Hereditary spherocytosis in a young female in Eastern Nepal: a case report

Introduction and importance

Hereditary spherocytosis (HS), a rare familial extravascular haemolytic disorder, typically follows an autosomal dominant inheritance pattern with variable expressivity. Despite its classical presentation of anaemia, jaundice, and splenomegaly, HS is infrequently reported among individuals of Asian descent, contributing to its under diagnosis or delayed diagnosis. The primary objective of this case report is to underscore the pivotal role of the osmotic fragility test in diagnosing HS, emphasizing the importance of accurate and timely identification for effective clinical management and improved patient outcomes.

Case presentation

The patient, without known prior co-morbidities, presented with recurrent abdominal distension, early satiety, and easy fatigability persisting for 6 years. Physical examination revealed icterus, gnathopathy, left hypochondrium tenderness, and palpable splenomegaly. The osmotic fragility of red cells was significantly elevated. The patient underwent optimization before splenectomy, receiving immunization against encapsulated bacteria. Packed red blood cell transfusions were administered to achieve optimal haemoglobin levels. Follow-up showed symptom relief, significantly improving the patient's quality of life.

Clinical discussion

This case underscores the challenges of delayed HS diagnosis, with the patient enduring symptoms for years before seeking appropriate medical attention. Overlooking the simplicity and cost-effectiveness of an osmotic fragility test prolonged the diagnostic journey, emphasizing the impact on overall well-being.

Conclusion

HS remains underdiagnosed, especially in our regions. The osmotic fragility test emerges as an economical diagnostic tool in resource-limited settings, particularly when spherocytosis is absent in the peripheral blood smears. Its inclusion in diagnostic protocols can expedite accurate HS identification and enhance patient outcomes.

Foix-Chavany-Marie syndrome due to unilateral opercular infarction-A case report

Key Clinical Message

Unilateral opercular lesions can result in Foix-Chavany-Marie syndrome, which is marked by acute anarthria, automatic-voluntary movement dissociation-most notably the absence of voluntary facial and tongue movements-and a generally better prognosis. Better patient outcomes are mostly dependent on early detection, management, and rehabilitation.

Abstract

Opercular syndrome is a rare neurological disorder caused by bilateral or unilateral lesions of the operculum that result in symptoms related to speech and swallowing difficulties with dissociation of automatic-voluntary movements in affected muscles. 78-year-old female presented with acute onset dysarthria, left sided facial deviation and difficulties in chewing, speaking, and swallowing. CT head revealed ischemic changes in left frontal operculum and was diagnosed with the unilateral opercular syndrome. The case was managed according to ischemic stroke protocol. The patient was discharged after 7 days of hospital stay, with MRS 2, NIHSS 9 and secondary stroke preventive measures. At 4 months follow-up, her MRS was 1, with mild dysarthria, that could be understood, and her swallowing improved to some amount of drooling while feeding. Early recognition, treatment, and rehabilitation play important role in prompt improvement of symptoms.

Discordant exencephaly in case of a twin delivery: a case report

Introduction and importance

Neural tube defect occurs as a result of failure of spontaneous closure of the neural tube between the third and fourth weeks of foetal life. Exencephaly is a rare malformation of the neural tube characterized by a large amount of protruding brain tissue in the absence of the calvarium.

Case presentation

The authors report a 29-year-old female, non-compliant to iron, calcium and folic acid tablets due to nauseating and itchy sensation after intake for 2 weeks, was admitted in ward Obstetrics ward in view of twin pregnancy. After proper counselling, she was advised for caesarean section, which revealed gross malformation in the form of cleft lip, cleft palate and exposed brain tissue covered by thin layer of membrane with incompletely formed cranial vault and multiple-haematoma and ulcerations in the exposed brain tissue suggestive of Exencephaly. The deformed baby survived for 2 days after birth while the other baby was grossly healthy.

Clinical discussion

Exencephaly is said to be the embryological precursor anomaly of anencephaly. Exencephaly is a type of cranial malformation that characteristically involves a large disorganized mass of brain tissue. The flat bones of calvaria are absent and the brain mass is left uncovered. This condition is incompatible with life.

Conclusion

Each and every pregnant lady must be advised to undergo ultrasonography in every trimester, especially second trimester scan (anomaly scan) to diagnose any gross congenital malformations. Each pregnant lady is suggested to take the necessary vitamins (like folic acid) to avoid any Neural tube defects.

