Case Series of Ethylmalonic Encephalopathy from Southern India

Ethylmalonic encephalopathy is a rare neurometabolic disorder with central nervous system involvement and vasculopathy. It is presented in infancy with developmental delay, acrocyanosis, petechiae, chronic diarrhea, and early death. This was a retrospective study of confirmed cases of ethylmalonic aciduria from a tertiary care hospital over a period of 5 years from January 2015 to December 2020. Case details including analysis of clinical history, investigations, and outcomes are presented. Of six cases, male-to-female ratio was 4:2. Mean age of presentation was 35.5 months (range: 14-83 months). Consanguinity, global developmental delay, failure to thrive, skin rashes, microcephaly, hypotonia, and exaggerated deep tendon reflexes were observed in all cases. Chronic diarrhea was presented in five cases. The serum levels of C4 carnitine and urinary levels of ethylmalonic acid were increased in all cases. Magnetic resonance imaging (MRI) of the brain showed heterogenous bilateral symmetrical changes in the basal ganglia in five cases, and in one case, MRI could not be done. Genetic testing in two cases showed a homozygous variant in ETHE1 gene. Four children died, while the other two cases showed a decreased in recurrent encephalopathies and diarrhea after starting metronidazole. All children had global developmental delay, failure to thrive, skin rashes, central hypotonia, increased C4 carnitine levels in the serum, and increased ethylmalonic acid in the urine. Chronic diarrhea, acrocyanosis, and basal ganglia change in the MRI of the brain also give important clues for diagnosis. Metronidazole is useful in preventing recurrent episodes of encephalopathy.

Assessment of neurological sequelae and new-onset symptoms in the long-term follow-up of paediatric Guillain-Barre syndrome: A longitudinal study from India

BACKGROUND

Guillain-Barre syndrome (GBS) is the commonest cause of acute flaccid paralysis in children. There is a paucity of studies that assess the long-term outcome of paediatric GBS.

AIM

To assess the frequency of neurological sequelae and the new-onset symptoms in the long-term follow-up of paediatric GBS and to identify the risk factors associated with them.

METHODS

This longitudinal study involved 78 children with GBS treated between January 2015 and 2021. The parents of those children were contacted to visit the hospital for a detailed neurological examination and to look for new-onset symptoms after the initial treatment for GBS.

RESULTS

Of the 78 children, acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, and acute motor-sensory axonal neuropathy variants were observed in 30 (38.5%), 27 (34.6%) and 11 (14.1%) children, respectively. The median (interquartile range (IQR)) duration of follow-up was 3 (2, 4.5) years. The median (IQR) time to independent ambulation was 30 (13.5, 105) days. The neurological sequelae were found in 22 (28.2%) children. GBS disability score at admission (odds ratio (OR) = 4.6; 95% confidence interval (CI): 1.1-19.8; P = 0.04) and axonal variant of GBS (OR = 4.1; 95% CI: 1.5-20.8; P = 0.04) were found to be independent predictors of neurologic sequelae. A total of 28 children experienced new-onset symptoms after GBS, with frequent falls while running and fatigue being the predominant symptoms. Those children with demyelinating variant achieved independent ambulation earlier than the axonal group on survival analysis (log-rank P value = 0.04).

CONCLUSION

The presence of neurological sequelae and new-onset symptoms were found in 28.2 and 35% of the GBS children, respectively. High GBS disability score at admission and axonal variant of GBS were independent predictors of neurological sequelae. Knowledge about these would help in devising a plan for rehabilitation.

Etiology, Comorbidities, and Rate of Progression of Pediatric Chronic Kidney Disease: A Cohort Study

OBJECTIVES

To evaluate the etiology of pediatric chronic kidney disease (CKD), assess comorbidities, and identify rate of progression of CKD and its risk factors.

METHODS

Children aged 2-18 y with the Kidney Disease Improving Global Outcome (KDIGO) CKD stages 2-4 were enrolled. The etiology of CKD and its comorbidities were recorded. Kaplan-Meier survival curves were used to analyze the time to progression of CKD.

