Child and Chest Health Care Delhi NCR

Satyam is a 5 years old male child,visited our OPD with parents ,who complained of their son is suffering from fever for last 9 days ,before which he was completely normal.He is not interested in eating anything even of his choice for last 5 days and not taking interest in any outdoor or indoor play for last 2 days.He has taken treatment form local doctor for the same with no relief.

On examination,he is febrile with axillary temperature of 102degreeF,Pulse rate 120/minute,regular with fair volume. Anthropometry was within normal limit.Respiratory rate 42/minute,regular and no chest retraction.There was no pallor,no icterus.Bilateral tender lymphadenopathy was there and there was bipedal edema with swelling in hands. There was maculopaular rashes over body.Throat was congested with bilateral conjuntival injections. Tongue was normal in colour with no coating.On systemic examination,chest was clear on auscultation,haert sounds were normal with no adventitious sound ,CNS examination was normal.Abdominal examination revealed non tender hepatosplenomegaly.

Following possibilities werw kept in mind

=ENTERIC FEVER

=MALARIA

=INFECTIOUS MONONUCLEOSIS

KAWASAKI DISEASES

and child was investigated accordingly.

TLC was 5000/cmm with neutrophilic predomonance.Hemoglobin was 11gm/dl,ESR was 38mm in onehour,Platelets 1.6 lacs/cmm

Serum widal and typhidot was negative,P.S .for MP and malaria antigen was negative and blood culture was sterile.

Serum anti EBV IgM was negative

LFT and KFT : liver enzymes were  within normal range,Serum electrolytes,blood urea and serum creatinine were normal.

BLOOD SUGAR:normal

Chest Xray shows mild right sided pleural effusion,USG abdomen shows mild ascites with mesenteric lymphadenopathy.

Echocardiography did not show any dilatation of coronary artery and its branches.

Then, upon reviewing the literature, it was suspected that it may be a case of SCRUB TYPHUS and investigated for that.

Weil Felix test was negative.

Serum IgM antibody against 56 kDa protein by ELISA was positive.Then we leveled the case as scrub typhus and the child responded well to azithromycin.

On retrospective history taking,there was no history of visit to hilly or forest regions in recent past but the child had visited a village in western U.P.India, in recent past.

SCRUB TYPHUS

It is an  infectious  disease(type of Rickettsiosis), caused by bites by mites which are common in Forest areas.

It is a vector born disease commonly seen in hills and forests but may be seen anywhere.

The organism responsible for the disease is known as Orientia tsutsugamushi which is transmitted to human from rodents by the bite of a mite,  when it is in larval stage(chigger).

The average incubation period is 10 days which varies from 5 to 20 days.

The bite is painless and so goes unnoticed, in most of the cases.

The site of bite becomes erythmatous which enlarges peripherally and there becomes central necrosis with peripheral erythmma which is known as Eschar and it is pathongnomonic of scrub typhus.

concurrent infection may inhibit the replication of HIV.

It causes vasculitis(endothelial inflammation0).

CLINICAL FEATURES:

symptoms

Fever is a universal feature which is usually of high grade 104 degree-105degree F(40-40.5 degree C).

Fever may be associated with chills and rigor.

There may be dry cough,malaise,loose motion or .vomiting, pain abdomen.The child may complaint of headache.

signs

There may be regional or generalised lymphadenopathy,which may be tender.

Eschar may be noticed in some cases at the site of mite bite.

There may be conjunctival injections.Edema may be present in lower limbs and there may be swelling of hands.

On systemic examination ,one can find hepatosplenomealy,hepatomegaly,or only splenomegaly

There may be signs of third spacing of fluids in the form of pleural effusion or ascites.

LABORATORY FINDING:Alongwith clinical features ,one can find following labratory abnormalities.

Anemia,lymphopenia followed by lymphocytosis(leukocytosis),thrombocytopenia,raised ESR,raised CRP.Increased level of liver trasaminases,hypoalbuminemia and hyponatremia.

DIAGNOSIS:The clinical triad of scrub typhus is fever,eschar and rash.

Weil Felix test which is widely available for the diagnosis of Rickettsial diseases, but it is less sensitive and less specific to diagnose this condition.The gold standard test to diagnose is, Indirect immunoflouresence test, which is available at selected centres of the world.In this test, patients serum is mixed with scrub typhus antigen ,which is then reacted to florescent bound anti human antibody.

TREATMENT:Apart from symptomatic treatment,specific therapy includes macrolides like azithromycin,roxithromycin,and telethromycin.Tetracycline and Doxycycline, chloramphenicol.Quinolones have been less used.

Rfampicin is given in multidrug resistant cases.

COMPLICATIONS:If not recognised and treated early ,it may be complicated by pneumonitis,meningoencephlitis acute renal failure and DIC ,that may be fatal.

MY OPINION: In any geographical location,when the child presents with fever with chills and rigor,with hepatosplenomegaly,one should investigate for typhus fever after ruling out malaria,enteric fever,leptospirisis and Dengue fever.

REFERENCES:

• Silpapojakul K, Chupuppakam S, Yuthasompob S, et al.: Scrub and murinetyphus in children with obscure fever in the tropics. Pediatr Infect Dis J.10:200–203 1991 2041666

• Silpapojakul K, Varachit B, Silpapojakul K: Paediatric scrub typhus in Thailand: a study of 73 confirmed cases. Trans R Soc Trop Med Hyg.98:354–359 2004 15099991

• Sirisanthana V, Puthanakit T, Sirisanthana T: Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J. 22:341–345 2003 12690274

• Watt G, Kantipong P, de Souza M, et al.: HIV-1 suppression during acutescrub–typhus infection. Lancet. 356:475–479 2000 10981892

• Koh GSKW,Maude RJ,Paris DH,NeutonPN,Blacksell SD.Diagnosis of scrub typhus.Am J Trop Med Hyg.2010;82:368-70.

