is a report of a child with CIM presenting as refractory ascites as a consequence of EMH in the peritoneum. The patient was treated with intermittent hydroxyurea with favorable response over 3 weeks. The patient was thereafter lost to follow up.

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.

Etiological profile of stroke and its relation with prothrombotic states

OBJECTIVE

To study the etiological profile of childhood stroke and its relation with prothrombotic states.

METHODS

Children with acute stroke with no evidence of CNS infection or head injury were studied. Stroke was confirmed by CT scan and further evaluated by MRI. Cardiac status was assessed with transthoracic echocardiography. Test for hypercoagulable state (antithrombin III, protein C, protein S, anticardiolipin antibody IgG and IgM and lupus anticoagulant) were done in all patients.

RESULTS

A total of 66 children were enrolled--36 cases and 30 controls. Presenting symptoms were motor deficit (72%), seizure (66%), altered sensorium (36%), aphasia (27%). Causes identified were antiphospholipid antibody syndrome (25%), Moya Moya disease (16.6%), cardiac disease (11.1%), vasculitis (5.5%), ATIII deficiency (5.5%), Protein C deficiency (2.7%). Etiology remained unknown in 25% of cases with infarction. Hemorrhage was seen in 8.2% of cases and they had DIC or liver disease as the underlying cause.

CONCLUSIONS

Magnetic Resonance Angiography and ELISA for antiphospholipid antibody should be done in all patients with stroke without an obvious cause.

Iodine nutrition status of exclusively breast-fed infants and their mothers in New Delhi, India

OBJECTIVE

To assess the iodine nutrition status of exclusively breast-fed infants and their mothers.

HYPOTHESIS

In the presence of environmental and maternal iodine deficiency, an exclusively breast-fed baby is likely to receive a suboptimal iodine supply during the period of rapid brain growth.

METHODS

Spot urinary iodine (UI) and serum TSH levels were measured in 175 healthy, exclusively breast-fed infants and their mothers. Iodine content of salt used by participants for domestic consumption was also analyzed.

RESULTS

The median UI levels in mothers and infants was 124 microg/l and 162 microg/l, respectively. 34% of mothers and 21% of infants had UI levels <100 microg/l indicating iodine deficiency. Serum TSH was elevated in 29% of mothers and 2% of infants. No correlation was observed between individual mother-infant UI or serum TSH levels (r = -0.036, r = -0.1 for UI excretion and serum TSH, respectively). 96% of the salt samples tested had adequate iodine concentration, i.e. >15 ppm.

CONCLUSION

The present study demonstrated significant iodine deficiency in both mothers and infants despite consumption of adequately iodized salt. The iodine nutrition status of the infants was better compared to the mothers, indicating a preferential iodine supply to the infants over the mothers.

Rare serotype non-typhoidal Salmonella sepsis

An 11-month female with a poor socio-economic status presented to a tertiary care paediatric hospital with complaints of fever of 4-5 days and diarrhoea of 20 days duration. The patient didn't respond to the prescribed antimicrobials namely--Norfloxacin and metronidazole. On admission she was diagnosed as persistent diarrhea with PEM grade III with sepsis. Stool examination and culture were negative for any pathogens, however blood culture yielded growth of Salmonella Virchow which was susceptible to most common antimicrobial agents excepting Trimethoprim Sulfamethoxazole. Salmonella Virchow is a common non-typhoidal Salmonellae causing bacteremia in the west, however this is the first report of bacteremia by S. virchow from India.

Berardinelli-Seip congenital lipodystrophy

Berardinelli-Seip congenital lipodystrophy (BSCL) is a very rare genetic disorder characterized by lipoatrophy, hypertriglyceridemia, hepatomegaly and acromegaloid features. On the basis of mutational and haplotype analysis, BSCL families have been classified into three types BSCL 1, BSCL2 and BSCLX. We report Berardinelli-Seip congenital lipodystrophy (BSCL2 type) in three subjects from two unrelated Indian families (family1 and family2). The mutation (c.IVS2 11 A GT G ) found in affected members of family1 is a newly identified mutation. We also report the association of renal anomaly with this new mutation.

