We report a case of isolated renal mucormycosis associated with renal failure in a 3-month-old infant. We have treated this patient by pyelotomy with the removal of the fungal ball and intravenous amphotericin B deoxycholate and achieved complete recovery.

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With reports of a multisystem inflammatory syndrome in children (MIS-C) related to COVID-19 infection resembling Kawasaki disease, there is an increasing need for awareness of this condition, especially in resource-limited settings. Herein, we report a 6-year-old previously healthy boy, who presented with a short history of fever, rash, and difficulty in breathing. At admission, he had bilateral nonexudative conjunctival congestion, oral erythema, maculopapular rash, and hemodynamic instability. Investigations showed neutrophilic leukocytosis, elevated inflammatory markers, and cardiac dysfunction. The child was managed with invasive ventilatory support, vasoactive agents, and broad-spectrum antibiotics and was given intravenous immunoglobulins and steroids. Reverse transcription-polymerase chain reaction for SARS-CoV-2 was negative; however, antibody test for SARS-CoV-2 was positive, confirming the diagnosis of MIS-C. The child improved clinically, inflammatory markers decreased, and the child could be discharged after 10 days of hospital stay.

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Disseminated tuberculosis (TB) not uncommon in children in developing countries like India, and the spectrum of the disease varies in the different age groups. Tubercular meningitis can present as central diabetes insipidus, which is rare in children characterized by polydipsia and polyuria, because of the inability to concentrate urine secondary to defective synthesis of antidiuretic hormone. Here, we present 7-year-old girl child who was admitted with polyuria, polydipsia for the last 2–3 months with respiratory problems for 2–3 weeks with a family history of active pulmonary TB in a completely unimmunized child. She had disseminated TB involving the respiratory system and central nervous system, So, presented with hypovolemic shock with severe hypernatremia with dilute urine with encephalopathy. She was resuscitated and managed for a hypovolemic shock with metabolic derangement such as hypernatremia, requiring deficit fluid correction, vasopressin therapy, and antitubercular therapy to respond clinically. The child recovered completely without a neurological deficit.

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Congenital tuberculosis (CT) is rare and is transmitted to the fetus hematogenously through the umbilical vein or by fetal aspiration or ingestion of infected amniotic fluids prior to or during delivery. Congenital cytomegalovirus (cCMV) infections are defined as those infections which are acquired through transplacental entry of organism from maternal blood stream into the fetus or transmitted during passage through the birth canal. We report the case of a 4½-month-old baby presented with fever and respiratory symptoms with hepatosplenomegaly and diagnosed to be a case of CT with cCMV infection further complicated by secondary hemophagocytic lymphohistiocytosis and severe acute respiratory distress syndrome and salvaged by high-frequency oscillatory ventilation, antitubercular drugs, and steroids.

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The systemic vasculitides are multifocal diseases characterized by the presence of blood vessel inflammation in multiple organ systems. Their clinical presentation is variable extending from self-limited illness to critical complications including diffuse alveolar hemorrhage and glomerulonephritis. Alveolar hemorrhage is a life-threatening manifestation of pulmonary vasculitis that can rapidly progress into acute respiratory failure requiring ventilatory support. We present the case of a 13-year-old patient admitted to the intensive care unit with respiratory distress and diffuse alveolar infiltrates in chest imaging that was later diagnosed as antineutrophil cytoplasmic antibodies-associated vasculitis. The report highlights the importance of differentiation between alveolar hemorrhage and acute respiratory distress syndrome of other etiology because alveolar hemorrhage is reversible with prompt initiation of treatment.

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Poorly controlled type 1 diabetes mellitus predisposes the child to opportunistic infections. Mucormycosis is one such infection, Rhino-cerebral form being the most common. Maxillary sinusitis can lead to facial nerve palsy. We report here a 9-year-old boy with poorly controlled diabetes, who presented with left facial swelling and deviation of mouth to the left side in diabetic ketoacidosis. He was diagnosed to have rhinocerebral mucormycosis, maxillary sinusitis, and osteomyelitis with a complication of facial nerve palsy. The child recovered on treatment with IV antifungals and surgical debridement. This case is unique in presentation as fungal rhinocerebral sinusitis with facial nerve palsy highlighting the need of high index suspicion for fungal infection especially in underlying immunocompromised state like T1DM.

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Oxygen supplement is administration of oxygen above normal atmospheric concentration or pressure in both acute and chronic conditions to prevent hypoxia or to treat certain conditions requiring hyperbaric oxygen. Delivery of oxygen depend on various factors. Oxygen should be used judiciously as its also associated with adverse effects. No concentration is safe in human.

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Objective: The study objective was to describe the safety and efficacy of ultrasound (US)-guided pigtail catheter (PC) (USGPC) placement at bedside for symptomatic pleural effusion and ascites in acute critically ill children in pediatric Intensive Care unit. and not critical care unit (PICU). Study Design: This was a descriptive study. Place: This study was conducted at the pediatric critical care unit (PICU) of The Indus Hospital, Karachi, Pakistan, from January 2018 to December 2019. Subjects and Methods: We retrospectively reviewed the electronic medical records of critically ill children who underwent USGPC insertion for symptomatic pleural effusions and ascites on bedside. Demographic data, clinical indication, success rate, and complications of procedures were collected using a structured questionnaire approved by the institutional ethical committee. The PC of 10–14 French size was placed under US guidance, using Seldinger technique by a pediatric intensivist team on bedside with procedural sedation and analgesia. Results: Forty patients (3.7% of the total admission) required PC insertion. The mean age of the patients was 8.3 years, and 55% (n = 22) were male. Nearly 85% (n = 34) of the patients had an underlying malignancy and presented as respiratory distress/failure secondary to either large pleural effusion and/or massive ascites. Indications were pleural effusions (n = 26, 65%) and ascites (n = 14, 35%). The procedure was successful in 92.5% of the patients. The mean duration of PC insertion was 13.9 days. Pneumothorax developed in three cases (7.5%) as a procedure-related complication, which resolved after chest tube insertion. None of the patients developed bleeding, or visceral injury. Resolution occurred in all cases. Conclusion: USGPC placement at bedside by intensivists for percutaneous drainage in symptomatic pleural effusion and ascites is a simple, safe, and an effective modality for critically ill children.

