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   Table of Contents - Current issue
Coverpage
November-December 2021
Volume 8 | Issue 6
Page Nos. 263-306

Online since Friday, November 19, 2021

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EDITORIALS  

COVID-19-associated multi-system inflammatory syndrome in children: Not “MIS-Cing” the wood for the trees! p. 263
Steven Loscalzo, Vijay Srinivasan
DOI:10.4103/jpcc.jpcc_87_21  
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Multisystem inflammatory syndrome associated with coronavirus disease 2019: MIS-C-concepts and MIS-concepts p. 266
Pradeep Kumar Sharma
DOI:10.4103/jpcc.jpcc_90_21  
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Scrub typhus - Suspect early, act fast p. 268
AR Mullai Baalaaji
DOI:10.4103/jpcc.jpcc_89_21  
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ORIGINAL ARTICLES Top

A multicenter study of clinical and biochemical profiles, treatments, and short-term outcomes in children with multisystem inflammatory syndrome associated with SARS-CoV-2 infection from Western India Highly accessed article p. 270
Rachit Mehta, Vinay H Joshi, Preetha Joshi, Amit Bhondve, Madhu Otiv, Soonu Udani, Mahesh Mohite, Bhakti U Sarang, Parmanand Andankar, Abhijit Bagade, Sameer Sadawarte, Sagar Sharad Lad, Pradeep Suryawanshi, Ashish Ramchadra Dhongade
DOI:10.4103/jpcc.jpcc_60_21  
Background: Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection can lead to multisystem inflammatory syndrome in children (MIS-C). This study was conducted to study epidemiology, clinical profile, treatment strategies associated in children MIS-C in two cities in Western India. Subjects and Methods: This is a retrospective, observational study of children who fulfilled the criteria for MIS-C, admitted to eleven pediatric intensive care units (PICUs) in Western India during the first wave SARS-CoV-2 infection in India, between February 2020 and December 2020. Demographic and clinical data including laboratory parameters, treatment regimens, and outcomes were collected and analyzed. Results: Of the 234 children presenting with MIS-C, they were categorized into 3 clinical phenotypes: fever and hyperinflammation, Kawasaki disease (KD)-like, and shock with multisystem organ dysfunction syndrome (MODS). C-reactive protein, procalcitonin (PCT), D-dimer, and pro-B-type natriuretic peptide levels were elevated in all patients. Intravenous immunoglobulin (IVIG) was used in 128 (54.7%), corticosteroids in 214 (91.45%), tocilizumab in 1 (0.4%), and remdesivir in 4 (1.7%). 95 (40.5%) children required vasopressors and invasive mechanical ventilation was necessary in 26 (11.1%). Two hundred and twenty-nine patients were discharged home with median duration of PICU stay of 4 days and hospital stay of 7 days, and 5 (2.1%) patients died during treatment. Significant reduction in the duration of hospital stay was observed in those who received both steroid and IVIG (P < 0.05) and also in the shock ± MODS group (P < 0.05). Conclusions: Combination of steroid and IVIG for the treatment of MISC, especially with Shock and MODS reduce the duration of PICU stay than treated with steroid alone.
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Knowledge, attitudes, and practice toward multisystem inflammatory syndrome in children among pediatrician in Eastern India: An online cross-sectional survey p. 278
Sanjay Kumar Sahu, Sibabratta Patnaik, Jyoti Ranjan Behera, Mukesh Kumar Jain, Mona Pathak
DOI:10.4103/jpcc.jpcc_69_21  
