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Background: With the introduction of antiretroviral therapy (ART), the mortality and morbidity of HIV/AIDS have decreased markedly. However, high adherence to ART (>95%) is necessary for a good therapeutic outcome. There is a paucity of data on paediatric adherence to ART and its correlates from developing countries, particularly India., Aim: To determine the rate of adherence to ART in HIV-infected Indian children and the factors associated with adherence., Methods: A cross-sectional study was conducted at an ART clinic in New Delhi, north India. Caregivers of 90 children were interviewed using a pre-designed, structured questionnaire and checklist. The primary measure of adherence was 4-day caregiver's recall. Adherence rates were correlated with 3-monthly CD4 counts., Results: Mean (SD, range) adherence was 91·4% (12·3, 75-100%). Adherence was low (<95%) in 31 (34·4%) patients. On multivariate logistic regression analysis, increasing time since ART initiation (OR 1·08, 95% CI 1·02-1·13), low caregiver educational status (OR 4·19, 95% CI 1·37-10·88), orphanhood (OR 3·57, 95% CI 1·13-9·25), efavirenz-based ART regimens (OR 3·65, 95% CI 1·05-10·69) and female gender (OR 3·15, 95% CI 1·03-7·68) were associated with lower adherence. The rise in CD4 count after ART initiation was more marked in the high adherence group, with the difference in the two groups becoming statistically significant after 6 months of ART (median CD4 count 698 vs 355, p=0·016)., Conclusions: It is possible to achieve high adherence to ART in a resource-limited setting. Caregiver recall is a reliable and inexpensive tool for measuring adherence. Paediatric adherence to ART is influenced by numerous factors and larger studies are needed to address the issue in India.

Justification: The first National Guidelines on Infant and Young Child Feeding (IYCF) were formulated by Ministry of Women and Child Development (Food and Nutrition Board) in 2004, and the same guidelines were revised in 2006. India is committed to halving the prevalence of under weight children by 2015 as one of the key indicators of progress towards the Millennium Development Goals (MDG). By the end of 2009 nutritional achievement goals did not make for happy reading. So there was need to revise the existing guidelines and to have more viable and scientifically accepted national guidelines on Infant and Young child feeding., Process: A National Consultative Meet was organized by Indian Academy of Pediatrics at Gurgaon in 2009 where members of IYCF and Nutrition Chapters of IAP, BPNI, WHO, UNICEF, USAID, WFP were present. Each group made detailed presentations after reviewing recent literature on the subject. After extensive discussions a consensus was reached and the guidelines were formulated., Objectives: To formulate, endorse, adopt and disseminate guidelines related to Infant and Young Child feeding from an Indian perspective (including infant feeding in the context of HIV infection)., Recommendations: Optimal infant and young child feeding: Early initiation of breastfeeding, exclusive breastfeeding for the first six month of life followed by continued breastfeeding for up to two years and beyond with adequate complementary foods is the most appropriate feeding strategy for infants and young children. Adequate nutrition and anemia control for adolescent girls, pregnant and lactating mother is also advocated.

Objective: To assess the metabolic drug toxicities of first-line, World Health Organization (WHO)-recommended generic highly active antiretroviral therapy (HAART) regimens, to estimate the prevalence of body fat redistribution and to identify associated risk factors., Methods: Cross-sectional observational study. During 3 month period, 52 HIV infected children (25 on HAART; 27 not on HAART) were assessed. Their sociodemographic, clinical, and immunological data was recorded. Children were examined or the signs of fat redistribution (peripheral lipoatrophy and central lipohypertrophy). Liver function tests, fasting blood sugar, lipid profile, serum amylase, serum lactate, blood pH and bicarbonate levels were done in all patients., Results: Twenty-two patients were on stavudine and three on zidovudine based HAART. None of the patients ever received any protease inhibitor. There were no cases of clinical or immunological failure. Children on HAART had significantly lower weight for age and body mass index but the mean height for age was similar between study groups. Only two cases of peripheral lipoatrophy were observed. Hypercholesterolemia was observed in four children on HAART but none without therapy. Hypertriglyceridemia was observed in three children on HAART and seven without therapy. Four cases of asymptomatic mild hyperlactatemia were observed. No case of any hyperglycemia or liver impairment was observed., Conclusion: Metabolic abnormalities and lipodystrophy are emerging complications of HAART in Indian children and needs very close follow up. Future studies with larger sample size and longitudinal model are recommended.

