Leptospirosis in children in Mumbai slums

OBJECTIVE: There is limited data available on symptomatic leptospirosis in Indian children. We report an outbreak of leptospirosis that occurred in children living in slums following heavy rainfall and flooding. This hospital-based prospective study was conducted from July to August 2001. METHODS: Diagnosis of acute leptospirosis was suspected by following the Indian Leptospirosis Society working definition for leptospirosis. Diagnosis was confirmed by detecting anti-Leptospira antibodies, using either a Leptospira genus-specific latex agglutination assay or a dipstick assay or by a macroscopic slide agglutination test. RESULT: Thirty (32%) out of 93 children admitted had acute leptospirosis. Fever, bodyache, chills, abdominal pain, headache, vomiting, cough, hepatosplenomegaly, edema and crepitations were the common presenting signs and symptoms. Twenty - two children had anicteric leptospirosis and 8 had Weil disease. Response to penicillin treatment was good in all except in one child with Weil disease who died of renal failure within 3 hours of admission. CONCLUSION: Leptospirosis has emerged as an infectious disease in Mumbai. During monsoon, parents should ensure that their child does not have contact with the contaminated flood water.     

An observational study to detect leptospirosis in Mumbai, India, 2000

Background: Leptospirosis is relatively uncommon in children. Following torrential rains and flooding an outbreak of leptospirosis was suspected in Mumbai. Aims: To investigate the possibility of an outbreak of leptospirosis and describe the clinical illness. Methods: From 24 July to 14 September 2000, children with a history of abrupt onset of high fever (>39°C), who presented to our hospital, were admitted and tested serologically for anti-Leptospira antibodies by a quantitative enzyme linked immunosorbent assay (ELISA) test. An IgM titre of more than 20U/ml confirmed the diagnosis of leptospirosis. Clinical features in the confirmed leptospirosis and leptospirosis negative groups were analysed. Results: Of 53 children screened, 18 (34%) had leptospirosis. In all 18, the disease was anicteric and responded well to intravenous penicillin. Four clinical features present at the time of admission were significantly associated with leptospirosis: a history of contact with flood water (18/18 v 16/35), conjunctival suffusion (5/18 v 1/35), abdominal pain (9/18 v 5/35), and skin rash (5/18 v 1/35). As the number of these four features concomitantly present increased, the chances of the child having leptospirosis also increased significantly. A history of contact with flood water had a sensitivity of 100%, and the presence of conjunctival suffusion, abdominal pain, and skin rash had a specificity of 97%, 86%, and 97%, respectively, for identifying children with leptospirosis. Conclusion: Leptospirosis should be suspected in febrile children with contact with flood water.     

Pediatric presentations of leptospirosis

Objective : Leptospirosis in children is an often under diagnosed condition due to the non specificity of the presentations except for the classical Weil’s disease.Methods : Children presenting with symptoms and signs suggestive of Leptospirosis were included in the study. Diagnostic criteria were fever, myalgia, conjunctival suffusion, Jaundice, headache, altered sensorium, seizures, bleeding manifestation and oliguria. Their clinical profile, lab parameters (general and specific), response to treatment and outcome were analysed.Result : One hundred and thirty nine cases were diagnosed during a 4-year period. The commonest symptoms were fever 133 (96%), headache and myalgia 34 (24%). Jaundice was present in only 25 (18%) of cases with renal failure in 2 cases. The frequently encountered clinical signs were hepatomegaly in 100 (72%), myalgia in 34 (24%) with icterus in 25 (18%),12 (9%) of children presented with shock and 10 (7%) had meningitis. CPK estimated was a useful index of myositis. The diagnosis was confirmed by Dark field microscopy and paired or single high serological tests (MAT, ELISA IgM). Overlapping infections such as culture positive Salmonella typhi with leptospirosis (Serology positive) or Dengue Hemorrhagic fever with Leptospirosis presented with complications such as a myocarditis, shock and ARDS.Conclusion : Presentation of non-icteric forms of Leptospirosis are often non-specific and may be missed unless there is a high index of suspicion. This study emphasizes the myositis and meningitis forms of leptospirosis. Delayed diagnosis leads to increased mortality and morbidity.     

