Dengue fever triggering Kawasaki disease

Background

Several bacterial and viral infections are listed as triggering factors for Kawasaki disease; association with dengue fever is rare.

Case characteristics

A 5-year-old girl who presented with fever that was confirmed to be dengue fever, and subsequently improved, except that the fever persisted. She fulfilled diagnostic criteria for Kawasaki disease on day 7 of fever.

Outcome

Child responded satisfactorily to intravenous immunoglobulin administration.

Message

Kawasaki disease should be kept as one of the probabilities in a case of dengue if fever persists beyond the expected duration.

     

Accuracy of tactile assessment of fever in children by caregivers: A systematic review and meta-analysis

Context

Fever is the most common complaint in the pediatric and emergency departments. Caregivers prefer to detect fever in their children by tactile assessment.

Objective

To summarize the evidence on the accuracy of caregivers’ tactile assessment for detecting fever in children.

Evidence-acquisition

We performed a literature search of Cochrane Library, PubMed, Web of Knowledge, EMBASE (ovid), EBSCO and Google Scholar, without restriction of publication date, to identify English articles assessing caregivers’ ability of detecting fever in children by tactile assessment. Quality assessment was based on the 2011 Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. Pooled estimates of sensitivity and specificity were calculated with use of bivariate model and summary receiver operation characteristics plots for meta-analysis.

Results

11 articles were included in our analysis. The summary estimates for tactile assessment as a diagnostic tool revealed a sensitivity of 87.5% (95% CI 79.3% to 92.8%) and specificity of 54.6% (95% CI 38.5% to 69.9%). The pooled positive likelihood ratio was 1.93 (95% CI 1.39 to 2.67) and negative likelihood ratio was 0.23 (95% CI 0.15 to 0.36). Area under curve was 0.82 (95% CI 0.7 to 0.85). The pooled diagnostic odds ratio was 8.46 (95% CI 4.54 to 15.76).

Conclusion

Tactile assessment of fever in children by palpation has moderate diagnostic value. Caregivers’ assessment as “no fever” by touch is quite accurate in ruling out fever, while assessment as “fever” can be considered but needs confirmation

     

Maturation of pelvic ossification centers on computed tomography in normal children

Background

The pelvis is composed of three paired primary ossification centers: the pubis, the ischium and the ilium. During maturation, multiple secondary ossification centers can be seen in the synchondroses between these bones and in the pelvic apophyses. The fragmented appearance of these centers can be confused with pathology.

Objective

To examine development of pelvic ossification centers by CT and determine normal appearance throughout childhood.

Materials and methods

Three pediatric radiologists reviewed 325 pelvic CT scans in children and young adults 5–18 years old and graded 6 pelvic ossification centers to evaluate maturational changes in critical structures.

Results

Rate and progression of ossification and age at complete fusion vary with gender at the different ossification centers in the growing pelvis.

Conclusion

Knowledge of the normal CT appearance of ossification centers throughout childhood is important to differentiate the normal appearance from pathology.

     

Hepatic visceral larva migrans causing hepatic venous thrombosis and prolonged fever

Background

Visceral larva migrans may present with systemic symptoms such as fever, hepatomegaly, pneumonitis or ocular symptoms.

Case characteristics

A 7-year-old girl with fever, pain abdomen and persistent eosinophilia. Imaging and histopathology were suggestive of visceral larva migrans.

Message

The diagnosis of visceral larva migrans is often delayed since similar symptoms of fever, hepatomegaly and peripheral eosinophilia occur in more common and identifiable tropical parasitic and non-parasitic diseases.

     

Clinical profile of scrub typhus in children and its association with hemophagocytic lymphohistiocytosis

Objective

To study the clinical profile of children with scrub typhus and its association with hemophagocytic lymphohistiocytosis.

Methods

Children presenting with unexplained fever and multi-systemic involvement between May to December 2011 were tested for scrub typhus using IgM ELISA kits. Occurrence of Hemophagocytic lymphohistiocytosis in IgM positive cases of scrub typhus was studied.

Results

Of the 35 children with unexplained fever and multi-systemic involvement, 15 children (9 boys) tested positive for scrub typhus. Thrombocytopenia, hypoalbuminemia and raised hepatic transaminases were observed in all children. Out of seven children evaluated for hemophagocytic lymphohistiocytosis. 3 met the criteria for hemophagocytosis. Two children (one with hemophagocytic lymphohistiocytosis) died.

Conclusions

Scrub typhus is a common cause of unexplained fever in children in northern India. Hemophagocytic lymphohistiocytosis can occasionally complicate scrub typhus in children.