We report a 4-year-old boy presenting with a tense massive ascites and large hydrocele. History and physical examination were unremarkable. Routine laboratory studies were normal. Abdominal ultrasonography revealed massive ascites. Contrast CT was suggestive of a large cyst covering the entire peritoneal cavity. At laparotomy, a large cystic tumor was found extending into the scrotum through the left inguinal ring. Histopathologic examination diagnosed the tumor as a cystic lymphangiomatous hemartoma. Although abdominal lymphangiomas are seen in children, but presenting as massive ascites with hydrocele is very rare.

Background: The clinical efficacy of highly active antiretroviral therapy (HAART) in children has been well documented in the developed countries, although most of the regimens are Protease Inhibitor (PI) based which are too expensive. To circumvent this problem World Health Organization (WHO) has recommended Non- Nucleotide Reverse Transcriptase Inhibitor (NNRTI) based regimen for resource-limited countries., Aim: To assess the long-term efficacy of first line World Health Organization (WHO)-recommended generic highly active antiretroviral therapy (HAART) regimens in treatment -naïve children., Materials and Methods: Observational retrospective analysis was done. Thirty patients on HAART for >or= 6 months were included (27 on Stavudine; three on Zidovudine with Lamivudine/ Nevirapine). No protease inhibitors were used., Results: Median age was seven years (Interquartile [IQR]: 5.62-8.50) and median duration on HAART was 18 months (IQR: 6-24). No new staging events were observed after six months of initiation of HAART. The median CD4% increased from 6.0 % at baseline to 15.5% at six months, 21.7% at 12 months, 25.4% at 18 months, 24.6 % at 24 months 25.3% at 30 months and 23.7% at 36 months. There was only one case of immunological failure. Stratifi ed analysis based on baseline CD4% show that even patients with a baseline CD4 % of <5% achieved percentage of >25% at 18-24 months and maintained it subsequently. Significant increase in the weight and body mass index Z scores was observed but significant fall in the height Z scores were observed. This sub group of patients with poor linear height velocity would require detailed endocrine evaluation after testing for viral loads., Conclusions: Non- Nucleotide Reverse Transcriptase Inhibitor based HAART regimens are feasible and effective in long term in resource-limited setting despite initiation of treatment in advanced stages. These can be continued in NACO/WHO scale up programmes at present for children.

Celiac disease (CD) is being increasingly reported from the wheat-eating population of north India. However, the exact prevalence of CD in children is not known as population screening studies are scarce. Our study aimed to determine the prevalence of CD in 400 children, 6 months to 12 years of age attending pediatrics department of a tertiary care hospital in north India. The study population was screened for antitissue transglutaminase (tTG) antibodies. Endoscopic duodenal biopsy was done in the anti--tTG positive subjects. Four patients were diagnosed with CD as per the modified ESPGHAN criteria. The prevalence of CD thus was 1 %, which was in concordance with screening studies using serological markers conducted in the West.

Background: Fever of unknown origin (FUO) is an important cause of morbidity and mortality in children, especially in tropical and developing countries., Aim: To determine the aetiology and outcome of FUO in Indian children., Methods: A hospital-based, prospective, observational study was conducted over a 1-year period (2006-2007). Children aged > or =3 months to 12 years who qualified for the definition of FUO were recruited. Initial evaluation included complete blood count, peripheral smear for malarial parasites, erythrocyte sedimentation rate (ESR), urine analysis and culture, blood culture, tuberculin test and chest X-ray., Results: Of 49 patients evaluated, a diagnosis was reached in 43 (88%). Infections were the predominant cause of FUO in 34 patients (69%). Enteric fever was the most common infection (14), followed by visceral leishmaniasis (10) and tuberculosis (5). The next most common cause was malignancy (6, 12%). Among the six undiagnosed patients, spontaneous resolution occurred in five whereas one child continued to be febrile without an established cause at the end of the study., Conclusion: Repeated, thorough clinical examination and carefully selected laboratory examinations proved useful in the diagnosis of FUO. Serology (e.g. enteric fever) and bone marrow examination (e.g. leishmaniasis, malignancy) were the most useful diagnostic tests.