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Introduction: Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency in children. The capillary beta-hydroxybutyrate (BOHB) is increasingly used in the diagnosis and management of DKA. This study's objective is to assess the clinical and statistical correlation of BOHB with standard acidosis markers such as pH and HCO₃. Materials and Methods: We retrospectively reviewed the electronic medical record of children aged 2 months to 16 years with DKA from January 2018 to January 2020 admitted in the pediatric intensive care unit of The Indus Hospital which is a tertiary care specialized center. All children received the treatment according to the standard protocol. Capillary blood BOHB was measured on admission, q 4–6 hourly, and blood glucose was also measured. All parameters were recorded on a structured sheet. Results: Among 1080 critically ill admissions, 26 patients (2.4%) were diagnosed as DKA. The mean age was 9.8 ± 3.8 years, and females were 54%. Half patients were newly diagnosed with Type 1-Insulin dependant diabetes mellitus (1DDM). Mild, moderate, and severe cases of DKA were 19%, 50%, and 31%, respectively. The median time to resolution of acidosis was 17 (10–39) h. At the time of resolution of acidosis, the correlation between capillary BOHB and blood pH (r = 0.11, P= 0.56), HCO₃(r = 0.37, P = 0.86), AG (r = 0.37, P = 0.06), and base deficit (r = 0.04, P = 0.82) was noted. Hyperchloremia was present in 61.5% of cases. Five patients (19.2%) developed AKI that recovered. There was a strong clinical correlation of beta-hydroxybutyrate (BHOB) with standard acidosis markers of DKA management. Conclusion: Bedside capillary blood BOHB is a simple, inexpensive, point-of-care test that helps diagnose and treat DKA, especially in resource-limited settings, for avoiding unnecessary delays.

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Introduction: Serum lactate is an important parameter to assess adequacy of microcirculation in septic shock. However, prediction of outcome in pediatric septic shock with mutli organ dysfunction (MODS) based on serial lactate levels and it's clearance is not well studied. Materials and Methods: In this prospective study from a tertiary PICU in India, 43 children with septic shock and MODS aged 1month to 16 years were enrolled over one year. Our objective was to predict early ICU mortality (within 72 hours) as well as in-hospital mortality using serial serum lactate levels and it's rate of clearance. Serial serum lactate levels were measured at admission to PICU (0 hours) and 6 hourly for initial 24 hours and 12 hourly till 120 hours. Results: The median (IQR) age of enrolled children was 32 (4.5,96) months. Median (IQR) PRISM-12 score was 16.5 (12,22). Seventeen children died. Serum lactate ≥2.6 mmol/L at 24 hours predicted early ICU mortality with sensitivity and specificity of 83.3% and 85.7% (AUC: 0.873, 95% CI 0.727, 1.000). In hospital mortality could be predicted with sensitivity and specificity of 60% and 73% (AUC: 0.734, 95% CI 0.571, 0.897) when serum lactate ≥1.8 mmol/L at 24 hours. Percentage of lactate clearance (median, IQR) at 24 hours of ICU stay were 15.1 (-21.4, 24.6) and -33.2 ( -262, 0.4) (p=0.04) between survivors and non-survivors at 72 hours of ICU stay. Conclusion: Pediatric septic shock and MODS carries high mortality and serum lactate of ≥2.6 mmol/L predicted early ICU mortality with good precision.

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Objective: The objective of this study is to describe the frequency of invasive critical procedures (ICPs) performed by pediatric critical care medicine (PCCM) fellows during their training period. Design: This was a retrospective study. Setting: This was a multidisciplinary, closed 6-bed pediatric intensive care unit (PICU) staffed by four pediatric critical care physicians. Methods: We reviewed the electronic medical record and logbook of each fellow from January 2018 to December 2019. Two most commonly performed ICPs included in this study were endotracheal intubation and ultrasound-guided central venous catheter (USG-CVC) insertion. Demographic data and details of ICPs performed were collected on a structured data collection sheet. The primary outcome was the frequency of ICPs performed by clinical fellows during the training period and their success rate. Results: Of the total 1080, 352 ICPs were performed on 560 (51.8%) patients by four PCCM fellows during the 2-year period. Only two most commonly performed procedures, i.e., ET-intubation and UG-CVC insertion were included in this study. These ICPs comprised of endotracheal tube placement (52.85%, n = 186) and USG central venous line insertion (47.15%, n = 166). About 64.4% of patients were under 5 years, 56% were male, and 72% were admitted with cardiorespiratory failure. The frequency of endotracheal intubation was 23/fellow/year and USG-CVC insertion was 21/fellow/year and the success rate was >90%. Conclusion: Our clinical fellows performed adequate numbers of endotracheal intubation and USG-CVC insertion to achieve competency of procedural skills during their training period.

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