     

Carbapenem-resistant <Emphasis Type="Italic">Enterobacteriaceae</Emphasis> in pediatric bloodstream infections in rural Southern India

Objective

To measure the frequency of antimicrobial resistance in pediatric blood culture isolates of Escherichia coli and Klebsiella spp. with focus on carbapenem resistance.

Methods

Over a period of three years, pediatric blood culture isolates were tested for antimicrobial susceptibility, including molecular investigations for carbapenem resistance.

Results

Amikacin, carbapenems, colistin and tigecycline had an antimicrobial efficacy of >70% (n=140). 7 of the 15 randomly selected isolates were positive for carbapenemase gene; among them, five were New Delhi Metallo β-lactamase (NDM).

Conclusion

There was a high prevalence of Klebsiella spp. in pediatric bacteremia and dissemination of NDMmediated carbapenem resistance in pediatric wards.

     

Obstructive uropathy and severe acute kidney injury from renal calculi due to adenine phosphoribosyltransferase deficiency

Background

Adenine phosphoribosyltransferase (APRT) deficiency is an uncommon genetic cause of chronic kidney disease due to crystalline nephropathy.

Methods

A case of a Chinese boy with APRT deficiency presenting with severe acute kidney injury secondary to obstructive uropathy from multiple renal calculi was reviewed.

Results

The patient underwent staged removal of the calculi. Infrared spectrometry of the renal calculi showed 2,8-dihydroxyadenine. APRT deficiency was confirmed with abolished APRT enzyme activity in red blood cells. He was started on allopurinol and low purine diet with complete resolution of the residual calculi.

Conclusion

APRT deficiency should be considered in patients with multiple radiolucent renal calculi.

     

Bilateral pleural effusion complicating umbilical venous catheterization

Abstract

Umbilical venous lines are sometimes complicated with pleural and or pericardial effusion, often due to line migration.

Case Characteristics

Bilateral chylous pleural effusion without pericardial effusion in a 28 weeks, extremely low birth infant who was on total parenteral nutrition.

Observations/Investigations

Investigations including chest x ray and 2D echocardiogram showed bilateral chylous pleural effusions but appropriate tip position of the umbilical venous line.

Outcome

Removal of the umbilical venous line and cessation of total parenteral nutrition resulted in complete resolution of the pleural effusion.

Message

In any newborn with central venous catheter in situ, acute deteriorations specially, those related to pleural and pericardial effusions should alert the clinicians to remove the catheter and should not be misguided by apparently appearing normal correct catheter position by x-ray or 2D echocardiogram.

     

Incidence and Risk Factors for Hypertension During Childhood Acute Lymphoblastic Leukemia Therapy

Objective

To determine the incidence of hypertension among children during the induction and re-induction phases of acute lymphoblastic leukemia (ALL) therapy and association with possible risk factors.

Methods

A retrospective analysis of 208 consecutive pediatric (age <18 y) ALL patients, treated per BFM-95 protocol between January 2009 and December 2013. Data were analyzed to determine the incidence of hypertension and risk factors for its development.

Results

Incidence of hypertension requiring antihypertensive medication, was 29% (61/208) during induction and 17% (33/198) during re-induction (P=0.003). Median (range) age of patients developing hypertension was 4 y (4 mo to 8 y). Age <10 y and presence of constipation were independently predictive of hypertension by multivariate analysis.

Conclusion

The present study reports a high incidence of hypertension among children undergoing ALL induction therapy.

     

Impact of system factors and modifiable ICU interventions on the outcome of cardio-pulmonary resuscitation in PICU

Objectives

To assess the impact of system factors and modifiable interventions on outcome of cardiac arrest in a pediatric intensive care unit.

Design

Retrospective medical record review.

Setting

Pediatric intensive care unit of a hospital in China.

Participants

Children (age<14 yrs) who had cardiac arrest within our PICU over a period of two years.

Results

Sixty-one of the 94 cardiac arrest events were successfully resuscitated. There was no significant association between personal and unit factors with immediate outcomes in our unit. The rate of unsuccessful resuscitation in sedated patients and those without sedation was 26% and 50%, respectively. Unsuccessful resuscitation occurred in 19% of patients who were on positive pressure ventilation as compared with 74% for those without positive pressure ventilation. Arrests which had resuscitation attempts that lasted more than 30 min had 135-fold higher odds of unsuccessful outcome. 78% of patients who received base supplement at the time of arrest had unsuccessful resuscitation compared with 21% for those without base supplement.

