Leucocytoclastic vasculitis in infant

Acute hemorrhagic edema of infancy is a laucocytoclastic vasculitis characterized by a triad of fever, large purpuric skin lesions and edema. The presentation is often dramatic. The manifestations are often misinterpreted as a septicemic illness. We report the occurrence of this syndrome in a 1 1/2-year-old-child, highlighting some of the diagnostic and therapeutic problems encountered.

Vitamin K deficiency in diarrhoea

The study was undertaken to determine the frequency of occurrence of vitamin K deficiency in infants with diarrhoeal illness. Infants were categorized into four groups as follows: A(acute diarrhoea), B(protracted diarrhoea) C(intractable diarrhoea) and D(healthy controls). Screening coagulation tests, PT and PTTK along with estimation of functional activity and total antigenic levels of prothrombin were performed. The ratio of functional to total prothrombin was calculated. PT was prolonged in 30% (24/75) of all infants with diarrhoea as compared to controls where the abnormality was observed in 11.1% infants (2/18). The ratio of functional to total prothrombin was significantly lower in infants with diarrhoea, the mean +/- SD values being 0.65 +/- 0.41 vs 1.1 +/- 0.26. This difference was statistically highly significant (p < 0.001). Low ratio was observed in 57.3% (43/75) infants with diarrhoea. Thus functional to total prothrombin ratio identified approximately twice as many diarrhoeal infants with vitamin K deficiency as compared to PT alone. There was no significant correlation with breast feeding as the only mode of diet, or the prior administration of antibiotics in infants with diarrhoea. The inherent malabsorptive state in diarrhoea may be a major contributory factor.

Transfusion reactions

Blood components are indicated in a wide variety of disease states. Although most transfusion therapies are administered uneventfully, there are a number of potential adverse transfusion reactions, some of which can assume serious dimensions. These reactions could occur during or even days after a transfusion. A brief description of the adverse effects of transfusion therapy has been outlined in this review. The etiopathogenesis, recognition and treatment of the adverse transfusion reactions have been highlighted. It is imperative that each transfusion of blood components has components be monitored carefully. Prompt recognition of an adverse event and early institution of remedial measures would help in decreasing transfusion related morbidity and mortality.

Immune functions in splenectomized thalassaemic children

A prospective study to assess the immune functions in splenectomized thalassaemic children. Children were those registered in the Thalassemia major. There were 10 splenectomized children (Group 1), 10 non-splenectomized children and 6 age-matched control (Group 3). All children were shown to be HIV seronegative. The mean concentrations of serum IgG and IgA were higher in Group 1 as compared to Groups 2 and 3 but the differences were not statistically significant. Nitroblue tetrazolium (NBT) dye reduction by stimulated polymorphonuclear leukocytes was normal in both study and control groups and the differences were not statistically significant. However, NBT reduction in the unstimulated state was much higher in Group 2 as compared to Groups 1 and 3. Phytohaemagglutinin induced mitogen proliferation was normal in all 3 groups. Children in Group 1 not only had a significantly higher absolute lymphocyte count but also had a lower CD4/CD8 ratio as compared to Groups 2 and 3. Splenectomy does appear to alter the immune status of thalassemic children but the exact mechanism by which this occurrence is not clear.

Hashimoto's thyroiditis: countrywide screening of goitrous healthy young girls in postiodization phase in India

Countrywide salt iodization, to prevent nutritional iodine deficiency, has been achieved in India recently. The current study was planned to evaluate the prevalence of goiter and thyroid autoimmunity and assess thyroid functional status in a cohort of 6283 healthy schoolgirls from different parts of the country in the postiodization phase. Goitrous girls (n = 1810; 28% of subjects) were investigated for serum T4 and TSH, antithyroid microsomal antibody (TMA) and antithyroglobulin antibody (TGA), urinary iodine excretion, and cytomorphology by fine-needle aspiration cytology (FNAC). FNAC carried out successfully in 764 goitrous girls revealed juvenile autoimmune thyroiditis (JAT) in 58 (7.5%), which included Hashimoto's thyroiditis in 43 (5.6%) and focal lymphocytic thyroiditis in 15 (1.9%). TMA and TGA estimated in 722 goitrous girls detected significantly positive titers of TMA (> or =1:1600) and TGA (> or =1:160) in 52 (7.2%) and 4 (0.55%) girls, respectively. Only 29 (67.4%) girls with Hashimoto's thyroiditis were TMA positive. In patients with FNAC-proven JAT, overt clinical and biochemical hypothyroidism was seen in three (6.5%) and subclinical hypothyroidism in seven (15%). Subclinical hyperthyroidism was detected in 5.1% cases of JAT, and none had overt hyperthyroidism. No definite correlation was seen between urinary iodine excretion and thyroid autoimmunity.