Sleep and childhood epilepsy

The inter-relationship between sleep and epilepsy is well recognized. Sleep is known to activate inter-ictal epileptiform discharges. A special timing of seizure in relation to sleep wake cycle is certainly a childhood epileptic syndrome. Children with epilepsy commonly have sleep problems which may be due to seizures or due to anxiety. Somnolence and diurnal sedation are frequent side effects of anti-epileptic drugs. Thus epilepsy and its treatment can affect sleep leading to adverse effect on behavior, cognition and seizure control. Lack of sleep is an important trigger for epileptic seizures, therefore regular sleep must be a part of management strategy in children with epilepsy.

Acute disseminated encephalomyelitis--a case series

Acute disseminated encephalomyelitis(ADEM) is an uncommon inflammatory demyelinating disease involving central nervous system white matter. A series of seven cases seen over a period of one year have been described. The patients presented with acute onset of focal neurological deficit (3 patients), alteration of sensorium(3) and ataxia(1). CT scan showed non specific hypodensity in 4 cases and was normal in 3 patients . MRI showed characteristic radiological changes. Complete recovery was seen in 3 patients , one died and 3 were left with sequelae.

Spina bifida occulta in functional enuresis

OBJECTIVE

To study incidence of spina bifida occulta in nocturnal enuresis cases and to compare outcome of enuresis with spina bifida occulta and enuresis without spina bifida occulta.

METHODS

Patients with enuresis divided into two groups based on X-ray lumbosacral spine. Outcome of these patients were compared on behavioral therapy.

RESULTS

Spina bifida occulta was detected in 18 out of total 48 patients. Levels of spina bifida were L5 vertebrae in 3,L5-S1 in 5,S1 in 8 and S1-S2 in 2 patients. Outcome was evaluated in 42 patients who were followed up for more than 6 months. There was no significant difference between both the groups.

CONCLUSION

Spina bifida occulta is a common finding in enuresis. Outcome of patients with spina bifida occulta is not different than the patients without spina bifida occulta.

Add-on melatonin improves sleep behavior in children with epilepsy: randomized, double-blind, placebo-controlled trial

This double-blind, randomized, placebo-controlled study in epileptic children, aged 3 to 12 years, evaluated the effect of add-on melatonin on the sleep behavior of these children on sodium valproate monotherapy using a parental questionnaire. Of the 31 patients, 16 randomly received add-on melatonin, whereas 15 received add-on placebo. The questionnaire showed good internal consistency in our patient population (Cronbach's alpha = .83). The percentage decrease in the median total sleep score was 24.4 (range 0.0-34.9) in the valproate + melatonin group compared with 14.0 (range -2.2-18.8) in the valproate + placebo group, the difference being statistically significant (P < .05). The median percentage decrease in the parasomnias score was 60 (range 0.0-70.8) in the valproate + melatonin group compared with 36.4 (range 0.0-63.2) in the valproate + placebo group, the difference being statistically significant (P < .05). There was no significant difference between the percentage decrease in the daytime drowsiness scores and sleep fragmentation scores. Parent-child interaction subscale scores were not significantly different between age groups. The age at onset of seizures and the type of seizures did not correlate significantly to the total sleep scores. Given that sleep problems are known to complicate epilepsy, add-on melatonin, which has a wide safety window, can be of promise in the pharmacotherapy of pediatric epilepsy.

Effects of add-on melatonin administration on antioxidant enzymes in children with epilepsy taking carbamazepine monotherapy: a randomized, double-blind, placebo-controlled trial

PURPOSE

Melatonin has been shown to exhibit antioxidant, antiexcitotoxic, and free radical-scavenging properties in various animal models. The study was designed to assess its effects on the blood levels of antioxidant enzymes in children with epilepsy receiving carbamazepine (CBZ).