An observational study to detect leptospirosis in Mumbai, India, 2000.

BACKGROUND: Leptospirosis is relatively uncommon in children. Following torrential rains and flooding an outbreak of leptospirosis was suspected in Mumbai. AIMS: To investigate the possibility of an outbreak of leptospirosis and describe the clinical illness. METHODS: From 24 July to 14 September 2000, children with a history of abrupt onset of high fever (>39 degrees C), who presented to our hospital, were admitted and tested serologically for anti-Leptospira antibodies by a quantitative enzyme linked immunosorbent assay (ELISA) test. An IgM titre of more than 20U/ml confirmed the diagnosis of leptospirosis. Clinical features in the confirmed leptospirosis and leptospirosis negative groups were analysed. RESULTS: Of 53 children screened, 18 (34%) had leptospirosis. In all 18, the disease was anicteric and responded well to intravenous penicillin. Four clinical features present at the time of admission were significantly associated with leptospirosis: a history of contact with flood water (18/18 v 16/35), conjunctival suffusion (5/18 v 1/35), abdominal pain (9/18 v 5/35), and skin rash (5/18 v 1/35). As the number of these four features concomitantly present increased, the chances of the child having leptospirosis also increased significantly. A history of contact with flood water had a sensitivity of 100%, and the presence of conjunctival suffusion, abdominal pain, and skin rash had a specificity of 97%, 86%, and 97%, respectively, for identifying children with leptospirosis. CONCLUSION: Leptospirosis should be suspected in febrile children with contact with flood water.     

Autism — Experiences in a tertiary care hospital

Pervasive developmental disorders (PDD) or Autistic Spectrum Disorders (ASD) include Autistic Disorder (commonest), Asperger's syndrome, Childhood Disintegrative Disorders, Rett's syndrome and PDD—NOS (not otherwise specified).Objective: Autism is an important cause of social disability and reported more often from the developed world than from the developing countries. The present study was aimed to establish the diagnosis of autism amongst children with derangements of language, communication and behavior; ascertain and treat the co-morbidities; identify underlying cause and create a sensitivity and awareness among various health care professionals.Methods: Sixty-two of the seventy-five referred patients fulfilled the DSM-IV (Diagnostic and Statistical Manual of Mental Disorder) criteria for autism. Evaluation included a detailed history, clinical examination, IQ assessment, Connor's scoring for hyperactivity and Fragile-X screening. Management of co-morbidities was done. A follow up of these patients was done. Parents' assessment of the child was also done. A registry for autistic children was established at the Department of Pediatrics with other major institutions of Delhi.Results: The male: female ratio was 8∶1 and missed diagnosis was common. Professional awareness is merited. Behavioral modification by early intervention and stimulation improved the core symptoms of autism. Important co-morbidities included mental retardation (95%), hyperactivity (53%) and seizures (10%) cases. Control of co-morbidities in these children facilitated child's periodic assessment and implementation of intervention programmes. In the registry initiated 62 patients were enrolled at AIIMS and 6 were identified from other hospitals.Conclusion: Autism does occur in Indian children too. Diagnosis is often missed. Capacity building among health professionals by a more structured teaching of developmental disabilities in the medical curriculum is required. The need to attend to co- morbidities and associated symptoms was clear. The initiation of the registry and beginning of networking was important.     