Background: Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome-coronavirus-2 is a new life-threatening entity whose diagnosis and management warrant awareness and in-depth knowledge. This study intends to estimate the knowledge, attitudes, and practice toward MIS-C among pediatricians of eastern India. Subjects and Methods: A descriptive, web-based cross-sectional survey was conducted among pediatricians of eastern India between January 1 and March 31, 2021, where they were invited to participate irrespective of their experience in treating COVID-positive children. Results: The majority of pediatricians (≥95%) are aware of the terminology MIS-C, its clinical features, presence of raised inflammatory markers, its treatment, and follow-up. Although 75% were aware of the vulnerable age group, only 50% knew the exact timing of occurrence. Fever as a mandatory criterion for diagnosis was known to 62.6%. The majority (75%) agreed that positivity of any of the tests (reverse transcription polymerase chain reaction, antigen, or antibody) or history of contact with COVID is necessary for diagnosis. Kawasaki Disease and Toxic Shock Syndrome as a common differential diagnosis of MIS-C were agreed upon by 86%. Pediatricians working in COVID hospital were more confident in managing MIS-C than who are not working (72.8% vs. 38.6%). Steroid and intravenous immunoglobulin used as first-line treatment by 94% and 72%, respectively. Conclusion: Although the majority of pediatricians are now aware of MIS-C, still there is need for continuing medical education (CME) and interactive sessions with experts, to make them suspect, detect early and manage it more effectively.
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Scrub typhus meningoencephalitis in children: A single centre, observational study from Eastern India p. 283
Preetinanda Parida, Aman Kumar Agrawal, Sebaranjan Biswal, Sibabratta Patnaik, Chinmay Kumar Behera
DOI:10.4103/jpcc.jpcc_74_21  
Background: Scrub typhus is being reported from different parts of India. Meningitis or meningoencephalitis among various neurological complication seen in scrub typhus is not uncommon. Delay in diagnosis may cause higher mortality without prompt treatment. The aim of the study was to describe the various manifestations of scrub typhus meningoencephalitis and their outcome from eastern part of India. Subjects and Methods: A prospective observational study of scrub meningoencephalitis was carried out at Kalinga Institute of Medical Sciences, between October 2018 and August 2020.The diagnosis was made based on the compatible clinical features, positive Scrub Ig M by ELISA and cerebrospinal fluid lymphocytosis (>5 cell/cmm), after excluding other causes of meningoencephalitis. Results: Twenty-seven (12.38%) cases of scrub meningoencephalitis were included in the study with male (66.6%) predominance. All had presented with fever of mean duration of 8.5 days of illness. Altered sensorium and seizure was observed in 70.5% and 62.9% of our patients along with two patients who had sixth cranial nerve palsy. Eschar was found in 25.9% of our children. The mean CSF cell count, protein and glucose were 25 cells/cmm,84.2 mg/dL and 62.9 mg/dL respectively with lymphocytosis in all cases. There was no mortality in this study. Conclusion: Meningoencephalitis is an important complication of scrub typhus in children. Unlike most viral encephalitis cases, it has a definite treatment with good outcome, if treated early.
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CASE REPORTS Top