METHODS

In a double-blind, randomized, parallel-group, placebo-controlled trial, we assessed the effect of add-on melatonin (6-9 mg/day for 14 days) on the antioxidant enzymes glutathione peroxidase (GPx) and glutathione reductase (GRd) in 31 children with epilepsy receiving CBZ monotherapy, who were seizure free at least for the last 6 months. The interaction of melatonin with CBZ and its active metabolite, carbamazepine-10, 11-epoxide (CBZ-E), also was studied.

RESULTS

An increase in GRd activity was noted in the melatonin group as compared with a decrease of the same enzyme in the placebo group. Changes in GPx activity failed to reach statistical significance. No significant changes were found in the serum levels of CBZ and CBZ-E in either group.

CONCLUSIONS

The study suggests that melatonin exerts antioxidant activity in patients with epilepsy receiving CBZ therapy.

A randomized, double-blind, placebo controlled trial of melatonin add-on therapy in epileptic children on valproate monotherapy: effect on glutathione peroxidase and glutathione reductase enzymes

AIMS

To compare the effect of add-on melatonin with placebo on the antioxidant enzymes (glutathione peroxidase and glutathione reductase) in epileptic children on valproate monotherapy.

METHODS

In a double-blind, randomized, placebo controlled trial, the effect of add-on melatonin administration on the antioxidant enzymes in epileptic children on valproate (VPA) monotherapy was assessed. A total of 31 patients met the entry criteria. 16 patients were randomly allocated to receive add-on melatonin, and 15 to receive add-on placebo. Blood samples (5 ml) were collected just before the morning dose of valproate for baseline values of glutathione peroxidase and glutathione reductase enzymes, and then after 14 days of add-on melatonin/placebo. Blood was then centrifuged at 3500 r.p.m., serum separated and stored in deep freezer at -20 degrees C until assay of glutathione reductase. Heparinized blood was collected and stored at -20 degrees C in eppendorfs in the deep freezer for assay of glutathione peroxidase. All activity assays were performed on the Ames (Technicon) RA 50 chemistry analyser.

RESULTS

Fifteen patients in the add-on melatonin group and 14 patients in the add-on placebo group were finally assessed. There was an increase in the activity of antioxidant enzymes, glutathione peroxidase (GSH-Px) and glutathione reductase (GSSG-Rd), in the add-on melatonin (MEL) group as compared with a reduction in the same in the add-on placebo group (P). After the addition of melatonin/placebo in the respective groups, there was a 7.5% decrease in GSH-Px in the valproate + placebo group, whereas a 11.9% increase in the valproate + melatonin group was observed, the difference between the groups being not statistically significant (P = 0.29). On administration of melatonin/placebo, the post-treatment concentrations of GSSG-Rd in the valproate + placebo group decreased from 92.0 U l(-1) to 67.0 U l(-1) and increased from 82.0 U l(-1) to 113.0 U l(-1), in the valproate + melatonin group, respectively, the difference between them being statistically significant (P = 0.05). The percentage change in the values of GSSG-Rd in the two groups was statistically significant (P = 0.005).

CONCLUSIONS

Melatonin exerts neuroprotection due to its antioxidant, antiexcitotoxic and free radical scavenging properties within the central nervous system. Melatonin, thus, as an adjunct, can be a putative neuroprotector in conditions involving oxidative stress like epilepsies.

Diabetes mellitus in an infant

Onset of diabetes in the first year of life is uncommon, most cases being those of transient diabetes of the newborn. We report the case of a child who presented at 10 weeks of age with diabetic keto-acidosis, and continues to be insulin dependent at 18 months.