Prevalence and significance of low 25-hydroxyvitamin D concentrations in healthy subjects in Delhi

BACKGROUND

Despite abundant sunlight, rickets and osteomalacia are prevalent in South Asian countries. The cause of this paradox is not clear.

OBJECTIVE

The objective was to assess 25-hydroxyvitamin D [25(OH)D] status and its functional significance in apparently healthy subjects residing in Delhi, a city in the northern part of India.

DESIGN

Serum 25(OH)D, total calcium, inorganic phosphate, alkaline phosphatase, intact parathyroid hormone, and 1, 25-dihydroxyvitamin D [1,25(OH)(2)D] were measured in groups of healthy subjects who differed with respect to variables relevant to vitamin D and bone mineral metabolic status, such as direct sunlight exposure, season of measurement, skin pigmentation, dietary calcium and phytate contents, and altered physiologic states such as pregnancy and neonatal age.

RESULTS

All groups except one with maximum direct sunlight exposure had subnormal concentrations of 25(OH)D. The 25(OH)D-deficient groups tended to have an imbalance in bone mineral metabolic homeostasis when exposed to winter weather and low dietary calcium and high dietary phytate, with significantly low calcium and elevated intact parathyroid hormone concentrations, chemical osteomalacia, or both. Increased values of 1,25(OH)(2)D during pregnancy did not help correct the imbalance in bone mineral metabolic homeostasis.

CONCLUSION

Healthy subjects with low 25(OH)D concentrations are at risk of bone mineral metabolic imbalance when exposed to factors that strain bone mineral homeostasis.

Protein energey malnutrition and skeletal muscle wasting in childhood acute lymphoblastic lukemia

OBJECTIVE

To determine the nutritional status and the extent of skeletal muscle wasting in children with acute lymphoblastic leukemia (ALL) at the time of diagnosis and after induction chemotherapy.

DESIGN

Prospective observational study.

SETTING

Tertiary care teaching hospital.

METHODS

25 new cases of ALL underwent somatometric measurements and ultrasonographic evaluation of skeletal muscle and subcutaneous fat at initial presentation and after completion of induction therapy.

RESULTS

Malnutrition (weight for age < 80percnt) was evident in 13 cases (52percnt), but cumulative incidence of malnutrition (weight for age < 80percnt, weight for height < 90percnt, height for age < 95percnt, skin fold thickness < 5th centile, midarm muscle circumference < 5th centile) was 88percnt. Nine children lost weight during induction (range: 0.2 to 5.8 kg; means +/- SD: 1.9 plusmn 1.8 kg). All these cases had a complicated course during induction chemotherapy. Fourteen children (56percnt) had skeletal muscle wasting during induction chemotherapy. All those children who had lost weight also had skeletal muscle wasting. Subcutaneous fat, in contrast increased in 24 cases (96percnt).

CONCLUSION

Malnutrition exists in a significant proportion of children with ALL. If induction chemotherapy is complicated, children lose significant weight and have significant muscle wasting. Increase in subcutaneous fat occurs in almost all children, which is probably a consequence of therapy with oral steroids

Long term survival in a young girl with renal cell carcinoma

A young girl with an uncommon renal tumour is the subject of this communication. A diagnosis of renal cell carcinoma was established post-operatively. Combined modality treatment including chemotherapy and radiotherapy has helped achieve a disease free survival of nearly 5 years.

Retro-peritoneal cystic lymphangioma in association with fetal hydantoin syndrome

Antiepileptic drugs are known to be teratogenic. Use of phenytoin during pregnancy can cause various congenital malformations leading to 'fetal hydantoin syndrome'. One such case reported is unique in the sense that it occurred with retroperitoneal cystic lymphangioma, itself a rare condition. Such an association is not described elsewhere.