Conclusions

Our data shows no impact of system factors on the outcome of cardio-pulmonary resuscitation in our PICU. Prearrest sedation in pediatric critical ill patients might be beneficial to the outcome of cardiac arrests.

     

Laser Treatment of a Tracheal Inflammatory Myofibroblastic Tumor

Background

Inflammatory myofibroblastic tumors of the trachea are rare childhood quasi-neoplastic lesions.

Case characteristics

7-year-old boy with recurrent episodes of cough, breathing difficulty and wheeze, initially treated as asthma.

Intervention

CT chest and flexible bronchoscopy revealed a mass lesion of the trachea, which was excised by diode laser through the ventilating bronchoscope. Histopathology confirmed it as the inflammatory myofibroblastic tumor.

Message

Use of laser ensured complete endotracheal excision of the tumor.

     

Ultrasound-guided core needle biopsy in the diagnosis of neuroblastic tumors in children: a retrospective study on 83 cases

Aim

Ultrasound-guided biopsy technique with the large-core needle has widely been applied in the diagnosis of adult abdominopelvic cavity, thyroid, and neck tumors. There are few reports on ultrasound-guided biopsy using large-core needle in pediatric abdominopelvic cavity tumors. This study was to evaluate the ultrasound features and the diagnostic value of ultrasound-guided core needle biopsy for pediatric neuroblastic tumors.

Methods

The pediatric patients with neuroblastic tumor that underwent ultrasound examination and ultrasound-guided core needle biopsy from January 2009 to November 2015 were reviewed. A minimum of two cores in each case was obtained. The biopsy results were confirmed by subsequent surgical histopathology. The ultrasound features and the diagnostic accuracy of ultrasound-guided core needle biopsy were evaluated.

Results

Eighty-three patients were enrolled into the study. Conventional ultrasound examination showed irregular hypoechoic or mixed echo masses and calcification and liquefied necrosis. The diagnostic accuracy of ultrasound-guided core needle biopsy was 96.4% (80/83). Three cases were misdiagnosed because of inadequate tissue sample. No serious complication, infection, or needle track seeding occurred.

Conclusions

Ultrasound-guided core needle biopsy seems to be an accurate, minimally invasive, and safe diagnostic method of pediatric neuroblastic tumor.

     

Study of Family Clustering and <Emphasis Type="Italic">PNPLA3</Emphasis> Gene Polymorphism in Pediatric Non Alcoholic Fatty Liver Disease

Objectives

To find association of pediatric NAFLD with metabolic risk factors, and Patatin-like phospholipase domain-containing protein 3 (PNPLA3) gene polymorphism.

Design

Cross-sectional study

Setting

Pediatric Hepatology unit of a tertiary care hospital

Participants

Overweight/obese children (<18 years) with (69 patients) or without (30 patients) NAFLD (ultrasonography based), and their parents.

Intervention

Metabolic screening, PNPLA3 gene polymorphism, and transient elastography

Outcome measure

Association of pediatric NAFLD with parental metabolic risk factors and PNPLA3 gene polymorphism.

Results

In the NAFLD group, there was high parental incidence of metabolic diseases, fatty liver (80%) and low high-density lipoproteins levels (84%). Family history of NAFLD (in any parent), higher alanine aminotransferase levels and higher total cholesterol levels in the child independently predicted possibility of NAFLD, but similar results could not be replicated for PNPLA3 gene polymorphism. Controlled attenuation parameter measurement (by transient elastography) had high sensitivity and specificity to diagnose steatosis.

Conclusion

There is high familial incidence of metabolic diseases in children with NAFLD. Controlled attenuation parameter can be useful as a non-invasive modality to screen fatty liver in children.

     

Brucella causing liver abscess in a child with selective IgA deficiency

Background

Brucella has been known to cause pyrexia of unknown origin.

Case Characteristics

9-year-old boy with fever and abdominal pain; multiple abscesses within the liver on ultrasonography.

Observations

IgM Antibodies against Brucella were raised in his serum sample, and Brucella serum agglutination test was positive. Immunological work-up suggested selective IgA deficiency. Reduction in size following treatment with trimethoprim-sulphamethoxazole, amikacin and doxycycline.

Message

Brucellosis should be considered as an etiology of liver abscess in patients not responding to conventional antibiotics.

     

Neuroschistosomiasis: An Unusual Intracranial Space Occupying Lesion

Background

Neuroschistosomiasis is an uncommonly reported disease.

Case characteristics

An adolescent Indian boy residing in Kenya presented with headache, visual symptoms and seizures, with MRI showing space-occupying lesions in the occipital lobe and cerebellum.