Evaluation of a child with cerebral palsy

Evaluation of a child with cerebral palsy (CP) requires a multidisciplinary approach with a team of professionals comprising of a pediatrician or pediatric neurologist, occupational therapist, a physiotherapist, child psychologist, and a social worker. The assessment is necessary to confirm the diagnosis, determine the cause, assess the motor function and associated problems. The diagnosis of CP is clinical but selected investigations may be required for ascertaining the cause. Evaluation includes assessment for common medical problems of childhood particularly nutritional disorders and assessment of family functioning. Additional disabilities are common. Routine assessment of vision and hearing is required in children with CP. Since CP is a changing disorder, some limitations may not be evident early in life but manifest in the school age or later. The evaluation of a child with CP is an ongoing process and should be a part of continuing care as the child grows from infancy to adolescence.

Add-on melatonin improves quality of life in epileptic children on valproate monotherapy: a randomized, double-blind, placebo-controlled trial

This randomized, double-blind, placebo-controlled study in epileptic children aged 3-12 years evaluated the effects of add-on melatonin administration on the quality of life of these children on sodium valproate (VPA) monotherapy using a parental questionnaire. Quality of Life in Childhood Epilepsy is a questionnaire designed to assess a variety of age-relevant domains such as physical function, emotional well-being, cognitive function, social function, behavior, and general health. Of the 31 patients, 16 randomly received add-on melatonin (MEL), whereas 15 received add-on placebo (P). The questionnaire had good internal consistency reliability, because for most of the multi-item scales Cronbach's alpha reliability exceeded 0.5 (range: 0.59-0.94). To our knowledge, this is the first study assessing quality of life in epileptic children with add-on melatonin administration in the form of a randomized, double-blind, placebo-controlled trial. The study suggests a potential use of melatonin as an adjunct to antiepileptic therapy due to its diverse spectrum of action as an antioxidant, neuroprotector, and free radical scavenger, thus offering the advantage of reducing oxidant stress and subsequent damage. The beneficial effects of melatonin on sleep, its wide safety window, and its ability to cross the blood-brain barrier have the potential to improve quality of life in pediatric epilepsy.

Current drug therapy of protozoal diarrhoea

Protozoal infections of the gastrointestinal tract occur worldwide and have substantial morbidity and mortality. Prevalence is higher in the economically deprived regions of the world, especially the developing countries. Infections like amoebiasis and giardiasis have a worldwide distribution, being endemic in India. Apart from producing GI symptoms, growth and development of children is also impaired. It is seen that protozoa multiply rapidly in their hosts and as there is a lack of effective vaccines, chemotherapy has been the only practiced way to treat individuals and reduce transmission. The current treatment modalities for protozoal diarrhoea include 5-nitrosoimidazoles, iodoquinol, diloxanide furoate, paromomycin, chloroquine, and trimethoprim-sulphamethoxazole.

Pelvic ultrasonography in pubertal girls

OBJECTIVE

To derive norms for the size of uterus, uterine shape (fundal-cervical ratio) and ovarian volume in girls in various Tanners stages of puberty.

METHODS

Pelvic ultrasound was performed in ninety-two healthy girls in the age group of 8-15 years. These included twenty girls each in Tanner stages 1-4 and twelve in stage 5. All the subjects enrolled in the study had a weight and height within 5th-95th percentile of NCHS standards and their bone ages corresponded to the chronological age. Uterine height, fundal-cervical ratio (FCR) and ovarian volume were measured in all the subjects. The data was stratified according to various pubertal stages as well as for different ages. Statistical analysis was carried out to derive the percentiles for the three parameters in different pubertal stages and to study the correlation between these parameters and age, weight and height of the subjects.

RESULTS

A statistically significant increase in uterine height, FCR and ovarian volume was observed with progressive pubertal stages. Maximum increase in uterine height was observed during the transition from stage 2 to stage 3. All girls beyond the age of 10 years or beyond Tanner stage 2 had a FCR>1. The ovarian volume, after showing an initial increase, tended to plateau and there was no significant increase from stage 4-stage 5. A significant correlation was found between the three parameters and the subject's age, weight and height, the maximum correlation was with age (correlation coefficients being 0.748, 0.648, 0.568 for uterine height, FCR and ovarian volume respectively). Centiles for these parameters were obtained for different pubertal stages.