Facial nerve palsy in an infant with hemophilia A

A 5-month-old infant with hitherto undiagnosed hemophilia A, who developed a unilateral lower motor neurone type of facial palsy, is described. A high-resolution CT scan confirmed the nerve palsy to be a consequence of a hemotympanum. The patient recovered completely in 7-10 days after therapy with factor VIII concentrate.

Clinical, biochemical and cytomorphological observations in juvenile chronic lymphocytic thyroiditis

OBJECTIVE

To determine the clinical, biochemical, ultrasonological and cytomorphological features in goitrous juvenile chronic lymphocytic thyroiditis(CLT).

SETTING

Tertiary referral center for thyroid disorders.

SUBJECTS

A total of 455 children were evaluated for goiter. Of these 122 children had features of CLT in FNAC and were further studied.

METHODS

All subjects were subjected to detailed clinical examination. The thyroid functional status was assessed by estimation of serum concentration of thyroid hormones (thyroxine and triiodothyronine) and thyrotropin (TSH). In addition the antithyroid antibody titers were measured. Ultrasonological and cytomorphological characteristics in these patients were also evaluated.

RESULTS

The mean age at presentation was 12.5 years (SD 3.93). The male: female ratio was 1:7.7. Thyroid functional status as assessed by serum thyroxine and thyrotropin levels revealed, euthyroidism in 67 (54.9%), hypothyroidism in 30 (24.6%), subclinical hypothyroidism in 22 (18%) and hyperthyroidism in 3 (2.5%). Thyroid antimicrosomal antibodies were detected in significant titers in 90 (73.8%) and antithyroglobulin was positive in 71 (58.2%). The positivity of the antimicrosomal and antithyroglobulin antibodies were much higher in subjects with hypothyroidism and was detected in 86.5% and 69.2%, respectively. The mean urinary iodine excretion was 74.1 micrograms/g of creatinine (SD 31.4) indicating mild iodine deficiency. Fine needle aspiration cytoloty (FNAC) revealed features of chronic lymphocytic thyroiditis. Hurthle cell changes was seen in only 12% of the cases. The epithelium was more often hyperplastic and vacuolation of the cytoplasm and peripheral vacuolations were seen frequently. Giant cells and epithelioid cells were seen in many cases.

CONCLUSIONS

In any child presenting with firm goiter, a diagnosis of CLT should be excluded. Many subjects with juvenile CLT have biochemical evidence of hypothyroidism but only few symptoms or clinical features.

Prevalence of chronic lymphocytic thyroiditis in adolescent girls

Chronic lymphocytic thyroiditis (CLT) is the most common cause of thyroid enlargement in children and adolescents in iodine sufficient areas. The prevalence and pattern of CLT in adolescent girls in iodine deficient regions supplemented with iodine is as yet not known. We therefore, carried out clinical examination for the presence of goitre in 330 healthy girls from Delhi in the age group of 16-20 years and those with goitre were further subjected to detailed biochemical (T3, T4, TSH), immunological (ATg ad ATm) and cytomorphological examination. The prevalence of goitre was found to be 40%. Fine needle aspiration cytology (FNAC) carried out in 94 girls with goitre (74%) revealed finding consistent with CLT in 13 (13.8%), colloid goitre with non-specific thyroiditis in 7 (7.4%), colloid goitre in 71 (75.5%) and specimen was inadequate in 3 (3.2%) girls. Thyroid antibodies were estimated in 114 of the goitrous subjects and both ATg and ATm were positive in 11 (9.6%) cases. Overall prevalence of CLT in this population was 4.0% and among those with goitre was 13.8%. When thyroid antibodies were also considered as an indicator of thyroiditis, prevalence rose to 14.4% among goitrous girls. Thyroid function tests were found to be within normal limits in all goitrous girls. This study for the first time reveals a high prevalence of CLT in goitrous adolescent girls from iodine supplemented region and underscores the need to study the prevalence of CLT in different age and sex groups from different regions of the country.

Blue rubber bleb nevus syndrome: a cause for recurrent episodic severe anemia

A 7-year-old boy had several episodes of severe anemia, requiring hospitalizations and blood transfusions. Skin hemangiomas characteristic of blue rubber bleb nevus syndrome were present since infancy, but were not recognized as being indicative of simultaneous existence of bowel hemangiomas, resulting in a delay of several years before an accurate diagnosis could be made.