Growth failure is one of the most common problems in children with thalassemia with multiple etiologies. We present a case of celiac disease, an underdiagnosed cause of growth failure in a child with beta-thalassemia major. A 10-year-old boy on a hypertransfusion regimen was referred for early onset growth failure. Serology for hepatitis B, hepatitis C, and HIV was negative. Serum zinc levels were normal. Thyroid function tests and growth hormone secretion, evaluated with clonidine stimulation test were normal. Malabsorption syndrome was suspected, even in the absence of gastrointestinal symptoms. Tissue transglutaminase were highly raised >300 IU/mL (normal values <15 U/L). Characteristic mucosal lesions on jejunal biopsy confirmed the diagnosis of celiac disease. Institution of a gluten-free diet resulted in rapid gain in weight and improvement in height velocity.

Caspofungin is a new antifungal drug meant for intravenous use. It has been shown to be comparable to other antifungal agents such as amphotericin B and fluconazole for empirical therapy in febrile neutropenic patients, oropharyngeal/esophageal candidiasis and invasive aspergillosis. Its efficacy has also been documented in children in small uncontrolled trials. The biggest assets of caspofungin are its excellent tolerability/safety profile and minimal drug interactions.

The management of Beta Thalassemia, the commonest form of hemolytic anemia in children, has changed significantly in the last few years. With the availability of better transfusion regimen, iron chelation therapy, proper management of complications and good supportive care, it is now possible for a thalassemic child to have a near normal life span with a good quality of life.

V. cholerae O1 Eltor serotype Ogawa has been causing most of the cholera outbreaks in India till recently. However this communication reports the occurrence of Vibrio Cholerae O1 Inaba in Delhi in 2005, as a predominant causative organism of cholera in children. All strains isolated were sensitive to gentamicin and a high level of resistance towards nalidixic acid and amoxicillin was seen. There was no case fatality.

Anticancer chemotherapy is associated with a variety of nail changes. We present two children who developed different nail changes, while receiving almost similar antineoplastic drugs.

Deferasirox is a new tridentate oral iron chelator developed by computer remodeling recently approved by FDA for children above 2 years. Phase II/III trials have demonstrated similar efficacy to desferrioxamine and better chelation efficiency. Adverse events were minor and growth remained unaffected. Data on cardiac iron chelation is limited although some studies have shown it comparable to deferiprone. The benefit to risk profile of deferasirox is favorable. This promising new drug might decrease the burden of subcutaneous or intravenous infusion improving compliance and hence the life expectation in thalassemic patients.

Objective: To evaluate the safety and reactogenicity of a reduced-antigen-content combined Diphtheria Tetanus Acellular Pertussis (dTpa) vaccine in Indian preschool children., Methods: GlaxoSmithKline Biologicals combination dTpa vaccine was administered as a single booster dose to 347 children aged 46 years in seven centers across India. All children were subsequently followed up for two weeks for safety and reactogenicity assessment., Results: A total of 345 subjects completed the study and two subjects were lost to follow-up. One serious adverse event (head injury) unrelated to vaccination was reported. Otherwise, all subjects were in good health throughout the study period. Three subjects (0.9%) reported transient general symptoms (such as irritability and drowsiness), which prevented normal activity. Pain at injection site, swelling and redness was reported in 31.1%, 18.2% and 8.9% subjects respectively. Five subjects (1.4%) reported severe pain preventing normal movement. This resolved within 48 hours in all cases. There were no other severe local reactions including large injection site reactions., Conclusion: The reduced antigen content combined dTpa vaccine is safe and well tolerated in Indian pre-school children.

The present study aimed to investigate pulmonary function tests (PFTs) in children with thalassemia and to assess the relation between the degree respiratory impairment with the body iron status. High resolution computed tomography of chest (CHRCT) and bronchoalveolar lavage (BAL) was performed to study the cause of pulmonary dysfunction. Thirty-one children with thalassemia over 8 years were included. PFTs were studied including lung volumes and carbon monoxide diffusion capacity (DLco). Patients with abnormal PFTs and/or impaired DLco were further subjected to CHRCT and BAL. Total cell count was measured; differential count was performed on Giemsa and PAP smears. Iron laden macrophages were identified on Perl's stain. PFTs were normal in 51.61%, diffusion capacity impaired in 41.16%, restriction in 16.12%, while obstruction in 3.22% of cases, respectively. There was significant inverse correlation between DLco and serum ferritin. Through multivariate regression analysis, ferritin was found to be a strong predictor for forced vital capacity and total lung capacity. Bronchial dilatation and areas of air trapping were the predominant CHRCT findings. Iron laden macrophages were demonstrated in 14 of 15 patients in BAL. A significant correlation between serum ferritin and DLco, forced vital capacity, total lung capacity, and the presence of iron laden macrophages in BAL indicates that iron plays a major role in the etiopathogenesis of these abnormalities.