CONCLUSION

This work has provided some guidelines for normative data for various pubertal stages as well as for ages between 8-15 years. These may be used as a reference in evaluation of patients with suspected disorders of puberty.

Etiology and clinical predictors of intractable epilepsy

To determine the etiology and clinical predictors of intractable epilepsy, a case-control study comprising 50 patients and 50 control subjects was performed. Patients included children who had more than one seizure per month over at least 6 months. Control subjects included children with epilepsy who had been seizure-free for more than 6 months. Patients were evaluated with special reference to birth history and development. Clinical examination and neurodevelopmental assessment were performed in all the patients. Drug monitoring was performed to exclude pseudointractability. Epilepsy in the study group was caused by perinatal problems (48%) and sequelae of central nervous system infection (24%) and was idiopathic in 20%. In the control group, epilepsy was idiopathic in 72%, a result of calcified granuloma in 22%, and perinatal problems comprised 6% of the subjects. On univariate analysis, strong association was evident between intractable epilepsy and several factors, including age at onset of seizure, remote symptomatic epilepsy, initial seizure type, history of neonatal seizure, high initial seizure frequency, microcephaly, and neurologic impairment. On multivariate analysis, neurologic impairment (odds ratio [OR] 12.25; 95% confidence interval [CI] 3.58-41.89), age at onset of seizure less than 1 year (OR 11.70; 95% CI 2.95-46.43), myoclonic seizure/infantile spasm (OR 10.36; 95% CI 2.39-44.93), and remote symptomatic epilepsy (OR 2.9; 95% CI 1.13-7.43), were independent predictors of intractability.

Nocturnal enuresis

Childhood enuresis is a common socially disruptive problem. The possible pathophysiological factors include a disorder of sleep arousal, nocturnal polyuria, and low bladder capacity. The evaluation of a patient with nocturnal enuresis is aimed to exclude any organic pathology, UTI and voiding dysfunction. An approach to management of this common disorder is outlined.

Spontaneous bladder rupture secondary to posterior urethral valves in a neonate

Bladder rupture is a rare cause of ascites in neonates. A review of literature revealed about 32 cases including both iatrogenic and spontaneous rupture. This case report describes a successfully treated case of spontaneous rupture of bladder with ascites in a neonate with posterior urethral valves.

Feeding problems in children with cerebral palsy

OBJECTIVE

To determine the magnitude and extent of feeding problems in children with cerebral palsy (CP) and to evaluate the effectiveness of nutritional interventions.

DESIGN

Prospective hospital based interventional study.

METHOD

Children with cerebral palsy of either sex were enrolled randomly and their parents were interviewed for their perception about feeding problems, nutritional status and for their views about the expected outcome of feeding problems. Each case was assessed for feeding problems based on Gisel and Patrick feeding skill score; for nutritional status by measurement of weight, skinfold thickness (at biceps, triceps, suprailiac and subscapular), mid arm circumference and caloric intake; neurologically for type and severity of cerebral palsy and for developmental age by Gasell s developmental scale. Equal number of age and sex matched controls were included for comparison of nutritional status and developmental quotient. Various rehabilitation procedures were applied and their response was observed in the followup ranging from 3-10 months.

RESULTS

One hundred children (76 boys and 24 girls) with cerebral palsy of mean age 2.5 years (range 1 to 9 years) and mean developmental age of 7.6 months (range 1 to 36 months) were included in the study. Oral motor dysfunction (OMD) was found in all cases and in each category. Spastic quadriplegic cerebral palsy (SQCP) and hypotonic patients had significantly poor feeding skill score (p < 0.001). Mean duration of feeding session was 31.5 minutes (range 10-60 minutes). Main food of children with cerebral palsy consisted of liquid and semisolid diet. Children with poor OMD were unable to take solid food. Cases with seizures had significantly more feeding problems than those without seizures (p < 0.001). Parental awareness about feeding problems of their children was significantly low and they overestimated the nutritional status of their children. Anthropometric indicators were significantly lower than controls (p < 0.001). Spastic quadreparesis, hypotonia and poor feeding skill score had negative effect on nutritional status. Thirty per cent parents of cerebral palsy patients were pessimistic about the possibility of any improvement in feeding problems. After nutritional rehabilitation, good improvement was seen in feeding problems, OMD and nutritional status.