Heart Failure: Past, Present, Future

There are 23 million people with heart failure in the world. Heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) need to be identified before advising treatment of heart failure. Coronary artery disease, dilated cardiomyopathy, valvular heart disease, and hypertension are the common causes of heart failure. Diuretics, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and neprilysin receptor blockers have been found to reduce mortality in heart failure. Natural compensatory mechanisms such as release of various vasoconstrictors and vasodilators in heart failure come into action to improve symptoms for some time. Ultimately compensatory mechanisms fail to work and patients reach end-stage heart failure. Mechanical circulatory support devices are recommended as a bridge treatment before heart transplant. The only option at this stage is heart transplant which is not feasible easily in the low and middle-income countries. Though end-stage heart failure treatment with inotropic drugs improves symptoms for a short period, various trials have shown increased mortality with their uses. On-going research on heart failure is expected to come out with more effective treatment of heart failure in future.

Unusual case of failure to thrive: Type III Bartter syndrome

Bartter syndrome Type III is a rare autosomal recessive disorder resulting from an inherited defect in the thick ascending limb of the loop of henle of the nephrons in kidney. The typical clinical manifestations in childhood are failure to thrive and recurrent episodes of vomiting. Typical laboratory findings which help in the diagnosis are hypokalemic metabolic alkalosis, hypomagnesemia and hypercalciuria. We report a case of Type III Bartter syndrome not responding to repeated conventional treatment of failure to thrive.

Mucopolysaccharidosis type II with inguinal hernia

Mucopolysaccharidosis Type II (Hunter syndrome) is a rare X-linked recessive storage disorder caused by deficiency of lysosomal enzyme iduronate-2-sulfatase, causing excess accumulation of glycosaminoglycans in the lysosomes resulting in cellular damage, organ failure and death. Severe subtype develops characteristic clinical features and cognitive impairment early and die in second decade of life. In a resource poor setting, we report a case of Hunter syndrome, severe subtype, based on global development delay, coarse facies, short stature, hepatosplenomegaly and dysostosis multiplex on X-ray with unusual large congenital inguinal hernia. The diagnosis was important because of risk of recurrence of hernia after repair.

Latex Agglutination Test for Early Detection of Causative Organism in Acute Bacterial Meningitis

Introduction: Acute bacterial meningitis is one of the leading causes of mortality and morbidity in children. Identification of the causative organism is crucial to its management and outcome. The objective of this study was to see the usefulness of latex agglutination test in the early diagnosis of acute bacterial meningitis. Materials and Methods: A hospital based prospective cross-sectional study was conducted at Kanti Children’s Hospital during December 2004 to August 2005. Cerebrospinal fluid from 150 consecutive clinically suspected cases of acute bacterial meningitis between the age group of 2 months to 14 years were analyzed. Bacterial culture and latex agglutination test was done on cerebrospinal fluid obtained from all 150 suspected cases of acute bacterial meningitis. Latex agglutination test was done using the BD DirectigenTM Meningitis Combo test kit (Becton, Dickinson and company, USA) for Streptococcus pneumoniae, group B Streptococcus, Escherichia coli, Neisseria meningitidis group A,C and Y/ W135, and Hemophilus influenzae type b. Data was analysed by using SPSS Version 11.5. Results: Of the 150 Cerebrospinal fluid samples analysed bacterial culture identified only 4 meningitis cases giving an isolation rate of 1.3% whereas latex agglutination test identified 29 cases giving an isolation rate of 19.3% from 150 samples. Streptococcus pneumoniae, Hemophilus influenzae type b and Group B Streptococcus were the most common causative organism. Conclusion: Latex agglutination test has a better yield, higher sensitivity, provides microbiological diagnosis earlier than the traditional cerebrospinal fluid culture and is easy to perform. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7047 J Nepal Paediatr Soc. 2013;33(1):34-38

Hospital-based study in children with rotavirus gastroenteritis and other enteropathogens

BACKGROUND

Rotavirus is the most common cause of life threatening gastroenteritis in infants and young children in the world. The objective of the study is to find out current trends and incidents of rotavirus, including other enteropathogens related with children diarrhoea and lastly identify the most common rotavirus serotypes that circulate in Nepal.

METHODS

A total of 1721 stool samples from less than 5 years of children were collected. Rotavirus in the stool samples were detected by Enzyme Immuno Assay (EIA) and strains were genotyped by Reverse-Transcription Polymerase Chain Reaction (RT-PCR). Bacteria and parasites were detected by following standard microbiological procedures.

