Background: Asthma is a common and potentially serious chronic disease that imposes a substantial burden on patients, their families, and community. The main treatment of an acute exacerbation includes inhaled short-acting β2-agonists (SABA). The aim of this of study was to compare the effectiveness of metered dose inhaler (MDI) with spacer and jet nebulizer for delivering SABA in children aged 5-14 years presenting to the emergency department with acute asthma. Subjects and Methods: One hundred subjects were randomly assigned to receive salbutamol by an MDI with spacer or a nebulizer at fixed intervals. The parameters such as respiratory rate, heart rate, use of accessory muscles, auscultatory findings, peak expiratory flow rate (PEFR), development of tremor, pCO₂ on venous blood gas, need for hospital admission, and duration of stay in the emergency department were compared between two groups. Statistical tests used were Student's t-test, Chi-square test, and Fisher's exact test. Results: Clinical improvement in the form reduction of respiratory rate, use of accessary muscles, wheeze, and PEFR was comparable between two groups. Increase in heart rate in children with MDI with spacer group was significantly lower (P < 0.001) than that of nebulizer group at all time intervals during the study period. No significant difference was observed for the need of pediatric intensive care unit admission, duration of stay in emergency department, and adverse events between two groups. Conclusions: In children aged 5-14 years presenting to the emergency department with acute exacerbation of asthma, the efficacy of MDI with spacer for delivering SABA was comparable with that of nebulizer.

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Mycoplasma pneumoniae is a common organism responsible for pediatric community-acquired pneumonia. Extrapulmonary complications including thrombosis, although rare, are known to be associated with severe M. pneumoniae pneumonia. We report the case of left atrial thrombus extending into right inferior pulmonary vein in a child with severe M. pneumoniae probably due to transient Antiphospholipid Antibodies (aPL). Pneumonia and thrombus were completely resolved after the treatment with antimicrobial and anticoagulant therapy in 3 months. aPL are more common in M. pneumoniae infections; hence, routine screening will be helpful to quantify the incidence of aPL as well as to plan future risk assessment and management strategies.

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Acute necrotizing encephalopathy of childhood (ANEC) is a potentially devastating illness characterized by fever, acute encephalopathy, and bilateral thalamic lesions. This case series is a retrospective review of clinical, laboratory, neuroimaging data of 19 children diagnosed with ANEC over 9 years at a single-center from south India. The median age was 84 months (interquartile range 25.5–120 months). All children had acute febrile encephalopathy, 12 had seizures and hypotension each, 8 had vomiting, and 5 had abnormal posturing. The liver transaminases were raised almost all children. All had bilateral thalamic lesions followed by lesions in cerebral white-matter, brain stem, and cerebellar white matter. Microbial etiology was established in 9 patients (7 dengue, 1 H1N1, 1 influenza A). Neurodeficits at discharge were seen in 63% and at follow-up in 33.3% cases. Neurodeficits at follow-up were seen in all cases with age <48 months, and only 11.1% with age >48 months age (P = 0.018).

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Background: Majority of published studies have looked at the risk factors for mortality in dengue. There are limited data on critical analysis of the causes of death in children with dengue when they are treated according to the World Health Organization guidelines. This study was conducted to analyze the immediate causes and epidemiology of deaths in children in two different outbreaks of dengue. Subjects and Methods: This was a retrospective observational study conducted at tertiary care teaching hospital during outbreaks in the years 2013 and 2017. All children who died due to Dengue during outbreaks were included in the study. A retrospective chart review was done using predesigned pro forma. Results: A total of 29 children died due to Dengue in two outbreaks. There were Eighteen deaths in the year 2013 and eleven deaths in the year 2017 outbreak. Myocarditis (27%), Encephalitis (24%), Massive hemorrhage (13%), and severe capillary leak (13%) were major immediate causes of death. Myocarditis (45%) was the leading cause of death in 2017 while Dengue encephalitis and massive bleed (23%) each in 2013. Hypoalbuminemia at admission was seen in 26 (89%) patients at admission among all deaths. Aspartate transaminase (AST) >1000 IU/L was seen in 10 (91%) Children and had a sensitivity of 91% and specificity of 50% in diagnosing myocarditis. Conclusions: The primary cause of death in fatal dengue had shown changing epidemiology during two outbreaks. Hypoalbuminemia can predict the beginning of the critical phase better than the defervescence of fever. AST >1000 IU/L may point towards myocarditis.