Peripheral gangrene as a manifestation of tuberculosis is very uncommon. An 8 year old male child presented with non-healing ulcer over the sole of left foot, left inguinal tubercular lymphadenopathy with scrofloderma, tubercular pleural effusion and gangrene of the right fore foot. The child improved on antitubercular treatment.

Objective: To evaluate the short-term effect of frequency of complementary feeding on total ad libitum consumption in breast fed infants., Methods: Twenty infants between 6 to 10 months of age were studied in a tertiary hospital in New Delhi for 48 hours. A traditional gruel made of rice and pulses (mean (SD) caloric density 54.22 (7.08) kcal/100 g) was offered in a randomized manner three (n = 10) or four (n = 10) times per day to the subjects over the first 24 hours with the subjects crossing over in the next 24 hours. They were allowed ad libitum breast feeding with no other food or fluid during the study period. Total caloric intake from breast milk and semisolids was computed for each day., Results: There was no difference in the total caloric consumption with a semisolid feeding frequency of three or four times per day. The frequency of breast feeding and the breast feeding duration were also comparable (P > 0.05). However, breast milk intake was lower with a semisolid feeding frequency of 4 times/day (mean difference -61.2 g/d [95% confidence interval (CI) -122.2-0.32]; P = 0.051). The time required for feeding was higher (mean difference 14.75 min; P < 0.001), whereas the per meal intake of semisolids was lower with four semisolid feeds per day (mean difference -5.5 kcal/meal; [95% CI -10.19 to -0.81]; P = 0.024)., Conclusion: In the short term, a change in semisolid feeding frequency from three to four times per day does not result in enhanced energy consumption because of lower breast milk intake.

Objectives: To evaluate the short term effect of oil supplementation of complementary food on total ad libitum consumption in breastfed infants., Methods: Twenty infants between 6 to 10 months of age were studied in a tertiary hospital in New Delhi for 48 hours. They were given three semi-solid complementary feeds per day and ad libitum breastfeeding. No other food or fluid was allowed during the study period. A traditional gruel made of rice and pulses with high energy density (oil added; caloric density = 35 kcal/100 g) or low energy density (without oil; caloric density = 20 kcal/100 g) was offered in a randomized manner on consecutive days to all infants. Total caloric intake from breast milk and semi-solids was computed for each day., Results: Infants consumed an equivalent amount of semi-solid (mean difference, 10.75 g/day; 95% confidence interval, 10.56 to 32.06; P = 0.304) and a lower amount of breast milk (mean difference, 121.1 g/day; 95% confidence interval, 35.13 to 207.16; P = 0.008) when high energy density feeds were offered. Although the caloric intake from semi-solids increased significantly (18.9 kcal/day; 95% confidence interval, 12.9 to 24.8; P < 0.001) with the high density diet, the total caloric intake (breast milk and study feeds) decreased (mean difference = 59.6 kcal/day; 95% confidence interval, 5.95 to 113.34; P = 0.031). An inverse relationship was found between caloric density of semi-solids and breast milk intake (r = 0.34, r = 0.12, P = 0.032)., Conclusion: In the short term, oil supplementation of complementary food in breastfed infants does not translate into enhanced total caloric intake, primarily as a result of breast milk displacement.