CONCLUSION

Nutritional status of children with cerebral palsy is poor due to summation of several factors. Therefore, they should be thoroughly assessed for feeding problems and nutritional status in order to start timely nutritional rehabilitation which can significantly improve their nutritional status and quality of life.

Malakoplakia of bone. A case report

BACKGROUND

Malakoplakia is an uncommon but distinctive granulomatous disease, characterized by an accumulation of histiocytes or Von Hansemann cells containing intracytoplasmic, laminated Michaelis-Gutmann bodies.

CASE

A 3-year-old male presented with a tender swelling in the left gluteal region that had been present for one month. Smears made from a fine needle aspirate showed large histiocytic cells containing intracytoplasmic, basophilic, laminated, targetoid Michaelis-Gutmann bodies resembling Von Hansemann cells in malakoplakia. Histopathology confirmed the diagnosis of malakoplakia of bone.

CONCLUSION

This case, histologically proven to be malakoplakia, demonstrated regression of the lesion following therapy. The characteristic cytologic features and presence of Von Hansemann cells may in themselves be diagnostic and obviate the need for biopsy.

Epilepsy in children with cerebral palsy

This article deals with the clinical profile of children with cerebral palsy and epilepsy, and to study the clinical predictors of response to anti-epileptic drugs. It is a prospective hospital based follow-up study. All the children who presented with cerebral palsy and history of seizure (other than neonatal seizures) over a period of one year were included. Seizures were classified according to ILAE classification. An EEG was obtained in all cases. Neuroimaging was done in all patients. Eighty-five patients were studied and followed for minimum of 12 months. Perinatal factors accounted for 62 (72.3%) cases. The motor deficits seen were quadriparesis (n = 64), hemiplegia (n = 12) and diplegia (n = 9). Associated mental retardation was seen in 80.9% patients with quadriparesis. A predominance of generalised epilepsy was seen with generalised tonic clonic seizures (32.9%) followed by mycolonic seizures (30.6%) and localisation related epilepsy (24.7%). The patients with quadriparesis were more likely to have generalised epilepsy and 52.4% of them required two or more anti-epileptic drugs for control of seizures. Patients with hemiplegia had localisation related epilepsy in 83.3% of cases. On multivariate analysis presence of quadriparesis, microcephaly, mental retardation and myoclonic epilepsy were found to predict the poor response to AED. Epilepsy in patients with cerebral palsy is of severe nature and difficult to control. Presence of quadriparesis, mental retardation and myoclonic seizures was predictive of poor response to anti- epileptic drugs.

CSF interleukin-1 beta, tumor necrosis factor-alpha and free radicals production in relation to clinical outcome in acute bacterial meningitis

OBJECTIVE

To study the relationship of CSF IL-1 beta and TNF-alpha with free radicals in acute bacterial meningitis (ABM) and to evaluate the clinical outcome in relation to the levels of these cytokines and free radicals in CSF.

DESIGN

Prospective with controls.

SETTING

Referral unit of a teaching hospital.

METHODS

32 children between 3m-12 yrs of age with proven acute bacterial meningitis comprised the study group. In the control group, 20 children with febrile seizures were included. CSF cytokines- Interleukin Ib and tumour necrosis factor a,free radicals O(2)-, H(2)O(2) and enzymes SOD and CPK were measured in all the children.

