Relationship between Clinical Profile, Severity and Outcome of Community Acquired Pneumonia with Hyponatremia in Children Aged 2-60 Months

Hyponatremia is the most common electrolyte imbalance seen in clinical practice and a common laboratory findings in children with community acquired pneumonia. This study aimed to find out relationship between clinical profile, severity and outcome of community acquired pneumonia with hyponatremia in children aged 2-60 months. This descriptive cross-sectional study was done in pediatrics department of Mymensingh Medical College Hospital, Bangladesh. Study period was 6 month from November 2016 to April 2017. Data were collected from 2 months to 60 months old children who fulfill the selection criteria. In this study sampling technique was purposive. Detailed history was taken, and meticulous examinations and relevant investigations were performed. 100 patients with community acquired pneumonia were enrolled, 34.0% patient had hyponatremia and 66.0% patients had no hyponatremia. Hyponatremia is more marked (45.5%) in severe pneumonia followed by moderate pneumonia (33.3%) and no hyponatremia found in mild pneumonia. Mean temperature, respiratory rate, heart rate, head nodding, nasal flaring, grunting, stridor, cyanosis, convulsion, feeding problem, Poor air entry were significantly higher in patient of pneumonia with hyponatremia when compared to patient of pneumonia without hyponatremia. Mean duration of symptoms and mean duration of hospital stay were also significantly higher in patient of pneumonia with hyponatremia. The mean serum sodium concentration was 132.18±1.51mmol/L in hyponatremic patients and 137.91±1.94mmol/L in normonatremic patients. Mean values of total leucocyte count, ESR, and C-reactive protein were significantly higher in patient of pneumonia with hyponatremia. Serum hemoglobin was significantly lower in hyponatremic patients than normonatremic patients. Maximum (55.9%) patients of community acquired pneumonia (CAP) with hyponatremia had patchy opacity, 26.5% had consolidation, 11.8% had interstitial opacity and 5.9% had pneumatocele. All the patients were treated with appropriate antibiotics and fluid and discharged after complete recovery without any complication. There was no death in the study population. From this study we can conclude that, hyponatremia is directly related with the severity of community acquired pneumonia (CAP). The intensity of clinical profile and investigation findings are also directly related with the severity of pneumonia.

Papillary Renal Cell Carcinoma with Massive Hemorrhage: An Autopsy Case Report

Introduction/Objective

Spontaneous renal hemorrhage is a rare complication of various kidney pathologies. It can be due to renal artery aneurysms, arteriovenous malformations, cystic renal diseases, renal calculus, coagulation disorders, as well as neoplastic lesions like angiomyolipoma and renal cell carcinoma (RCC). Individuals present with sudden flank or scapular pain, hypovolemic shock, termed as Wunderlich syndrome (WS). 30-35% cases of WS are from spontaneously ruptured RCC, commonly clear cell variant (70%) followed by papillary (10-15%) and chromophobe variant (4-6%). We present an autopsy case of a papillary variant RCC identified as a small kidney mass with a pathogenetic correlation behind the intractable bleeding.

Methods/Case Report

An 81-year-old Caucasian man with a history of atrial fibrillation, on long-term Xarelto treatment, was found to have a 1.2 cm incidental mass in the right kidney. He started experiencing right-sided scapular pain, then rapidly became hypotensive, drowsy. CT scan revealed a large right-sided perinephric and retroperitoneal hematoma (17.5 x 5.7 x 8.9 cm) extending in the pelvis. Despite receiving blood products, other supportive treatment, and successful angio-embolization, his condition worsened to acute kidney injury, bowel ischemia, and persistent lactic acidosis leading to death. On autopsy, bloody ascites, clots on mesenteric root insertion, and bulging in retroperitoneal spaces were seen. The perinephric spaces had organized clots. The bleeding originated from a 2.0 x 2.0 cm brown mass in the middle pole of the right kidney. There was a slit-like vessel at the interface of the kidney and the mass. Microscopic examination of the mass shows trabecula of abnormal cells with abundant eosinophilic cytoplasm in the hemorrhagic and necrotic background. These cells are positive for PAX8, CK7, CD10, dim positive for CAIX, and negative for CD117, which is consistent with renal cell carcinoma, papillary variant.