Hepatitis C virus is considered to be the main aetiological agent responsible for the occurrence of post-transfusion hepatitis. Patients with thalassaemia acquire hepatitis most often from viruses contracted through blood transfusions. The present study was undertaken to evaluate the prevalence of hepatitis C virus (HCV) in thalassaemic patients with multiple blood transfusions. The association of HCV seropositivity with number of blood transfusions and liver enzyme profile was also analysed. The study group consisted of fifty patients (40 males and 10 females) attending the thalassaemic unit of Lok Nayak Hospital, a tertiary care hospital at Delhi, within the age group of 1-25 years. Thirty patients (60%) were found to be seropositive for HCV antibodies while one patient (2%) was co-infected with HCV antibodies and hepatitis B surface antigen. Study of liver enzyme profile showed aspartate aminotransferase levels to be significantly higher, although the level of serum alanine aminotransferase, alkaline phosphatase, total protein, bilirubin and albumin were not significantly altered in these patients. It is inferred from this study that 60% of the thalassaemics were infected with HCV and this was directly related to the number of blood transfusions received by them. The regularised national blood policy followed by blood banks for providing safe blood along with better screening method of donated blood in blood banks would bring down the incidence of hepatitis C in such high risk group.

A case of idiopathic hypereosinophilic syndrome who had an unusual presentation in the form of pericardial effusion is being presented here. The child initially responded to corticosteroids but could not maintain normal eosinophil counts on tapering of steroids. Therefore he was put on hydroxyurea and low dose of steroids with regular monitoring of absolute eosinophil counts.

Nutritional status of 44 children with newly diagnosed malignancy was evaluated by anthropometric, hematological and biochemical parameters before initiating therapy and response to therapy was assessed during follow up. Malnutrition was seen in 56.8% children by weight for age criteria (WFA <-2 z). Low hemoglobin was found in 82% children, 25% had low total proteins (<5.7 g/dL), 20.5% low serum albumin (<3.2 g/dL), 27.3% low serum transferrin (<210 mg/dL) and 16.3% low serum iron (<60 ug/dL). Mean anthropometric and biochemical parameters were higher among the survivors compared to non-survivors. Significant difference between the well nourished and the malnourished group was detected in the achievement of remission/response (69.5% vs 38.1%), delays in therapy (8. 7% vs 38.1%) and mortality (30.5% vs 61.9%). Complications like febrile neutropenia and bleeding were more in the malnourished group. A statistically significant higher incidence of infection was seen in children with serum iron<60 ug/dL than those with higher values of serum iron (42.8% vs 8%). Malnutrition is a major determining factor in treatment planning, complication rates, response to therapy and survival.

MMR is a live attenuated vaccine. Indian children show almost 90% seroconversion against measles and rubella and 90% against mumps. Several adverse effects have been reported. Epidemiological studies do not support a causative link between MMR and autism, IBD or GBS. There is an association between the Urabe strain of mumps vaccine and viral meningitis. Vaccine associated thrombocytopenia has been reported. Severe hypersensitivity reactions occur, mainly due to the gelatin component. Outbreaks of measles occur in areas of high measles vaccine coverage, when susceptible individuals accumulate. A second dose is given mainly to vaccinate those who missed the first dose or had primary vaccine failure, rather than to boost waning antibody levels. The possibility or eradication of mumps with a second dose of mumps vaccine is being considered.

The objectives of the present report were to study the site of infections and pathogenic organisms during febrile episodes in different childhood malignant conditions, to correlate febrile episode with Absolute Neutrophil Count (ANC) and to know the sensitivity pattern of bacteria to different antibiotics so as to know the most appropriate antibiotic regimen in these children. The study material comprised of forty two febrile episodes occurring in children aged lt 12 years with various malignancies. All the episodes were worked up in detail including complete history, physical examination and relevant hematological, microbiological and radiological investigations. Out of the 42 episodes, 15 (36%) occurred in children with acute leukemias, 20 (48%) in children with lymphomas and 7(17%) in children with solid tumors. 26 (62%) episodes were seen in children during chemotherapy, while 12% each in freshly diagnosed and remission and 14% in relapse cases. 12 (28%) episodes occurred in children with ANC < 500/mm3. 36% were microbiologically confirmed. Klebsiella species was the commonest organism isolated followed by E. coli. Maximum sensitivity (75%) was seen with ciprofloxacin against both Klebsiella species and E.coli.