Superior vena cava syndrome

Objective : In order to study the clinical profile of children presenting with superior vena cava syndrome (SVCS), case records of all children presenting with SVCS over a 10-year period were retrospectively analyzed.Methods :Twenty one children (20 males and 1 female) with a median age of 10.0 years (range 5.0 to 12.0 years) were detected to have an underlying hematological malignancy.T-cell acute lymphoblastic leukemia accounted for a major share (57%) in the underlying etiology; 33% of the subjects had non-Hodgkin’s lymphoma (T-cell lymphoblastic lymphoma).Result : No Patient required radiotherapy or urgent thoracotomy. Among survivors (n=11), who were alive and well at the time of writing this report, the median follow-up was 6.5 years, (range 0.5–9.6 years). T-cell ALL and lymphoblastic lymphoma are common underlying causes of SVCS in Indian children.Conclusion : The value of diagnostic interventions performed under local anaesthesia and prebiopsy corticosteroids usage was found to be reassuring since long-term survival without disease is achievable.     

The use of acoustic reflectometry in the study of middle ear effusion in children suffering from acute otits media,upper respiratory tract infection and in healthy children

This report focuses on the occurrence of middle ear effusion in children with acute otitis media (n = 62), upper respiratory tract infection (n = 81) as well as in healthy control children (n = 152). Data are reported in age categories 0–4 and 5–13 years. Middle ear effusion was found in 86% of children with acute otitis media, 49% of children with upper respiratory infection and 13% of healthy children. The younger the child, the more likely the presence of middle ear effusion in all groups. Acute otitis media and upper respiratory tract infection were clinically indistinguishable in infants. Conclusion Middle ear effusion is not generally a particularly significant clinical problem in children. Received: 31 January 1996 Accepted: 12 April 1996     

Concurrent outbreak of leptospirosis and dengue in Mumbai, India, 2002

This prospective study was undertaken to investigate the possibility of a concurrent outbreak of leptospirosis and dengue and to describe the clinical illnesses. From 20 June to 14 November 2002, children who presented to our hospital with a suspected diagnosis of leptospirosis or dengue were admitted. In every child with suspected leptospirosis, a screening latex agglutination test was carried out to detect anti-Leptospira antibodies. The diagnosis of leptospirosis was confirmed by a positive enzyme-linked immunosorbent assay (ELISA) test or microagglutination test. The diagnosis of dengue was confirmed by a positive IgM antibody capture ELISA test. Clinical features in the leptospirosis and leptospirosis-negative groups, and dengue and dengue-negative groups were analysed. Of 90 children screened, 15 (16.7 per cent) had leptospirosis. Two children with Weil's disease died and the remaining 13 responded well to intravenous penicillin. Five clinical features were significantly associated with leptospirosis, namely conjunctival suffusion (p=0.007), haemorrhage (p=0.020), abdominal pain (p=0.011), hepatosplenomegaly (p=0.044), and oedema (p=0.007). As the number of these five features concomitantly present increased, the chances of the child having leptospirosis also increased significantly (p<0.0001). Of 90 children screened, 16 (17.8 per cent) had dengue. All responded well to the treatment and went home. Two clinical features were significantly associated with dengue, namely arthralgia (p=0.020) and thrombocytopenia (p=0.001). If both these features were present, the chances of the child having dengue increased significantly (p=0.001). Our study shows that a concurrent outbreak of leptospirosis and dengue had occurred in the slums of Mumbai city.     

Acute leptospirosis in children in Reunion Island: a retrospective review of 16 cases]