Results (if a Case Study enter NA)

NA.

Conclusion

Papillary RCC is much less vascular and less aggressive than clear cell RCC. However, necrosis or bleeding into renal vessels may occur. In this case, blood-leaks and accumulation in enclosed space followed by necrosis, fibrosis, and hyalinization cause neovascularization forming a negative spiral for re-bleeding. Anticoagulants can lead to profuse sustained bleeding from even very small size RCC.

Serum Electrolyte, Serum Calcium and Blood Sugar Status in Severe Acute Malnutrition and Their Relationship with Edema, Vomiting and Diarrhea

Severe acute malnutrition (SAM) is the most severe form of protein energy malnutrition (PEM). Few studies found serum electrolyte, serum calcium level changes as important factors of poor outcome. Hypoglycemia is already established as a risk factor for death in severe acute malnutrition. Edema, diarrhea and vomiting are commonly present in severe acute malnutrition which has impact on electrolyte balance and blood sugar level in healthy children. Their impact in severe acute malnutrition is not clearly established. This cross sectional descriptive study was conducted in Department of Pediatrics, MMCH from March 2018 to October 2019 to estimate serum electrolyte, serum calcium and random blood sugar level in severe acute malnutrition and their relationship with edema, vomiting and diarrhea. Forty-one (41) cases of SAM were enrolled in this study. Test samples were collected before starting the treatment. Case record form was used to collect information. Cases were divided into Group A and Group B based on the presence or absence of vomiting or diarrhea, respectively. Again, all cases were divided into Group C and Group D based on presence or absence of edema, respectively. Data were analyzed using IBM SPSS statistics version 23. Mean age was 9.71±10.4 months with 85.36% having age less than 1 year. Twenty-four (58.5%) were male and 17(41.5%) were female. Parents had low level of education with 48.8% mother and 51.2% father having primary education or no education. Higher number of serum electrolyte, serum calcium and blood sugar were found with hyperglycemia present in 29.3%, hypocalcemia in 22%, hypokalemia in 22% and hyponatremia in 19.5% cases. Hypokalemia was present more in SAM with vomiting or diarrhea (p=0.008). Other disturbances do not vary on presence or absence of edema and vomiting or diarrhea. Result of the present study shows hypokalemia is associated with SAM with vomiting/diarrhea. Hypocalcemia, hyperglycemia, hyponatremia and hypernatremia were also present in high number. These changes should be detected early and treated accordingly.

Efficacy of Probiotics in Treatment of Acute Rotavirus and Non Rotavirus Watery Diarrhoea in Children Admitted in Mymensingh Medical College Hospital

Probiotics are live microorganisms that, when administered in adequate amount helps in reducing the duration of diarrhoea. Objective of this double blind randomized controlled clinical trial was to assess the efficacy of probiotics in treatment of acute rotavirus & non rotavirus watery diarrhoea among children aged 6 months to 2 years admitted at diarrhoea corner of Paediatrics Department of Mymensingh Medical College Hospital from October 2017 to May 2019. It was a double blind randomized controlled clinical trial. Total 500 sample were divided into Group A=ORS, zinc plus placebo (n=250) and Group B=ORS, zinc plus probiotics (n=250). Both Group A and Group B consisted of children presented with rotavirus and non-rotavirus diarrhoea. Placebo or probiotics were given once daily for 5 days which was prepared and coded by department of Pharmacology. Stool specimens were taken to Microbiology Department of MMCH for rotavirus detection. Rotavirus was detected by Polyacrylamide gel electrophoresis (PAGE). Data was analyzed by computer using SPSS program version 23.0. A total of 500 children with acute watery diarrhoea were included. Among them 188 children were diagnosed as rotavirus positive. Among group A found 89 rotaviral and 161 non rotaviral diarrhoea patients. Among group B found 99 rotaviral and 151 non rotaviral diarrhoea patients. Baseline characteristics were similar in both groups. The duration of diarrhoea, hospital stay, and fever was significantly lesser in probiotics group when compared with control (p<0.001). But duration of vomiting did not reduce significantly in probiotics group. Frequency of stools reduced significantly in probiotics group.