RESULTS

In between 2009 to 2010, of the total 1721, the prevalence of rotavirus was 24.7%. Of them, 906 (52.6%) were collected in the year 2009 and 815(47.5%) in the year 2010. Rotavirus was frequently detected in inpatients (31.6%) than outpatient (16.8%). Rotavirus detection was higher in female (26.4%) than male (23.7%). The prevalence was seen higher in age group 0-23 months in both years. Among six different bacterial isolates, Escherichia coli was most frequently isolated (6.5%). Similarly, Giardia lamblia (1.3%) was most common among six different parasites detected. A total of rotavirus positive 425 stool samples were detected over 2 years (2009-230, and 2010-195), G12P6 was the predominant strain circulating in both (45% in 2009 and 28% in 2010) years. G9P6 emerged in 2010 (6%). There were significant numbers of mixed infections (14.0% in 2009 and 29.8% in 2010). Thirty five samples were partially typed and 15 were completely untyped over the two year period.

CONCLUSIONS

The study helps comprehend the prevalence of rotavirus along with other intestinal pathogens including bacteria and parasites. Major genotypes of rotavirus are also introduced in the study.

Children with First Episode of Fever with Seizure: Is Lumbar Puncture Necessary?

Fever with seizure, a common presentation with which a child may present to the emergency is mainly due to febrile seizure, but it may also be due to meningitis. This study was done to find out the incidence of meningitis and to find out whether lumbar puncture is necessary in different age groups of children presenting with first episode of fever with seizure. A prospective study was conducted in the emergency department of Kanti Children's Hospital. Children who presented with first episode of fever and seizure in the age group of 6 months to 5 years were included. Meningitis was diagnosed on the basis of either cytological and biochemical criteria or if a bacterial pathogen was isolated. Of the 175 children included, 17% were diagnosed to have meningitis. Cerebrospinal fluid was positive for a bacterial pathogen in 4.5% of the cases. In the age group of 6 months to 12 months, 30% of the children had meningitis as compared to 20 % and 5% in other age groups of 12- 18 months and above 18 months respectively. All children with culture proven bacterial meningitis were in the age group of 6-12 months and had no evidence of meningeal irritation. Signs of meningeal irritation had high specificity in diagnosing meningitis. Organisms grown were Haemophilus influenza in three cases, Streptococcus pneumoniae in two cases and Staphylococcus aureus in three cases. In conclusion, incidence of meningitis was found to be high in children presenting with first episode of fever and seizure. Lumbar puncture to rule out meningitis should especially be considered in children in the younger age group even without evidence of meningeal irritation.JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):109-112.

Children with first episode of fever with seizure: is lumbar puncture necessary?

Fever with seizure, a common presentation with which a child may present to the emergency is mainly due to febrile seizure, but it may also be due to meningitis. This study was done to find out the incidence of meningitis and to find out whether lumbar puncture is necessary in different age groups of children presenting with first episode of fever with seizure. A prospective study was conducted in the emergency department of Kanti Children's Hospital. Children who presented with first episode of fever and seizure in the age group of 6 months to 5 years were included. Meningitis was diagnosed on the basis of either cytological and biochemical criteria or if a bacterial pathogen was isolated. Of the 175 children included, 17% were diagnosed to have meningitis. Cerebrospinal fluid was positive for a bacterial pathogen in 4.5% of the cases. In the age group of 6 months to 12 months, 30% of the children had meningitis as compared to 20 % and 5% in other age groups of 12- 18 months and above 18 months respectively. All children with culture proven bacterial meningitis were in the age group of 6-12 months and had no evidence of meningeal irritation. Signs of meningeal irritation had high specificity in diagnosing meningitis. Organisms grown were Haemophilus influenza in three cases, Streptococcus pneumoniae in two cases and Staphylococcus aureus in three cases. In conclusion, incidence of meningitis was found to be high in children presenting with first episode of fever and seizure. Lumbar puncture to rule out meningitis should especially be considered in children in the younger age group even without evidence of meningeal irritation.