RESULTS

Of the 131 patients enrolled, CKD stages 2, 3a, 3b, and 4 constituted 62 (47.3%), 17 (13%), 26 (19.8%), and 26 (19.8%), respectively. At the last follow-up [at median (IQR) 24 (12, 30) mo], the number of children in CKD stages 2, 3a, 3b, 4 and 5 were 48 (36.6%), 16 (12.2%), 23 (17.6%), 28 (21.4%), and 16 (12.2%), respectively. Etiologies of CKD included obstructive uropathy [48 (36.6%)], chronic glomerular disease [19 (14.5%)], reflux nephropathy [14 (10.7%)] and cystic renal disease [11 (8.3%)]. Comorbidities during follow-up included CKD-MBD [87 (66.4%)], metabolic acidosis [95 (72.5%)], hypertension [88 (67.1%)], growth retardation [69 (52.6%)], and anemia [63 (48.1%)]. The number of patients with metabolic acidosis, hypertension, MBD and anemia in CKD stage 2 were 27 (56%), 26 (54.2%), 24 (50%), 15 (30%), respectively. The median (IQR) rate of decline in eGFR was 3.3 (2, 4.6) mL/min/1.73 m²/y. On multivariable analysis, proteinuria [hazard ratio 3.5 (95% CI 1.4, 8.8) p = 0.01] and hyperphosphatemia [hazard ratio 2.2 (95% CI 1.1, 4.3) p = 0.03] were significant predictors for progression of CKD.

CONCLUSIONS

Even the earlier stages of CKD had significant comorbidities. The median decline in eGFR was 3.3 mL/min/1.73 m²/y. Proteinuria and hyperphosphatemia were the risk factors for progression of CKD.

A rare cause of stroke in young children: minor head trauma associated with mineralising lenticulostriate angiopathy in three patients

Acute basal ganglia infarct following minor head trauma in association with mineralisation of lenticulostriate arteries is an increasingly recognised entity in childhood stroke. Three cases with a classical history and phenotypical features of mineralising angiopathy are described. Case 1 was a 2-year-old girl who presented with acute onset hemiparesis with a same-side upper motor neuron (UMN)-type facial palsy following minor head trauma. Case 2 was a 14-month-old boy who presented with a left side hemiparesis and a left UMN-type facial nerve palsy following a minor fall. Case 3 was an 8-month-old boy who, following a fall from his cot, had a sudden-onset hemiparesis on the right side and deviation of the angle of the mouth to the left. In brain computed tomography, all three cases demonstrated characteristic basal ganglia calcification of the mineralising angiopathy. Magnetic resonance imaging of the brain demonstrated features supportive of acute infarcts in the lentiform nucleus, caudate nucleus and putamen. Two of the patients had iron deficiency anaemia with haemoglobin of 7.0 g/dL and 7.8 g/dL, respectively. On follow-up, Case 1 had mild residual weakness and the other two made a complete recovery. None of the patients had a recurrence of stroke. Basal ganglia stroke with mineralising angiopathy should be considered in toddlers presenting with sudden-onset focal neurological deficits preceded by minor head trauma.Abbreviations: ADC: apparent diffusion coefficient; CT: computed tomography; DWI: diffusion-weighted imaging; Hb: haemoglobin; IDA: iron deficiency anaemia; MRI: magnetic resonance imaging; SLV: sonographic lenticulostriate vasculopathy; SWI: susceptibility weighted imaging; UMN: upper motor neuron.

Paradoxical upgrading reaction following treatment of disseminated tuberculosis-associated haemophagocytic lymphohistiocytosis in an infant without HIV: a case report and review of the literature

Tuberculosis-associated haemophagocytic lymphohistiocytosis (HLH) is rare in paediatrics and can be fatal if not recognised and treated on time. A 3-month-old infant with tuberculosis and HLH is described. He was successfully treated with anti-tuberculous therapy (ATT) which comprised isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin and dexamethasone (10 mg/m²/day). On Day 28 of therapy, he developed a paradoxical upgrading reaction to ATT for which he was again treated with (oral) corticosteroids for 4 weeks. He recovered successfully and is now completely well and asymptomatic. To the best of our knowledge, this is the first case of a child having a paradoxical upgrading reaction following treatment for TB-HLH.Abbreviations ATT: anti-tuberculous therapy; CB-NAAT: cartridge-based nucleic acid amplification test; CECT: contrast-enhanced computed tomography; HLH: haemophagocytic lymphohistiocytosis; NK: natural killer, PUR: paradoxical upgrading reaction; sHLH: secondary HLH.

