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Background: Limited data is available in children with nonthyroidal illness syndrome (NTIS) and its association with prognosis in acute illness. This study was conducted to compare thyroid function as marker of severity with pediatric risk of mortality (PRISM) and pediatric index of mortality (PIM) in pediatric high dependency unit (PHDU). Subjects and Methods: This was a prospective, cross-sectional observational study of 225 patients, aged 1–14 years with respiratory symptoms, admitted to a PHDU in a secondary care hospital in Brazil. PRISM-IV and PIM-2 scores were calculated and serum thyroid-stimulating hormone (TSH), free T4, T3, and T4 levels were measured on admission. The presence of NTIS was considered in patients with total T3 below reference values, which may be associated with normal or low levels of total T4. Results: The mean age of the study population was 52.9 ± 35.9 months; Male-to-female ratio is was 1.2. All patients had normal free T4 levels. In 65.9% of cases, TSH remained within normal limits, while 34.1% were below the reference range for age. The prevalence of NTIS was 45.8%. Total T3 was normal in 54.2% and total T4 was normal in 90.2% of cases. Low total T3 with normal total T4 was found in 36% of patients while both total T3 and T4 were low in 9.8% of cases. Lower PRISM IV scores (P = 0.0014) and lower PIM-2 scores (P < 0.0001) were significantly correlated with absence of NTIS. Conclusions: Patients without evidence of NTIS have lower disease severity scores and a better prognosis.

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Background: Essential step in the management of septic shock is prompt recognition at an early stage and prediction of fluid responsiveness. Existing methods of assessing septic shock in children have limited accuracy. This study was conducted to determine the serial inferior vena cava (IVC) dimension and its correlation with clinical cardiopulmonary-cerebral assessment in children with septic shock. Subjects and Methods: A prospective observational study was conducted from 1 month to 12 years of children with septic shock resuscitated in the emergency department. Serial ultrasound measurements of IVC/aorta ratio were obtained before and after each fluid bolus of 10 ml/kg over 20 min. Chi-square tests were used to find out whether the statistical differences between assessing fluid status with clinical parameters and assessing fluid status with IVC/aorta ratio after fluid boluses were really significant or not. Results: Hundred patients were enrolled and included in the final analysis. Using Chi-square test, there were significant (P < 0.05) strong associations between heart rate, pulse volume, capillary refill time, blood pressure, and IVC/aorta ratio during multiple assessments following fluid boluses. Conclusions: IVC/aorta ratio was statistically significantly associated with volume status and clinical assessment. A single assessment of IVC/aorta ratio did not appear useful. Serial determinations of IVC/aorta ratio emerged statistically significant in the assessment of fluid status in children with septic shock during resuscitation in the emergency department.

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Cladophialophora bantiana is a rare melanized neurotropic fungus. We report a case of cerebral pheohyphomycosis due to C. bantiana in an immunocompetent child. The patient was a 12-year-old male who presented with a headache, intermittent vomiting associated with decreased movements of the right upper and lower limbs, and right-sided deviation of the mouth. Brain magnetic resonance imaging showed multiple conglomerated lesions in the left gangliocapsular region and corona radiata with perilesional edema and mass effect and a few small ring-enhancing lesions also. Aspiration of brain abscess sent for a culture and isolated C. bantiana. The clinical and radiological presentations are similar to the common organisms such as tuberculosis and thus can be misleading while diagnosis. Despite aggressive management, the patient succumbed to his illness. It is imperative to isolate microorganisms, using all microbiological tests. Fungi should also be considered irrespective of the immunocompetency.

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We describe a case of previously normal 22-month-old male who presented with vomiting, loose motions, lethargy, and seizures for 1 day. He had high anion gap metabolic acidosis, hyperglycemia, and ketosis managed elsewhere as diabetic ketoacidosis. Early management included hemodynamic stabilization, mechanical ventilation, correction of metabolic acidosis, seizure control, and later peritoneal dialysis. He was finally diagnosed with succinyl CoA 3 ketoacid transferase deficiency, a disorder of ketone metabolism usually presents with metabolic acidosis, ketosis, and hypoglycemia. Most cases present during the neonatal period (50%) and remain up to 20 months of age. The pathognomic finding is a nonspecific elevation on ketones in urine gas chromatography–mass spectrometry. Genomic sequencing is confirmatory.

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The occurrence of deep vein thrombosis (DVT) in tuberculosis (TB) is not uncommon in adults but is relatively rare in children. We report the case of a 13-year-old girl who presented with fever and cough for 2 months followed by acute onset of pedal edema. She was diagnosed with disseminated TB and DVT of the right femoral and common iliac veins. A timely diagnosis of DVT and prompt initiation of anticoagulant therapy along with antitubercular therapy, not only averted the rare, yet dangerous complication of thromboembolism but also hastened her path to recovery. The challenge of maintaining international normalized ratio in the desired range, was met by replacing Warfarin with a short-acting oral anticoagulant (Acenocoumarol) to overcome the enzyme-inducing action of Rifampicin. Screening tests to rule out autoimmune etiology of thrombosis; and tests done to rule out a hereditary predisposition to thrombosis, were normal. In the case of disseminated TB, a considerable degree of awareness is required, for the early detection and treatment of a potentially serious complication like DVT, to avoid the life-threatening complication of pulmonary embolism.

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Few case studies of atypical presentation of pediatric Rasmussen's encephalitis (PRE) have been reported, but none of them described the emergence of super-refractory status epilepticus. Despite substantial advances in identifying the underlying routes, triggers, and etiology, the prognosis for Rasmussen's encephalitis (RE) patients remains uncertain. Epileptic spasms with delayed onset in RE patients are common but not drug-resistant epilepsy. In this article, we aim to describe an atypical presentation of PRE which was complicated by super-refractory status epilepticus.

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Hyperferritinemia has been associated with increased mortality in severe sepsis and also described with scrub typhus. We describe a case of a 10-year-old child with acute febrile illness, altered sensorium, seizures, and left hemiparesis, along with septic shock. The child had markedly elevated inflammatory markers, along with hyperferritinemia and increased D-dimer. Serological tests for scrub typhus were positive. The child was started on doxycycline along with supportive management. In view of hyperferritinemic sepsis with accompanying cytokine storm, septic shock, and disseminated intravascular coagulopathy, IgM-enriched intravenous immunoglobulin and dexamethasone were administered with good outcome. Neuroimaging revealed cerebral infarcts managed with low-molecular-weight heparin and aspirin. The child was discharged with normal sensorium and with improving left hemiparesis. Early use of immunomodulatory drugs in such atypical presentations in scrub typhus may reduce mortality, and further research is warranted.

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