Change of Hemoglobin Level among Exclusively Breastfed Term and Preterm Babies up to Six Months of Age

There is progressive increase of Hb levels is observed during course of intrauterine development of fetus but high concentrations found at birth. In preterm neonate normal Hb is characteristically deviated from term neonate. Breast milk is the only natural ideal food for both term and preterm babies from birth up to 6 months. Preterm milk was found to contain significantly higher concentrations nutrients particularly iron than term milk. Preterm human milk is more suitable for the premature infant than term human milk. As Hb concentration varies in term and preterm babies in different counties in different feeding practices. The purpose of this longitudinal descriptive study is to find out the pattern of changes in the Hb level among exclusively breastfed preterm and term infants during the first six months of life. This study was carried in the Neonatal Intensive Care Unit (NICU), Mymensingh Medical College Hospital (MMCH), Mymensingh from September 2016 to February 2018. One hundred fifty (150) neonates both term and preterm were included in this study and followed up to 6 months of age. After admission informed written consent was taken from parents, thorough history taking and clinical examination were done. Data were collected in a pre-designed case record form. All the babies of Group A provided 2mg/kg iron supplementation from 6 weeks for 2 months for universal recommendation. Hb level was measured of all exclusively breast feed babies at admission after birth then next follow-up at 6 weeks, 3 months and 6 months. All information regarding history, anthropometrics measurement, Hb level was recorded in structural questionnaire. Data analysis was done by SPSS version 20.0. Male were predominant in both groups. Most of the preterm (72.0%) and term babies (65.3%) were delivered by vaginal route. Mean Hb level was found significantly higher among preterm babies than term babies after birth were 16.55g/dl and 15.98g/dl respectively. Sharp fall of Hb concentration was observed after birth up to 6 weeks in both preterm and term babies but Hb level was found significantly lower in preterm in comparison to term babies (9.27gm/dl vs. 9.58gm/dl). In term babies, even after 6 weeks fall of Hb level continued to 3 months of age followed by gradual increase up to 6 months without iron supplementation. Hb level of in preterm babies gradually increased from 6 weeks up to 6 months with universal iron supplementation. Hb level fall sharply up to 6 weeks in both exclusively breastfed term and preterm babies but even after 6 weeks term babies experienced gradual fall of Hb levels up to 3 months. Hb level increases in exclusively breast-fed term babies without iron supplementation from 3 months of age. Hb level in exclusively breastfed preterm babies increase from 6 weeks onward might be effect of universal iron supplementation.

Efficacy of Carbetocin versus Oxytocin for the Prevention of Primary Post Partum Haemorrhage after Caesarean Section in Mymensingh Medical College Hospital, Bangladesh

Prevention of postpartum haemorrhage has been a major issue for its life threatening impact on maternal morbidity and mortality worldwide. Conventional continuous infusion of oxytocin has been employed for this condition. Apparently, in place of conventional oxytocics, application of carbetocin with longer half-life shows the same clinical benefits. This requires doing this present study. To compare the effectiveness of I/V bolus cabetocin and oxytocin infusion used for prevention of primary PPH after caesarean section. This descriptive cross-sectional comparative study was carried out in Department of Obstetrics and Gynaecology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from November 2015 to April 2016. A total of 100 pregnant women undergoing elective or emergency caesarean section were enrolled and divided into two groups on the basis of exclusion and inclusion criteria. Group I (n=50) received bolus of 100μgm IV carbetocin after delivery of the baby & Group II (n=50) received 20 IU of oxytocin in 1000ml of Hartman solution I/V in 8 hours continuous infusion after delivery of the baby. Baseline demographic and obstetric profile, indications for C/S, estimated blood loss, hemoglobin level, additional uterotonic agents, blood pressure and the diuresis were compared immediate postoperatively and 24 hours after operation. The patients were followed up for 24 hours after operation regarding outcomes variables. Baseline profiles were similar between two groups. Regarding haemodynamic effects, both drugs have a hypotensive effect but a greater reduction in blood pressure is found in oxytocin group. There was no significant difference in respect of estimated blood loss, blood transfusion, additional oxytocics and diuresis between two groups. It can be concluded that a single injection of carbetocin is as effective as continuous oxytocin infusion to prevent postpartum haemorrhage, with similar haemodynamic profile. So, carbetocin as a uterotonic agent is an acceptable alternative for prevention of postpartum haemorhage after caesarean section.