RESULTS

CSF IL-Ib and TNF-a concentration were markedly elevated in children with ABM (441.5 +/- 216.1 pg/ml, and 1009 +/- 529.1 pg/ml, respectively) as compared to controls (52.67 +/- 6.92 pg/ml, and 86.42 +/- 16.24 pg/ml) (p <0.0001). Free radicals viz., superoxide anion, hydrogen peroxide production and enzymes creatinine phosphokinase and superoxide dismutase were also significantly elevated in ABM as compared to controls. There was direct correlation of CSF cytokines with CSF cytology, protein and free radicals production in ABM. Patients who expired or had neurological sequelae had markedly elevated concentrations of cytokines and free radicals.

CONCLUSION

IL-I beta, TNF-alpha and free radicals are significantly elevated in CSF of patients with ABM. The concentration of these cytokines correlated well with free radical production, and with routinely measured CSF parameters and had a direct bearing on outcome of ABM

Evaluation of free radical status in CSF in childhood meningitis

The study was undertaken to investigate the possible role of free radicals and antioxidants in childhood meningitis. Sixty children suffering from acute bacterial meningitis (ABM) or tuberculous meningitis (TBM) according to their clinical and laboratory findings were enrolled in the study. The production of superoxide anions (O2.-), hydrogen peroxide (H2O2) and malondialdehyde (MDA) and the activities of xanthine oxidase (XO), superoxide dismutase (SOD) and glutathione peroxidase (GPx) were monitored in the study groups and findings compared with those in 20 age-matched controls. Children with ABM and TBM who died registered significant increases in the production of O2.- and MDA and in the activities of SOD and CPK compared with survivors. The rate of production of oxidants and MDA and the activities of XO, SOD and CPK were of a much higher magnitude in deceased ABM and in ABM survivors than in fatal TBM and survivors, respectively. The abnormalities in most of the biochemical parameters investigated were more marked in the children with ABM than in TBM and controls (p < 0.001). Increased MDA production and creatine phosphokinase (CPK) activity of different magnitudes in the two study groups suggest varying degrees of tissue damage. The alterations observed in 20 children who died (14 from ABM, 6 from TBM) revealed elevated levels of oxidants, antioxidants and toxicity markers, particularly in ABM patients, which suggests the possibility that natural or synthetic antioxidants might prevent disease progression and tissue damage in childhood meningitis.

Spontaneous rupture of choledochal cyst

Choledochal cyst in an uncommon congenital anomaly with classic presentation triad of abdominal pain, jaundice and right upper abdominal mass. Presentation due to biliary peritonitis following cyst rupture is extremely rare. One such case which was successfully treated is being reported.

An epidemic of dengue hemorrhagic fever and dengue shock syndrome in children in Delhi

OBJECTIVE

To study clinical profiles and outcome of children of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) during 1996 Delhi epidemic.

DESIGN

Retrospective study.

SETTING

Hospital based study.

METHODS

Children hospitalized from September to November 1996 were studied. All patients were diagnosed, managed and monitored according to a standard protocol.

RESULTS

One hundred and thirty four children (80 (60%) males and 54 (40%) females) were studied. Sixty (45%) children were less than 6 years of age of which 12 presented during infancy. There were 92 (67%) cases of DHF and 42 (33%) cases of DSS. Common symptoms were fever (93%), abdominal pain (49%) and vomiting (68%). The commonest hemorrhagic manifestation was hematemesis (39%) followed by epistaxis (36%) and skin bleeds (33%). Hepatomegaly was observed in 97 (72%) cases and splenomegaly in 25 (19%). Serology was positive (IgM hemaglutination antibody titres > 1: 160) for dengue type 2 in 31 (80%) of 39 patients in whom sera was tested during the acute phase of illness. Mortality was 6%. Hematocrit > 40% was observed in only 25 (18%) patients and hence the management protocol was based on clinical signs and symptoms and not on hematocrit.

CONCLUSIONS

A management protocol of DHF/DSS in which fluid therapy is not based on haematocrit values needs to be formulated.