• Panpanich R, Garner P: Antibiotics for treating scrub typhus, Cochrane Database Syst Rev (3):CD002150, 2002.
• Lee KY, Lee HS, Hong JH, et al.: Roxithromycin treatment of scrub typhus(tsutsugamushi disease) in children. Pediatr Infect Dis J. 22:130–133 200312586976

  Watt G, Kantipong P, Jongsakul K, et al.: Doxycycline and rifampicin for mildscrub–typhus infections innorthern Thailand: A randomised trial. Lancet.356:1057–1061 2000 11009140

Peter is a male child of 2 years and 9 months, who was brought to our OPD, by their parents.Parents complained of, they saw their son playing with glass mercury thermometer which was broken.The child was suffering from fever.They took advice from local doctor and the doctor adviced them to give syrup paracetamol when temperature by mouth was more than 99.5 degree F.They measured the temperature and forgot to keep the thermometer at safe place.They could not see the mercury in the thermometer which was broken in the hand of their son and assumed that the child has ingested the mercury.There was no vomiting and the child was not restless after the event.Parents recalled the time lapsed from event to reaching the OPD,was approximately 2-3 hours.On examination the mouth cavity was completely normal with no sign of any cut or abrasion.Vital parameters were within normal limits.Chest on auscultation was clear.On abdominal examination,there was no distension and no tenterness.The child was admitted for observation of any sign of deterioration.Chest X-Ray and abdominal X-Ray were done next day.Abdominal X-Ray showed white dots scattered throughout the abdomen which we thought,was due to mercury particles.The child remained stable throughout the hospital course and the repeat X-Ray abdomen showed the clearance of white dots at the time of discharge.

Mercury is a silver white element which is liquid at room temperature.It is used in mercury thermometer to record temperature and in manual sphygmometer to measure blood pressure .Both are commonly used in houses in India.On ingestion,it is not absorbed by the mucosa of mouth and intestine as long as the mucosae are intact.But abrasion or cut due to any reason in the mucosa breach this barrier and it gets absorbed and affects various organ including kidney and reproductive organs.In our case there was no breach in the continuity of mucosa ,so the mercury could not be absorbed and the course of hospital stay of the child was uneventful.Glass mercury thermometer contains 500-700 mg of mercury,which if get absorbed may harm different organs.

On ingestion,vomiting should not be induced and activated charcol should not be given but close monitoring is essential.

REFERENCES :

1.Yaghmaie B, Jazayeri SB, Shahlaee A.Mercury ingestion from a broken thermometer. Arch Dis Child.2012; 97:852.

2.Caravati EM, Erdman AR, Christianson G, Nelson LS, Woolf AD, Booze LL, et al; American Association of poison control centres.Elemental mercury exposure:an evidence-based consensus guideline for out-of- hospital management. Clin toxicol (Phila).2008; 46:1-21.

3.Saxena R, Kumar A,Satkurunathan Mercury aspiration from a broken thermometer. BMJ case Rep.2009.doi:10.1136/bcr.04.2009.1741.

On the day of Doctors Day today, when we are celebrating the day in the memory of DR B.C.ROY,who was born and died on 1st July,I would  like to highlight the issue of how useful and harmful is to expose our children to media.

By using the word media,I mean to say television news and different programmes on television which attract children,social media including Facebook,Whatsapp ,videogames of different types and access to internet.

Everything and anything may be useful and harmful depending on how we interpret and use it.Children specially less than 8 years old are usually not able to discriminate between what he or she watch and what should not be watched.Moreover,the can not interpret the contents in its perspective correctly.Any information bad or good impacts a lot on the growing brain.Sometimes, children imitate to do what they watch, being unaware of what is its consequence.There are so many mental problems occurring in children which may be and have been linked to media exposure by research study.The most important which is affecting our societies worldwide is violence .Children are becoming less tolerant and more demanding due the impact of media.

On the other hand, children have developed sedentary habits by giving much time to media They are sitting for a long time in different desirable and undesirable postures ,avoiding outdoor activities and games.These habits are giving room to develop different physical diseases including Obesity,Diabetes mallitus,Hypertension and different cardiovascular diseases .It affects eye vision and the radiation coming from these electronic devices, lowers the level of Melatonin which is an antioxidant, naturally occurring in our body.This in turn make them susceptible to cancer.

So ,media exposure should be limited to one hour in a day and restricted to quality content which gives positive impact on the growing brain.On the other hand,if possible, parents should be available at that time to explain the contents by correctly interpreting it, in its perspective.

REFERENCES:

.American Academy of Pediatrics, committee on communications. Children, Adolescents, and Television (RE0043).Pediatrics. 2001; 107:423-6

.Williams CL, Heyman LL, Daniels SR, Robinson TN,Steinberger J,Paridon S et al.Cardiovascular health in childhood.J circulation. 2002; 106:143-60

.Drzal GJ, Snela S,Rykala J , Podgorska J, Rachwal M.Effects of the body position on sitting posture of children aged 11-13 years.Work.2014; 6:1-8

.Wood B, Rea SM, Plitnick B, Figueiro GM.Light level and duration of exposure determine the impact of self luminous tablets on Melatonin suppression. Applied Ergonomics J.2013; 44:237-40.