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Background: Over the past decades, the indications for tracheostomy in children and the routine posttracheostomy course have changed significantly. The purpose of this study was to identify the indications, complications, and outcomes of pediatric tracheostomy. Subjects and Methods: This prospective observational study was conducted involving all children admitted to the pediatric intensive care unit (PICU) requiring tracheostomy from January 2018 to June 2019. A pre-structured proforma was used. The data regarding indications of tracheostomy, complications, and outcomes were analyzed. Patients were followed up till decannulation during the study period. Results: Out of 73 patients included in the study, 68.5% (n = 53) were males and 31.5% (n = 20) were females, with a mean age of 5.4 years. The most common primary indication for tracheostomy was neurological impairment (56.2%, n = 41) and airway obstruction (19.2%, n = 14). The average duration of PICU stay at the time of tracheostomy was 15.4 days. Prolonged mechanical ventilation was required in 62.3% of patients. Elective tracheostomy was done in 84.9% of patients. Complications due to tracheostomy were noted in 43.8% (n = 32) of cases, of which suprastomal granulations were the most common. The average length of PICU stay after tracheostomy was 21.8 days. The rate of successful decannulation was 69.9%. The most common cause for decannulation failure was subglottic stenosis. Conclusions: Neurological impairment requiring prolonged mechanical ventilation was the most common indication for tracheostomy. Suprastomal granulations were the most common complication and subglottic stenosis being the most common cause for decannulation failure.

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Acute hemorrhagic encephalomyelitis (AHEM) is a rare form of acute disseminated encephalomyelitis (ADEM) characterized by a fulminant course, poor response to immunomodulation, and unfavorable outcomes. Early clinical and radiological suspicion can enable aggressive use of immunotherapy, thereby improving outcomes. Pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a novel disease, with protean clinical manifestations being reported from all over the world. Although multiple neurological manifestations of PIMS-TS have been reported previously, AHEM has been less commonly reported. We describe a case of PIMS-TS with AHEM and highlight very rare presentation of this novel disease.

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Apart from being the most common endocrine emergency in the pediatric intensive care unit, some clinical manifestations of diabetic ketoacidosis such as vomiting and continued acidotic breathing may, on the rare occasion, lead to unexpected complications such as pneumomediastinum, pneumopericardium, pneumothorax, and subcutaneous emphysema. The differentials for the same include Hamman's syndrome secondary to forceful coughing or Valsalva maneuver, Boerhaave syndrome resulting from forceful vomiting, and even spontaneous air leaks due to severe swings in intrathoracic pressure during Kussmaul breathing, leading to alveolar rupture causing air leak. These complications may have subtle signs as well as a significant overlap in presentation and require a high index of suspicion to diagnose and careful evaluation to differentiate. We hereby report a 3-year-old child with new-onset type 1 diabetes mellitus in severe DKA, leading to pneumomediastinum and pneumopericardium where computed tomography of the thorax helped rule out differentials and the air leak resolved spontaneously with the resolution of acidosis.

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Diaphragmatic rupture after blunt abdominal trauma is a rare entity in pediatric age group. We report a 2-year-old child who presented to us with respiratory distress after he fell from bike. Initial evaluation had a suspicion of pneumothorax, but computed tomography scan confirmed that he had a diaphragmatic tear along with herniation of abdominal contents in left hemithorax. The child was managed successfully with open surgical approach. Since there are no specific signs and symptoms to diagnose this condition, high index of suspicion should be kept in all cases of abdomino-thoracic injuries.

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