INTRODUCTION: Leptospirosis is a worldwide zoonosis caused by pathogenic species of the genus Leptospira. This infectious disease known with a high incidence in Reunion island (French overseas territories in Indian Ocean) is in state of endemia especially during rains season. OBJECTIVES: The aim of our work was to identify the mains epidemiologic, clinical, biological, and therapeutic features of leptospirosis in children. POPULATION AND METHODS: We conducted a retrospective analysis of children hospitalized in pediatric unit with the diagnosis of leptospirosis from January 2001 to June 2004 in general hospital of Saint-Denis. We found out 16 cases (mean age 14 years, range 9-17), mainly boys (ratio 7:1). RESULTS: The patient sera reacted most strongly with Leptospira interrogans serovars canicola (66%), icterohaemorrhagiae (17%), and sejroe (17%). Epidemiologic data indicated contact with contaminated water in most cases (68%). Jaundice was present in 43% of the patients, increased transaminase levels in 56%, renal failure in 50%, meningitis in 25%, ECG abnormalities in 6%, respiratory manifestations in 6%, systemic manifestations in 12% and thrombocytopenia in 56%. Death rate was zero, but renal failure is likely to induce life prognosis. DISCUSSION: The diagnosis' traps are numerous, leading to an underestimation and underdiagnosis of the leptospirosis, more over there is a lack in specific, reliable, and quick biological test to make the diagnosis. A negative polymerase chain reaction analysis (PCR) do not exclude the diagnosis, and the microagglutination test (MAT) remains the reference of the undoubtly diagnosis of leptospirosis. It appears that it is more often the conjunction of epidemiologic data (young boy, swimming or fishing in river, rains season), with clinical and biological data that lead to the diagnosis. Diagnosis was not evoked at the emergency room in 37% of the patients. CONCLUSION: Leptospirosis should be considered face to an influenza like illness especially during rains season.     

Practical approach to recurrent respiratory infections

Respiratory diseases are a major cause of morbidity and mortality in developing countries. Recurrent respiratory infections in children pose a great challenge to the pediatrician where he has to exercise his clinical acumen and methodical, approach, for correct diagnosis and treatment. It is a fact that children should suffer 7 to 8 upper respiratory infections per year until they are 5 years of age when their immune status reaches adult level. In this situation, it is essential to find out whether the frequencies are abnormal. Whenever a child has the following, problems, then only it needs to be investigated.—(a) repeated bacterial pneumonias; (b) a child less than 3 months old having repeated respiratory infections; (c) a child of 9 months old without a history of exposure infections; (d) infections, complicating into bronchiectasis and; (e) in a child where there is no history of allergy or asthma. Once the problem is established as a true recurrent respiratory infection, the clinician should pose questions—whether it is chronic, acute or recurrent, to find out the site of pathology, seriousness of the problem, response to previous medications, to establish the possible diagnosis which fall into six categories—congenital anamolies, aspiration syndrome, genital disorders, immunological, diseases, immune deficiency disorders and allergic diseases. The author discusses quoting some examples for various categories avoiding non pulmonary causes for recurrent respiratory infections in children.     

Factors influencing the spread of pertussis in households

The objective of this study was to compare the spread of pertussis in children and adults being secondary contacts after household exposure. The study was nested in an efficacy trial of an acellular pertussis vaccine. The spread of the disease was also monitored with respect to gender and antibiotic therapy. A total of 453 index cases, of which 133 were monitored for adult disease, fulfilled the WHO definition of pertussis. They had contacts to 173 unvaccinated children aged 6–47 months, and a total of 101 adults with pertussis were followed. Detection of the bacteria, or a significant increase of specific antibodies confirmed the diagnosis. Secondary spread of the disease was assumed, when a household member coughed for 7 days or more and had laboratory evidence for pertussis. Crude attack rates (AR) were 69% in children and 31% in adults (P < 0.05). AR in children were independent of gender but more women than men (P = 0.02) were affected in those households where the index case was a child. Erythromycin treatment of the index case reduced the AR in exposed toddlers from 80% to 57% (P = 0.06), and in exposed adults from 40% to 21% (P= 0.2). Erythromycin therapy in contacts did not alter the clinical course of the disease significantly. Conclusions In a household study of pertussis, 69% of children and 31% of adults (more women than men) contracted the disease. Erythromycin reduced the number of infections in household contacts, but did not alter the clinical course in those who contracted pertussis. Received: 12 June 1997 / Accepted in revised form: 29 September 1997     

Myringoplasty for chronic otitis media

Methods :25 children in the age group of 8—-14 years suffering from chronic suppurative otitis media were taken up for myringoplasty using onlay technique under general anaesthesia.Results: All selected cases had a central type of dry perforation, good cochlear reserve and healthy middle ear mucosa. Cases having enlarged adenoids, infection in nose or throat, any traumatic perforation or previous attempt at closure were excluded from the study. It was found that there was 76% take up of graft after two months who also had improvement in hearing.Conclusion: We conclude that myringoplasty stands a good chance in children.     