Fulminant myocarditis, severe pediatric acute respiratory distress syndrome associated with H1N1 influenza and enteric fever rescued by prone ventilation: A case Report p. 288
Goutam Goswami, Pradeep Kumar Sharma, Nikhil Vinayak
DOI:10.4103/jpcc.jpcc_44_21  
H1N1 influenza-associated fulminant myocarditis with pediatric acute respiratory distress syndrome (PARDS) is rare. We report a child of fulminant myocarditis, severe PARDS associated with H1N1 and enteric fever. She rapidly developed severe PARDS and refractory hypoxemia. She was successfully rescued with prone ventilation. Fulminant myocarditis with PARDS can be a manifestation of H1N1 infection. These scenarios pose a tough challenge, especially in resource-limited settings. Although we successfully managed our patient with prone ventilation, success in one case cannot be generalized until more evidence is generated.
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Stevens–Johnson syndrome complicated by pneumomediastinum and cerebral venous sinus thrombosis in a 10-year-old girl: A case Report p. 291
Pawan Jain, Rakesh Singh, Shriyanka Jain, Ankur Saxena, Ujjwala Verma, Vikash Kumar Bhojasiya
DOI:10.4103/jpcc.jpcc_57_21  
Stevens–Johnson syndrome (SJS) is a life-threatening condition with severe mucocutaneous reaction in response to an offending medication. We report a case of SJS complicated with pneumomediastinum and cerebral sinus venous thrombosis in a girl. These two complications occurring simultaneously in a pediatric patient with SJS are hitherto unreported. Laboratory workup pointed underlying connective tissue disease in her. She received supportive care along with steroids, antimicrobials, and anticoagulant under supervision of a multidisciplinary team. She recovered well at discharge and is on follow-up. Clinical vigilance identifies rare but important complications of SJS early, mitigating severe morbidity and mortality.
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Multiple opportunistic infection-associated hemophagocytic lymphohistiocytosis in nephrotic syndrome: A case report p. 295
Sireesh Varadaraju, Priyanka Khandelwal, Jhuma Sankar, Pankaj Hari
DOI:10.4103/jpcc.jpcc_64_21  
Multiple opportunistic coinfections during corticosteroid therapy for the nephrotic syndrome are uncommon. Infection-associated hemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal multisystem disorder, manifesting as a state of hypercytokinemia in response to an infectious trigger. We describe a 4½-year-old boy with steroid-dependent nephrotic syndrome receiving high-dose steroids, who developed respiratory failure due to pulmonary tuberculosis, Cytomegalovirus, and Pneumocystis jirovecii coinfections; HLH complicated the course. Aggressive management of the underlying infections with antitubercular, antiviral, and antifungal therapy, prompt recognition of HLH, and immunomodulation with intravenous (IV) immunoglobulin and IV methylprednisolone enabled convalescence. This report emphasizes the serious risks of immunosuppression and the need for strict vigilance for rare opportunistic infections with multiple pathogens in patients receiving oral steroids for nephrotic syndrome. Clinical distinctions between severe sepsis and HLH may be ambiguous; a high level of suspicion is required for timely recognition and management.
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Acute carbamazepine toxicity in a child: A case report p. 299
Manjinder Singh Randhawa, Prateek Sharma, Suresh Kumar Angurana, Arun Bansal
DOI:10.4103/jpcc.jpcc_65_21  
Carbamazepine is a commonly prescribed antiepileptic drug with a potential to cause fatal toxicity in acute overdose in children. Symptoms of acute toxicity include central nervous system depression, seizures, anticholinergic toxidrome, and arrhythmias. We report a 5 year old male child with accidental carbamazepine toxicity treated sussessfully with good suppotrive management. Intestinal decontamination therapies may be beneficial if used at the appropriate time. Multidose activated charcoal may be used if multiple controlled release tablets are ingested. Extracorporeal therapies for drug removal may be required in life-threatening toxicity to reduce plasma drug levels and hasten recovery. Appropriate and timely management leads to excellent neurological outcome.
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Persistent left superior vena cava presenting as brain abscess: A case report p. 302
Neha Mohan Rao, Guruprasad Hassan Shankar, Bhakti U Sarangi, Sanjay Bafna, Priscilla Joshi, Rahul Jahagirdar
DOI:10.4103/jpcc.jpcc_75_21  
A persistent left superior vena cava (PLSVC) draining into the left atrial appendage can exist as an unidentified right-to-left shunt often with no demonstrable evidence of hypoxia on history but predisposing to life-threatening clinical implications. We present a 7-year-old boy with a brain abscess who was incidentally noted to have features of hypoxia on examination. His evaluation revealed the presence of a PLSVC on computed tomography pulmonary angiogram, draining into the left atrium, thereby acting as a right-to-left shunt explaining the brain abscess. He underwent a craniotomy with a course of intravenous antibiotics, remained well on follow-up, and was referred for definitive surgery for PLSVC. Children with unidentified right-to-left shunts may present with brain abscesses in the event of which both intracardiac and extracardiac shunts have to be ruled out with the help of history, a focused clinical assessment, and more advanced imaging.
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BOOK REVIEW Top

Egan's fundamentals of respiratory care 12th edition p. 306
Aninday Mittal, Kundan Mittal
DOI:10.4103/jpcc.jpcc_88_21  
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