Relationship of Respiratory Symptoms and Signs with Hypoxemia in Infants Under 2 months of Age

Introduction: Hypoxemia is the most serious manifestation of any acute illness in infants less than two months and has shown to be a risk factor for mortality. Hypoxia can be detected using a pulse oxymeter or arterial blood gas analysis. However this facility is not available in most centers of Nepal. This study has correlated different signs and symptoms to predict hypoxia. Methodology: This hospital based prospective cross sectional study included 160 infant < 2 months, presenting to OPD or Emergency department with any acute illness A complete history was taken and weight, temperature, respiratory rate, heart rate and oxygen saturation was recorded. Presence or absence of nasal flaring, cyanosis, chest indrawing, head nodding, grunting, wheezing and crepitations on auscultation was recorded subsequently. Clinical signs of hypoxemic and non hypoxemic infants were compared and then analyzed. Results: 160 infants, 95 (59.4%) were male and 65 (40.6%) were female. Of the total population, 56(35%) were hypoxic where as 104(65%) were non hypoxic. Infants who presented with more than 3 symptoms, were lethargic, tachypneic or had chest indrawing had higher sensitivity(92.8%, 75%, 75% and 89.3 % respectively) where as infants with nasal flaring, grunting, head nodding or central cyanosis had high specificity (91.3%, 87.5%, 98% and 100%) respectively. Conclusion: Infants presenting with ≥ 3 symptoms, lethargy, respiratory rate of ≥ 70/minute or chest indrawing can be used for screening purpose to detect hypoxia and infants showing signs like grunting, head nodding, nasal flaring or central cyanosis should be considered hypoxic and treated with supplemental oxygen. Key words: Hypoxia; Respiratory rate; Chest indrawing; Nasal flaring DOI: http://dx.doi.org/10.3126/jnps.v31i3.5359 J Nep Paedtr Soc 2011;31(3): 202-208  

Pleural Effusion in Children: How often do we suspect Tubercular origin?

Introduction: Pleural effusion is a common problem in children; mostly due to common causes like pyogenic or tubercular infections. Different studies have showed that about 30%-60% of pleural effusion have resulted into formation of empyema. Method: This was an observational study done in children aged 3 months to 14 years with a diagnosis of pleural effusion admitted at Kanti Children’s Hospital, Maharajgunj from August 2009 to March 2010. The aim of the study was done to find out different modalities of treatment for the same and their outcome. A detailed clinical history and physical examination, was done in all children. Chest x-ray, laboratory reports and treatment were recorded and all patients followed up until death or discharge. Any change of management was also noted. Pleural effusion caused by nephritic syndrome or congestive cardiac failure were excluded from the study. Results: During the study period of eight months, 64 patients were admitted with the diagnosis of pleural effusion. Boys to girls ratio was 2:1. Right-sided pleural effusions were more common than left sided pleural effusions (53% vs. 37%). Most of patients improved with parental antibiotics along with chest tube drainage (62%). One in three patients (31%) received anti-tubercular drugs. Three patients (4.6%) were referred to surgeon for decortications and one patient (1.6%) died. Conclusion: Though chest tube drainage with parental antibiotics was the mainstay of treatment of pleural effusion, however one-third of patients also received anti-tubercular drugs. Key words: Pleural effusion; pyogenic; decortication; adenosine deaminase (ADA). DOI: 10.3126/jnps.v30i3.3914J Nep Paedtr Soc 2010;30(3):132-134Introduction: Pleural effusion is a common problem in children; mostly due to common causes like pyogenic or tubercular infections. Different studies have showed that about 30%-60% of pleural effusion have resulted into formation of empyema. Method: This was an observational study done in children aged 3 months to 14 years with a diagnosis of pleural effusion admitted at Kanti Children’s Hospital, Maharajgunj from August 2009 to March 2010. The aim of the study was done to find out different modalities of treatment for the same and their outcome. A detailed clinical history and physical examination, was done in all children. Chest x-ray, laboratory reports and treatment were recorded and all patients followed up until death or discharge. Any change of management was also noted. Pleural effusion caused by nephritic syndrome or congestive cardiac failure were excluded from the study. Results: During the study period of eight months, 64 patients were admitted with the diagnosis of pleural effusion. Boys to girls ratio was 2:1. Right-sided pleural effusions were more common than left sided pleural effusions (53% vs. 37%). Most of patients improved with parental antibiotics along with chest tube drainage (62%). One in three patients (31%) received anti-tubercular drugs. Three patients (4.6%) were referred to surgeon for decortications and one patient (1.6%) died. Conclusion: Though chest tube drainage with parental antibiotics was the mainstay of treatment of pleural effusion, however one-third of patients also received anti- tubercular drugs. Key words: Pleural effusion, pyogenic, decortication, adenosine deaminase (ADA). DOI: 10.3126/jnps.v30i3.3914J Nep Paedtr Soc 2010;30(3):132-134