Grandmothers’ influence on child care

Objective: This paper compares child care-giving and child's nutritional status among rural families where grandmothers were present and those where grandmothers were absent. Methods: From 27 villages in rural Vadodara, four were randomly selected and all the families (n=31) with children (3–24 months) where grandmothers were present (GMP) were compared with 39 families where grandmothers were absent (GMA). Semi structured questionnaires were used to assess beliefs-practices of mothers and grandmothers regarding breastfeeding and complementary feeding (BF-CF). Nutrient intake of the children and nutritional status were measured using standard procedures.Results: Some deleterious practices were present in a similar proportion of both GMP and GMA groups: giving prelacteals, delaying initiation of BF, exclusive breastfeeding <3 months and delaying initiation of CF. Favorable practices present in significantly more GMP were: active feeding and use of anganwadi services. Grandmother’s help enabled mother to practice more care-giving behaviors. However, children in both the groups had low calorie intake (<40% RDA) and a high prevalence of under nutrition: 56–64% (Weight-for-Age z score <−2).Conclusion: Role of family members in childcare and the benefits of including them in interventions to improve child survival, health and nutrition status need to be further researched.     

Pediatric HIV infection

Objective : The present cross sectional study was undertaken to study clinical profile of HIV infection in children in Northern India.Methods : 64 children from newborn to eighteen years, presenting for confirmation of diagnosis of HIV infection or monitoring of CD4-CD8 counts in confirmed cases, were evaluated. Children were categorized as per CDC classification of Pediatric HIV. The diagnosis was confirmed by serological tests or PCR assay. CD4-CD8 counts were done by FACS Count.Results : Majority of the children were between 18 months to 5 years. Adolescents comprised 24% of the case. 51.5% children were infected through the mode of mother to child transmission. 39% of the case was transfusion-mediated. Unsafe medical injections probably contributed to 6.2% and heterosexual promiscuity led to 3.1% cases. Clubbing, not described in Indian studies so far, was seen in 9.3% cases.Conclusions : HIV infection is a chronic childhood disease extending into adolescence, and contaminated blood and unsafe medical injections are still important routes of HIV transmission in India.     

Precipitants in 42 cases of erythema multiforme

A total of 42 children with erythema multiforme (aged 0.1 to 15.8 years, median 6.1 years) were treated between 1978 and 1997 at the Department of Paediatrics, University of Bern, Switzerland. Antecedent infections were noted in 30 cases: Mycoplasma pneumoniae infection (n = 14), acute upper respiratory tract disease (n = 10) and herpes simplex infection (n = 6). Four cases were associated with antecedent medication (n = 3) or immunization (n = 1). In 12 of the 30 patients in whom erythema multiforme followed an infectious disease, drugs described in the literature as inducers of erythema multiforme had been given for symptoms not suggestive of the condition. In the remaining eight children no precipitating agent could be detected. Conclusion In this survey infections were found as a definite or at least presumptive trigger of erythema multiforme in 71% of cases. Drugs (including immunization) implicated as triggers of erythema multiforme played a definite causative role in 10% and a presumptive role in a further 29% of patients. In 19% of patients an associated condition was not diagnosed. Received: 1 September 1998 / Accepted in revised form: 16 April 1999     