Convulsions in tuberculous meningitis

One-hundred-and-thirty-six children below 12 years of age hospitalized with a diagnosis of tuberculous meningitis (TBM) have been investigated to identify the underlying cause of convulsions. One-hundred-and-one children (74 per cent) presented with seizures before and/or during hospitalization. Generalized tonic and clonic seizures (GTCS) were the commonest (58 per cent) type of seizures followed by focal seizures (FS) (38 per cent) and tonic spasms (TS) (4 per cent). EEG changes were more frequently observed in cases with FS and in those children with GTCS who presented after first week of hospitalization. EEG findings included generalized dysrythmia with paroxysmal slow activity (38 per cent), interhemispheric asymmetry (23 per cent), multiple spike and wave pattern (10 per cent), and focal spike and wave pattern (15 per cent). CT scan findings were more common in those children with GTCS and TS who presented with recurrent seizures and/or seizures manifesting after first week of hospitalization. FS presenting at any stage of the disease were associated with CT scan abnormalities. Abnormalities detected in CT scan of brain included meningeal enhancement (55 per cent), hydrocephalus (32 per cent), tuberculomas (27 per cent), and cerebral infarctions (13 per cent). Clinical presentation and investigations indicate that the probable cause of convulsions could be attributed to cerebral edema (57 per cent), syndrome of inappropriate secretion of antidiuretic hormone (35 per cent), hydrocephalus (32 per cent), tuberculoma (27 per cent), abnormal electric focus (25 per cent), and cerebral infarction (13 per cent).

Long-term anticonvulsant therapy in tuberculous meningitis--a four-year follow-up

A treatment protocol for long-term anticonvulsant therapy (ACT) in children with tuberculous meningitis (TBM) has been followed depending upon clinical characteristics and EEG/CT scan findings suggestive of the underlying cause of convulsions. Sixty-three children which included all patients with focal seizures (FS), and those with generalized tonic and clonic seizures (GTCS), and tonic spasms (TS) manifesting more than once during hospitalization and/or associated with abnormal CT/EEG findings were given long-term ACT (Group A). Thirty-eight cases with GTCS before hospitalization, and/or not more than one seizure during first week of hospitalization and without any specific CT/EEG abnormalities (Group B) and 35 cases without any seizures (Group C) did not receive any ACT. Forty-four patients who were finally discharged on long-term ACT, were given phenobarbitone (57 per cent), phenytoin (23 per cent), and a combination of phenobarbitone+phenytoin (14 per cent), and phenobarbitone+sodium valproate (7 per cent). Follow-up was continued for 4 years with 93, 84 and 81 per cent attendance, respectively, in groups A, B and C. Some of the side-effects observed with anti-convulsant drugs included gingival hypertrophy in 11 out of 16 cases (69 per cent) on phenytoin, hyperkinetic behaviour in 3 out of 34 (9 per cent) cases on phenobarbitone, hypocalcaemia in 3 out of 44 cases (7 per cent), hypophosphataemia in 10 out of 44 cases (23 per cent) and increase in alkaline phosphatase in 14 out of 44 cases (32 per cent). CT scan of brain repeated in six cases with multiple tuberculomas showed marked improvement. While 4 out of 41 (10 per cent) cases in group A had recurrence of seizures in the follow-up, only 2 out of 28 cases (7 per cent) in group B presented with GTCS during first 3 months after discharge which was successfully controlled by long-term ACT in later part of the follow-up. Two out of 21 cases (10 per cent) in group C also presented with myoclonic seizures 3 and 5 months after discharge. There was no statistically significant difference in the recurrence/appearance of seizures in the three groups (P = > 0.05). Our results suggest that long-term ACT is not indicated in all cases of TBM with seizures. In view of the known side-effects of anticonvulsant drugs and danger of interaction with antitubercular drugs, it is mandatory to clinically evaluate the patients, identify the cause and restrict long-term ACT only to those cases who are likely to have some abnormal focus resulting in secondary epilepsy. All the cases with FS and some of the patients with GTCS and TS may need to be started on ACT. However, a close follow-up is necessary in all particularly in those for whom ACT has been withheld.