Recurrent Skin Ulcers with Facial Dysmorphism and Sinopulmonary Infections: Thinking Beyond Hyper-IgE Syndrome

Prolidase deficiency (PD) is a rare inborn error of metabolism causing ulcers and other skin disorders, splenomegaly, developmental delay, and recurrent infections. Most of the literature is constituted of isolated case reports. It occurs due to the mutations in the prolidase gene (PEPD) that result in loss of prolidase activity. We reported here a child who had presented with features compatible with hyper-immunoglobulin E syndrome (HIES) like recurrent skin ulcers, recurrent infections, facial dysmorphism, retained primary teeth, and elevated levels of immunoglobulin E levels but with normal flow cytometric assays, which was later diagnosed as PD.

556 A Prospective Review of Risk Factors, Clinical Presentation and Management Outcomes for Chronic Pancreatitis

Aim

and objectives: To identify the risk factors, symptoms, and severity of Chronic pancreatitis (CP) on admission. To determine the relationship between pancreatic duct diameter and severity of pain and to assess extent of pain relief achieved by medical, endoscopic, and surgical intervention.

Method

75 patients with CP were admitted over 2 years. Data collected included etiology, symptoms, pain scores and CT/MRCP findings. Patients were classified into mild, moderate, and severe category according to Cambridge classification. Type and response to treatment was recorded. Statistical correlation of the pancreatic duct diameter and pain severity as well as the comparison of pain scores after medical, surgical and endoscopy was performed using Chi square test (p value <0.05)

Results

Median age of presentation of CP was 43 years. Male: female ratio was 3:1. Alcohol was the etiology in 66 %, 99% presented with pain, 65 % belonged to severe category. There was no statistical correlation between pain severity and duct diameter. Pain relief following medical management was 66 %, endoscopic - 73% and surgical - 83 %. There was no correlation between Cambridge classification and pain severity. There was no statistical difference between pain relief offered by either of the three modalities. However, there was a statistically significant correlation between duct diameter and type of intervention.

Conclusions

There is no consensus on the best treatment modality for CP as pain relief was equivalent amongst all the modalities. Therefore, the choice of intervention for patients suffering from chronic pancreatitis should be based on imaging characteristics and symptomology.

Neuronal Ceroid Lipofuscinosis: Clinical and Laboratory Profile in Children from Tertiary Care Centre in South India

Neuronal ceroid Lipofuscinosis (NCL), inherited disorders of lysosomal storage disorders, constitute the most common progressive encephalopathies with an incidence of 1.3 to 7 in 100,000 live births. We reported clinical, electrophysiological, radiological, ultrastructural, and molecular genetic features of NCL. This is a retrospective review, in a tertiary care center from January 2016 to December 2019. All children with clinical features of NCL and confirmed by pathogenic mutation and/or enzyme assay were included. A total of 60 children (male:female = 3:1) were studied. The commonest type was CLN 2 (41.7%). Neuroregression, seizures, and ataxia were present in all cases. Retinal arterial attenuation was seen in 38.33% cases. Magnetic resonance imaging (MRI) brain was abnormal in all patients, thalamic and caudate nucleus atrophy common in CLN1 (62%). Electroencephalography was abnormal in all children, but photoparoxysmal response at low intermittent photic stimulation frequencies was seen in four children of CLN2. Electron microscopy done in 43 children revealed abnormal inclusions in 20 (46.52%) children. Enzyme study showed low levels in 36 (78%) out of 46 cases. Of these, 21 had low tripeptidyl peptidase and 15 had low palmitoyl protein thioesterase levels. Molecular testing done in 26 cases showed pathogenic variant in 23 (88%) cases. Infantile onset with thalamic atrophy on MRI is common in CLN1 and refractory epilepsy, visual impairment and specific EEG changes are common in CLN2. These features are helpful in selecting enzyme assay for CLN1 versus CLN2. Electron microscopy helped in the diagnosis and genetic testing in subtyping. Thus, a multimode approach played a role in the diagnosis of NCL.