The study was conducted on 75 multitransfused children aged between 2 and 13 years who attended the Department of Paediatrics, LNJPN Hospital, New Delhi from July 1990 to July 1991. These included 64 cases of thalassaemia major, 4 cases of haemophilia, 3 patients of acute lymphatic leukaemia and one each of acute myeloid leukaemia, aplastic anemia, chronic idiopathic thrombocytopenic purpura and acute haemorrhagic pancreatitis. HBsAg was tested in all, Anti-HBc was tested in 44 patients and Anti-HCV in 43 patients. Anti HDV was tested in HBsAg positive patients and IgM anti-HAV was tested in patients suffering from hepatitis. Liver function tests were evaluated in all patients. HBsAg was positive in 31% of patients; 40% of males and 15% of females were HBsAg positive, the difference being statistically significant. 84% of patients were Anti-HBc positive, 21% were anti HCV positive, 4% were Anti HDV positive. 15% of the patients had post transfusion hepatitis. Anti HCV was present in 57% of the hepatitis patients; none had anti-HAV IgM.

Twenty one children of beta thalassemia major aged between 2 and 14 years of age on regular blood transfusion were given subcutaneous desferrioxamine. Their serum ferritin, 24 hours baseline urinary iron excretion and subcutaneous desferrioxamine induced urinary iron excretion were measured. The result showed a close correlation between serum ferritin and amount of blood transfusions received by the patient. There was good correlation between serum ferritin and desferrioxamine induced urinary iron excretion. A negative iron balance could be achieved in 15 out of 21 children with one dose of desferrioxamine therapy.

Locally available commercial preparations of oral rehydration solutions (ORS) were analyzed for their composition, package instructions and availability. A survey from 50 chemist stores, revealed that ORS packets available belonged to 28 different pharmaceutical companies. None of the shops stored more than five different brands and alternate preparations were handed over the counter freely. Only 48% of the available ORS formulations had the WHO recommended composition. In about one-fourth preparations, the sodium concentration was 30 mEq or less per litre. Forty-one per cent solutions had glucose concentrations more than 2%. The glucose and sodium ration of 1:1 was maintained in only 48% of the formulae. Bicarbonate and citrate both were used with almost equal frequency in these preparations. Cost, flavor, additional ingredients and package instructions varied widely in different packets. ORS formulations most commonly found in the drug stores had low sodium and high glucose concentration. The attitude of doctors and nurses of Pediatric Department and Chemists towards commercial ORS was also studied. While 92% doctors were aware about WHO-ORS, none of the chemists and only 4% nurses had this awareness. All the respondents could remember only up to 3 or 4 brand names and except 30% doctors, none were aware about the composition of those brands of ORS. Regarding importance of composition, preparations and precautions, practically nobody was up to the mark, but doctors were definitely better as compared to nurses and chemists.

In a series of 89 patients with acute leukemia, orbital granulocytic sarcomas were observed in 7. All these patients had acute nonlymphocytic leukemia, and they were all children. The orbital involvement usually was bilateral, and the patients had proptosis, conjunctival hemorrhage, and chemosis. Morphologic, cytochemical, and immunophenotypic analyses did not show a predilection for any particular myeloid cell type. Two patients had biphenotypic leukemias with myeloid components. The ocular manifestations responded well to chemotherapy irrespective of the hematologic response.

There is a paucity of data on the incidence of sporadic viral hepatitis in Indian children. Clinical, biochemical and etiological profile of 54 patients with acute viral hepatitis was evaluated. Of these, 32 (59.25%) patients had Hepatitis A, 18 (33.33%) had NANB, 2 (3.7%) had Hepatitis B and 2 (3.7%) concurrent Hepatitis A and B infection. It was not possible to distinguish the etiological agents on the basis of the clinical and biochemical profile. Fulminant hepatitis was documented in 8 (14.8%) cases. Children with NANB infection were at a greater risk (p less than 0.05) of developing fulminant hepatitis as compared to Hepatitis A infection.

Recently reversible computerized tomographic (CT) lesions following seizures have been reported, mostly in adult subjects. Focal CT lesions following seizures were recorded in 20 children. The distribution of the lesions was parietal in 17, frontal in two, occipital in one, and temporo-parietal in one. Multiple simultaneous lesions were observed in one child. Plain scan revealed evidence of cerebral oedema in 16 patients (mild 10, moderate four, and severe two). Enhanced scan showed a ring lesion in 12, hyperdense focus in five, and non-enhancing (hypodense) lesion in two children (excluding one child who had multiple lesions; three rings and one dense focus). These subjects were treated with anti-epileptic drugs only. Repeat CT scans yielded a complete resolution in 12 and a significant resolution in eight. It is concluded that in children with seizures, reversible CT demonstrable focal abnormalities may occur.