Risk Factors of Neonatal Sepsis in Neonatal Intensive Care Unit (NICU) of Mymensingh Medical College Hospital

Neonatal sepsis is associated with increased mortality and morbidity including prolonged hospital stay. Management of such cases is difficult, costly and need expert centers in many cases. Therefore, continued surveillance is mandatory to identify risk factors of neonatal sepsis which help optimizing its management. With the above idea, this cross-sectional descriptive study was conducted at the neonatal intensive care unit (NICU) in the department of Neonatology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2017 to December 2017 to observe the effects of maternal and neonatal risk factors in the development of neonatal sepsis and to determine risk factors of neonatal sepsis. Ninety four neonates (0-28 days) who were admitted in NICU with suspected sepsis were included in this study by purposive sampling technique. After admission written informed consent from parents or guardians obtained and histories were obtained including perinatal history and full physical examination of the infants were done and septic screening were sent. All the relevant information was recorded in a pre-designed questionnaire and all data were compiled, tabulated and then analyzed by SPSS version 21.0. Among 94 cases, 72.3% were preterm and 27.6% were term. There was male predominance and male/ female ratio was 1.9:1. Most (76.6%) of the patient admitted within 72 hours of birth. Most (83%) had low birth weight (<2500gm). Most came from rural area 61(64.9%) and also from low income family 59(62.8%). Premature onset of labour 40(42.6%), PROM >18 hours 36(38.3%), vaginal route of delivery 52(55.3%), instrumental resuscitation 15(16%), prelacteal feeding 11(11.7%), bottle feeding 15(16%) were the antenatal, natal and postnatal risk factors in this study. Also the neonatal factors, like prematurity, resuscitation at birth and low APGAR score carried the significant risk of developing sepsis. Poor feeding, lethargy, respiratory distress, jaundice were more common presenting symptoms. Tachycardia, tachypnea, chest indrawing, cyanosis hypothermia, hyperthermia and apnoea were found as more common presenting sign of sepsis in this study. Based on result it is concluded that prolonged rupture of membrane>18 hours, vaginal route of delivery, preterm birth, instrumental resuscitation, prelacteal feeding, bottle feeding were the major perinatal risk factors in this study.

Serum Iron Profile and Red Cell Indices in Children with Severe Acute Malnutrition in A Tertiary Level Hospital

This cross-sectional analytical study was conducted in the department of Paediatrics, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from March 2017 to August 2018 to assess the pattern of serum iron profile and red cell indices in children with severe acute malnutrition. Seventy children having severe acute malnutrition were compared with 70 age matched children those had normal growth. Age range of the studied children was 6 months to 59 completed months. Male was found predominant (54.3%) in both study group and comparison group. Mean serum iron, serum ferritin, serum total iron binding capacity and transferrin saturation in severely malnourished children were 45.3±19.3μg/dl, 26.5±20.0ng/ml, 246.3±47.5μg/dl and 16.4±2.0% respectively which were significantly lower than that of healthy children (p<0.05). Mean Hb level in children with severe acute malnutrition was found 8.3±1.6gm/dl which was also found significantly lower than that of normal children (p<0.05). Anaemia was found in all (100%) severely malnourished children compared to 25.7% of children in comparison group. Mean MCV, MCH and MCHC in children with severe acute malnutrition was found 71.7±13.5fl, 24.0±5.8pg and 31.4±4.0gm/dl respectively which were significantly lower than that of comparison group (p<0.05). Serum iron profile and red cell indices should be routinely done in severely malnourished children for early intervention and management of iron deficiency anaemia.