Studies on the synthesis, characterization, human serum albumin binding and biological activity of single chain surfactant-cobalt(III) complexes

The interaction of surfactant-cobalt(III) complexes [Co(bpy)(dien)TA](ClO4)3 · 3H2O (1) and [Co(dien)(phen)TA](ClO4)3 · 4H2O (2), where bpy = 2,2'-bipyridine, dien = diethylenetriamine, phen = 1,10-phenanthroline and TA = tetradecylamine with human serum albumin (HSA) under physiological conditions was analyzed using steady state, synchronous, 3D fluorescence, UV/visabsorption and circular dichroism spectroscopic techniques. The results show that these complexes cause the fluorescence quenching of HSA through a static mechanism. The binding constant (Kb ) and number of binding-sites (n) were obtained at different temperatures. The corresponding thermodynamic parameters (∆G°, ∆H° and ∆S°) and Ea were also obtained. According to Förster's non-radiation energy transfer theory, the binding distance (r) between the complexes and HSA were calculated. The results of synchronous and 3D fluorescence spectroscopy indicate that the binding process has changed considerably the polarity around the fluorophores, along with changes in the conformation of the protein. The antimicrobial and anticancer activities of the complexes were tested and the results show that the complexes have good activities against pathogenic microorganisms and cancer cells.

A comparative study on the binding of single and double chain surfactant-cobalt(III) complexes with bovine serum albumin

The comparative binding effect of single and double aliphatic chain containing surfactant-cobalt(III) complexes cis-[Co(bpy)2(DA)2](ClO4)3·2H2O (1), cis-[Co(bpy)2(DA)Cl](ClO4)2·2H2O (2), cis-[Co(phen)2(CA)2](ClO4)3·2H2O (3), and cis-[Co(phen)2(CA)Cl](ClO4)2·2H2O (4) with bovine serum albumin (BSA) under physiological condition was analyzed by steady state, time resolved fluorescence, synchronous, three-dimensional fluorescence, UV-Visible absorption and circular dichroism spectroscopic techniques. The results show that these complexes cause the fluorescence quenching of BSA through a static mechanism. The binding constants (Kb) and the number of binding sites were calculated and binding constant values are found in the range of 10(4)-10(5) M(-1). The results indicate that compared to single chain complex, double chain surfactant-cobalt(III) complex interacts strongly with BSA. Also the sign of thermodynamic parameters (ΔG°, ΔH°, and ΔS°) indicate that all the complexes interact with BSA through hydrophobic force. The binding distance (r) between complexes and BSA was calculated using Förster non-radiation energy transfer theory and found to be less than 7 nm. The results of synchronous, three dimensional fluorescence and circular dichroism spectroscopic methods indicate that the double chain surfactant-cobalt(III) complexes changed the conformation of the protein considerably than the respective single chain surfactant-cobalt(III) complexes. Antimicrobial studies of the complexes showed good activities against pathogenic microorganisms.

Methadone-exposed newborn infants: outcome after alterations to a service for mothers and infants

OBJECTIVE

To evaluate the impact of a shared care approach in clinical management with a drug liaison midwife (DLM) service for mothers and infants established in 1995-1996 in an inner city area and to address the problem of congenital abnormality and microcephaly with fetal drug exposure.

METHODS

Descriptive analysis of data in live births of women enrolled in a methadone maintenance programme in 1991-1994 (n = 78) and 1997-2001 (n = 98), including time spent in hospital, treatment for neonatal abstinence syndrome (NAS), admission to the neonatal medical unit (NMU) and follow-up for child health checks.

RESULTS

In 1997-2001 compared with 1991-1994, the mothers used more methadone in the last week of pregnancy (median 40.0 mg/day vs. 21.5 mg/day, P = 0.0006) and there were more preterm deliveries (36% vs. 21%, P = 0.03). The infants spent less time in hospital (median 5 days vs. 28 days, P < 0.0001), a smaller proportion had treatment for NAS (14% vs. 79%, P < 0.0001), and NMU admission was reduced (median 14 days vs. 26 days, P < 0.0003). Neonatal convulsions (P = 0.0001) and jaundice (P < 0.001) occurred less frequently, and more infants were breastfed (P = 0.001). One infant in each study group had a cleft palate and none had microcephaly. Child health checks for 18-24 months showed a favourable outcome in 1997-2001.

CONCLUSIONS

We altered antenatal care and modified neonatal management, subsequently infants spent less time in hospital and NMU admissions were reduced with less NAS treatment. Congenital abnormalities and microcephaly were not common and as regular child health checks were possible, the impact of the DLM service in shared management merits further investigation, for mother-infant bonding and developmental outcome.