Mental health status of runaway adolescents

There are 47.22 million homeless and runaway adolescents roaming on the streets of our country (Voluntary Health Association of India — VHAI) of which one lakh are in Delhi. Very little is known about them, their needs or their experiences.Objective: (1) To assess the psychological problems amongst the runaway adolescent boys. (2) To determine possible risk factors.Methods: This study was cross-sectional in design and done at a child observation home for boys in Delhi. All runaway boys aged 10 to 16 years of age were included in the study. The study was conducted from 15^th June to 15^th July 2001. A comprehensive schedule consisting of five parts, viz identification data, hopelessness scale for children by Kazdin, Beck depression inventory, Psychological survey questionnaire and RUTTER-B2 scale were used to assess various mental health problems.Results: 20.7% of children were found to have high hopelessness and 8% of children had depression. 2% of children revealed that they had attempted suicide at any point of time in life. Among children with high hopelessness, 3.2% had ever attempted suicide. 8.3% of the depressed children gave history of suicidal attempts. 38% of children gave history of physical abuse, 14.6% of sexual abuse and a large number reported substance abuse. 69.33% were found to have behavioral problems (i.e. scored above the recommended cut off score of 9). 81% of children had antisocial behavior, 7.8% were neurotic and 10.5% remained undifferentiated.Conclusion: Runaway adolescents suffer from a wide array of mental health problems and there is a need for a broad based psychosocial intervention programme.     

Play in orphanages

Objectives: This paper attempts to validate the programme of structured play lasting 90 minutes a day, for use in orphanages, to check if it can be replicated in other orphanages, with similar results.Methods : A 2-week workshop on the structured play scheme was conducted at the Missionaries of Charity Orphanage in Delhi, the venue of the original project. 15 MOC sisters from 6 centers attended the workshop. The authors selected the MOC orphanage at Chandigarh to track the benefits of the programme. The development quotient of all the residents between the ages of 6 months — 3 years was assessed by a pediatric-clinical-psychologist using the Development Assessment Scale for Indian Infants (DAS II) scale. A reassessment of all these children was done again 3 months after initiating the programme of structured play here.Results. The mean motor and mental scores at the orphanage in Chandigarh before the start of the intervention were 57.9 and 58.2 respectively. Post intervention assessments showed a rise of 23 points in both the scores.Conclusion: The development of children in orphanages rises dramatically after initiating a programme of play. The pre-intervention development scores is similar to that in a pilot study and the benefits after play was also similar. The play programme can be easily replicated in other orphanages with similar results     

Respiratory tract infections by Mycoplasma pneumoniae in children: a review of diagnostic and therapeutic measures

 This review discusses the current knowledge on laboratory tests and treatment of respiratory tract infections caused by Mycoplasma pneumoniae (MP) in children. MP infection is endemic in most areas of the world. The highest incidence is seen in children aged between 3 and 14 years. Most infections are mild and non-pneumonic. Parapneumonic complications of MP pneumonia are rare. Complications are described affecting the skin, central nervous system, kidneys, heart, muscles and the eyes. To diagnose an acute MP infection in children, a combination of PCR and IgM serology is sensitive and convenient. In both tests it is possible to obtain a result in 1 to 2 days. As a consequence, adequate antibiotic treatment can be prescribed to the child. Macrolides are the first choice in treatment of MP infection in children. Conclusion  The most sensitive and rapid test to diagnose a Mycoplasma pneumoniae infection in children is a combination of nasopharyngeal polymerase chain reaction and IgM enzyme immunoassay. The treatment of choice in children is a macrolide. Received: 25 October 2000 and in revised form: 28 February and 30 March 2001 / Accepted: 30 March 2001     

Lipid peroxidation in bronchial asthma

Objective: To study the levels of free oxygen radicals in children with bronchial asthma during an attack and symptom free interval.Methods: Serum Malondiadehyde (MDA) levels were studied in 25 children between the age of 6 years-14 years who presented with an acute attack of bronchial asthma. In each patient, serum MDA levels were measured at the time of admission, 24–48 hours after good response to treatment and after a symptom free interval of 3 weeks. Results were compared with control group.Results: In study group serum MDA levels were highest at the time of admission, which decreased significantly at 24–48 hours with treatment. After a 3 weeks symptom free interval serum MDA levels had decreased further but were still higher than healthy control group.Conclusion: Lipid peroxidation is increased in bronchial asthma during an acute attack and symptom free period.