Neuro-developmental Outcome of High Risk Neonates in a Tertiary Level Hospital

An observational longitudinal study was conducted in the Department of Neonatology and Child Developmental Center, Mymensingh Medical College Hospital (MMCH), Bangladesh during the period of September 2016 to February 2018 to find out the neuro-developmental outcome of high risk neonates at the age of 6 months. Five hundred seventy six (576) high risk neonate who were admitted in the neonatology department in Mymensingh Medical College Hospital were selected as study population by Purposive sampling technique. After admission written informed consent from parents or guardians obtained and Data was collected in a pre-designed case record form. At 6th months of age total 400 baby were came to Child Development Centre and their motor, cognition and behavior development were assessed by Bayley Scale of Infant Development and severity of cognitive, motor and behavior impairment were graded. All data were compiled, tabulated and then analyzed by computer software SPSS version 20.00. Mean age was 7.2±3.3 days. Among studied newborns 18.1% were preterm and 81.9% were term. Most of the newborn were male (63.0%). Developmental delay was found in 81.5% and neuro-developmental outcome was found normal in only 18.5% newborns. Significant delayed motor performance was found in 52% newborns where 17% had mild delay. Significantly delayed mental performance was found in 57.0% and 28.52% had mildly delayed mental performance. Non-optimal behavior was found in 57.0% newborns and14% had questionable behavior. Very low birth weight, preterm very low birth weight, home delivery, perinatal asphyxia and neonatal seizure were found to have significant relation with developmental delay. Most of the high risk neonates develop developmental delay.

Antimicrobial Sensitivity Pattern in Neonatal Sepsis in Neonatal Intensive Care Unit of Mymensingh Medical College Hospital

This cross-sectional descriptive study was conducted at the neonatal intensive care unit (NICU) in the department of Neonatology, Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from July 2017 to December 2017 to determine antimicrobial sensitivity pattern in neonatal sepsis. Ninety four neonates (0-28 days) who were admitted in NICU with suspected sepsis were included in this study by purposive sampling technique. After admission written informed consent from parents or guardians obtained and then septic screening along with blood culture and antimicrobial sensitivity was done. All data were compiled, tabulated and then analyzed by SPSS version 21.0. Among 94 cases, 68(72.3%) were preterm and 26(23.4%) were term. There was male predominance and male female ratio was 1.9:1. Most of the patient admitted within 72 hours of birth. Most (84%) had low birth weight (<2500gm). Pre-mature onset of labour, pre-mature rupture of membrane >18 hours, vaginal route of delivery, instrumental resuscitation, pre-lacteal feeding, bottle feeding were the major perinatal risk factors in this study. Early onset sepsis (76.6%) was most prevalent in this study. Blood culture yielded positive growth in 20(21.3%) cases. Among them, Klebsiella was found in 7(35%). E. coli in 6(30%), Acinetobacter was in 3(15%), Staphylococcus aureus in 2(10%) cases. Pseudomonas and Enterobacter were found in rest 2(10%) of the cases. Gram negative bacteria were found in 18(90%) cases. Klebsiella was sensitive to Imipenem (85.7%), Colistin (85.7%) and Ciprofloxacin (77.5%). Sensitivity of E. coli was Imipenem (100%), Colistin (100%), Amikacin (66.7%), Ciprofloxacin (66.7%), Netilmicin (66.7%) and Gentamicin (50%). Acinatobecter had sensitivity to Netilmicin, Colistin, Imipenem (100%). Staphylococcus was 100% sensitive to Imipenem, Netilmicin and Vancomycin. Pseudomonas was found sensitive to Imipenem (100%), Amikacin (100%), Netilmicin (100%) and Colistin (100%). Enterobacter was found highly sensitive to Ciprofloxacin, Colistin and Imipenem. Almost all organisms were resistant to Ampicillin, Gentamicin, Cefotaxime and Ceftazidime. Based on result it is concluded that Klebsiella pneumoniae and Escherichia coli are the leading cause of neonatal sepsis in this study and most of them resistant to multiple antibiotics. Organisms found more sensitive to Imipenem, Colistin, Ciprofloxacin and Netilmicin.