Observation

Brain biopsy was diagnostic of neuro-schistosomiasis; complete recovery was seen with praziquantel and corticosteroid therapy.

Message

This case highlights the importance of considering epidemiology in differential diagnosis and establishing definitive diagnosis even if it is by invasive methods.

     

Repeated administrations of rituximab along with steroids and immunosuppressive agents in refractory steroid-resistant nephrotic syndrome

Background

A recent randomized control trial in children with steroid-resistant nephrotic syndrome revealed that two doses of rituximab did not reduce proteinuria.

Case characteristics

A 14-month-old boy developed refractory steroid-resistant nephrotic syndrome due to focal segmental glomerulosclerosis.

Observation

The patient achieved complete remission 11 months after disease onset following eight doses of rituximab combined with steroids and cyclosporine.

Message

Long-lasting B cell depletion with repeated rituximab administrations may be required to achieve complete remission in patients with steroid-resistant nephrotic syndrome and massive proteinuria.

     

Bilateral Spontaneous Urinoma in a Cyanotic Child

Background

Urinoma is an encapsulated collection of extravasated urine, secondary to trauma or obstructive uropathy. Spontaneous bilateral urinoma is rare.

Case characteristics

7-year-old boy with cyanotic heart disease and fever of unknown origin.

Obeservation

The ultrasound abdomen and CT abdomen revealed bilateral spontaneous urinoma which was aspirated and was found to be infected. Following intravenous atibiotics the child became afebrile, with subsequent renal scans showing no recurrence.

Message

Hypoxia and consequent polycythemia may be responsible for perinephric leaks leading to Non-traumatic spontaneous urinoma.

     

Pediatric inflammatory bowel disease

Background

The incidence of inflammatory bowel disease is increasing in the pediatric population worldwide.

Need and purpose of review

There is paucity of high quality scientific data regarding pediatric inflammatory bowel disease. Most of the guidelines are offshoots of work done in adults, which have been adapted over time to diagnose and treat pediatric patients. This is in part related to the small numbers in pediatric inflammatory bowel disease and less extensive collaboration for multicentric trials both nationally and internationally.

Methods

A literature search was performed using electronic databases i.e. Pubmed and OVID, using keywords: pediatric, inflammatory bowel disease, Crohn’s disease, Ulcerative colitis, epidemiology and guidelines. This article amalgamates the broad principles of diagnosing and managing a child with suspected inflammatory bowel disease.

Main conclusions

25% of the patients with inflammatory bowel disease are children and and young adolescents. The primary concern is its impact on growth velocity, puberty and quality of life, including psychosocial issues. Treatment guidelines are being re-defined as the drug armamentarium is increasing. The emphasis will be to achieve mucosal healing and normal growth velocity with minimal drug toxicity.

     

Trypanosomiasis in a Young Infant from Rural Gujarat,India

Background

Human trypansomiasis due to infection by animal trypanosomes is rarely reported from India.

Case characteristics

We describe clinical presentation of a 2-month-old boy from a rat infested house in rural Gujarat who was diagnosed to be havinginfection with the rodent parasite Trypanosoma lewisi.

Observation

The fever and parasitemia resolved on treatment with liposomal amphotericin B, Ceftriaxone and Amikacin, and there was no recurrence of parasitemia over a 2 month follow-up.

Message

The case highlights the need for increased awareness and heightened surveillance for this rare zoonotic infection.

     

Characterizing pediatric surgical capacity in the Eastern Democratic Republic of Congo: results of a pilot study

Purpose

Characterize pediatric surgical capacity in the eastern Democratic Republic of Congo (DRC) to identify areas of potential improvement.

Methods

The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey was used in two representative eastern DRC provinces to assess existing surgical infrastructure and capacity. We compared our results to previously published reports from other sub-Saharan African countries.

Results

Fourteen hospitals in the eastern DRC and 37 in 19 sub-Saharan African (SSA) countries were compared. The average PediPIPES index for the DRC was 7.7 compared to 13.5 for SSAs. The greatest disparities existed in the areas of personnel and infrastructure. Running water was reportedly available to 57.1% of the hospitals in the DRC, and the majority of hospitals (78.6%) were dependent on generators and solar panels for electricity. Only two hospitals in the DRC (14.3%) reported a pediatric surgeon equivalent on staff, compared to 86.5% of facilities sampled in SSA reporting?≥?1 pediatric surgeon.

Conclusions

Significant barriers in personnel, infrastructure, procedures, equipment, and supplies impede the provision of adequate surgical care to children. Further work is needed to assess allocation and utilization of existing resources, and to enhance training of personnel with specific attention to pediatric surgery.