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Fronto-temporal lobectomy for refractory intracranial hypertension following an acute arterial ischemic stroke in a child is rarely performed following failed conventional measures including decompressive craniectomy. We present a case of a 10-year-old child who presented with acute ischemic stroke with intractable cerebral edema and failed conventional measures including decompressive craniectomy and had significant neurological recovery following frontotemporal lobectomy.

The objective of the study is to estimate the incidence of acute liver failure (ALF) in dengue infection, understand the demographic and biochemical profiles, and identify prognostic factors associated with mortality.This is a retrospective observational study. We evaluated the data of all pediatric dengue patients admitted over the last 5 years in our hospital to identify patients who fulfilled the criteria for pediatric ALF (PALF). Demographic profile, and biochemical and radiological parameters were assessed. Their outcomes and mortality data were analyzed to identify prognostic factors.Thirty children with dengue infection were identified to have developed a during the ALF study period which was 29.1% (30/103) of all our ALF admissions. Total of 189 children with dengue infection needed admission during the same period and 15.8% (30/189) of them developed ALF. The mean duration of onset of ALF was 5.4 days after fever onset. Twenty-two patients (73%) survived, and 8 patients expired. High creatinine, low albumin level, and multisystemic involvement were identified as poor prognostic markers in those patients who did not survive.ALF is common in admitted severe dengue patients. A significant proportion of acute liver patients in endemic countries can be attributed to dengue infection. Low serum albumin, high creatinine, and multiorgan dysfunction during acute illness can be used as prognostic markers in these children. Multicentric prospective studies are needed to validate these results.

Hemophagocytic lymphohistiocytosis (HLH) is a rare, multisystem, potentially fatal clinicopathologic syndrome. HLH presenting predominantly as pediatric acute liver failure (PALF) has been rarely reported. Early recognition is imperative to initiate life-saving treatment but is often hampered due to the rarity of this syndrome, variable clinical presentations, and nonspecific clinical and laboratory findings. In this article, we reported a case of secondary HLH (H1N1 and RSV positive) presenting as PALF from India. A previously healthy 22-month-old boy presented with fever, vomiting, and altered sensorium for 10 days. He had coagulopathy and deranged liver functions. He was evaluated for underlying etiology and managed on lines of PALF. Due to persistent bicytopenia and excessively high ferritin levels, HLH was strongly suspected though he did not fulfill all clinical criteria for the diagnosis of HLH. Presence of seizures and cerebrospinal fluid analysis was suggestive of central nervous system involvement. There was no evidence of primary HLH on genetic evaluation. Real-time polymerase chain reaction amplifications were positive for RSV and influenza A H1N1, confirming the causative triggers. After the administration of immunosuppressants and oseltamivir, the patient's symptoms improved dramatically and he recovered completely. To the best of our knowledge, this is the fourth case reported worldwide till date of successful rescue of ALF in a child associated with HLH completely without resorting to liver transplantation. Clinical vigilance is crucial for possible presence of HLH with varied initial presentations in PALF despite incomplete diagnostic criteria, with detailed etiological workup for commencing life-saving therapy in time.

Background Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the COVID-19 pandemic. Materials and methods Demography, clinical, and laboratory variables of children admitted from April to September 2020 with MIS-C were studied retrospectively at eight hospitals in Delhi, India. Results We identified 120 patients [median age: 7 years (interquartile range (IQR): 4–10)] with male-to-female ratio of 2.3:1. Overall, 73 out of 120 children (60.8%) presented with shock, 63 (52.5%) required inopressor support, and 51 (43%) required respiratory support. We categorized the cohort into three observed clinical phenotypes: MIS-C with shock (n = 63), MIS-C with Kawasaki disease (KD) (n = 23), and MIS-C without shock and KD (n = 34). Atypical presentations were hypothermia, orchitis, meningoencephalitis, demyelination, polyneuropathy, pancreatitis, and appendicitis. Ninety-four percent had laboratory evidence of SARS-CoV-2 (78.3%, seropositive and 15.8%, RT-PCR positive). The median C-reactive protein (CRP) was 136 mg/L (IQR, 63.5–212.5) and ferritin was 543 ng/mL (IQR, 225–1,127). More than 90% received immunomodulatory therapy (intravenous immunoglobulins and/or steroids) with an excellent outcome (96% survived). CRP and absolute neutrophil count (ANC) were correlated statistically with severity. Conclusion MIS-C data from Delhi are presented. Rising CRP and ANC predict the severe MIS-C. How to cite this article Mehra B, Pandey M, Gupta D, Oberoi T, Jerath N, Sharma R, et al. COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study. Indian J Crit Care Med 2021;25(10):1176–1182.

Aneurysmal bone cysts (ABC) are expansile lytic lesions constituting around 1% of all benign bone tumors with an annual incidence of 1.4/100000. A variety of treatments are available ranging from curettage with or without bone grafting (autologous or allogeneic), curettage with use of adjuvants [Polymethylmethacrylate (PMMA) bone cement, high speed burr, phenol, liquid nitrogen], wide en-block excision with or without reconstruction, selective arterial embolization of the feeding vessels, radiation therapy, high precision megavoltage radiotherapy and percutaneous radio-nuclide ablation, sclerotherapy (ethibloc, aetoxisclerol, alcohol gel, polidocanol). The optimal treatment is debatable due to various indications and contraindications of different modalities of treatment. Recent data suggest that percutaneous sclerotherapy with polidocanol is safe and effective alternative to surgery for treatment of ABCs as it has minimal side effects. We are reporting the first case of life-threatening adverse reaction to intra-lesional polidocanol in a three-year-old boy with a proximal femoral aneurysmal bone cyst. The importance of reporting this case is to make people aware regarding the adverse reaction of polidocanol and to highlight the precautions one should follow while using polidocanol for aneurysmal bone cysts.

Covid-19 is generally a mild disease in children. Coinciding with the peak of the pandemic many children have been reported with a severe disease syndrome comprising fevers, shock with hyper-inflammation, and multiorgan dysfunction, now named pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2-(CoV-2). Although initially thought to be a spurt in cases of Kawasaki Disease (KD) the clinical manifestations differ from KD in being more common in older children with more severe derangements of inflammatory markers and cardiac dysfunction. Gastrointestinal symptoms are prominent. This is likely a postinfection hyper-inflammatory response as almost 90% test positive for antibodies against CoV-2 with significantly raised inflammatory markers and cytokine levels. Most children require cardiovascular and respiratory support and vasoactive therapy in intensive care units. Extracorporeal support is occasionally needed. Intravenous immunoglobulin, aspirin, and steroids are the cornerstones of therapy, though some refractory cases require immune-modulating agents. With adequate treatment, most have shown a favorable outcome.

How to cite this article Jerath N. Viral Bronchiolitis in Children: Less is More. Indian J Crit Care Med 2021;25(11):1219–1220.

Aim The aim of the study is to report feasibility and safety of endoscopic esophageal substitution in infants with pure esophageal atresia and wide gap tracheoesophageal fistula with a minimum one year follow-up. Materials and methods This prospective study was conducted from January 2012 for twenty four consecutive months at Apollo Hospital, New Delhi. All babies either followed up or referred for esophageal substitution without any history of mediastinitis or associated major congenital anomaly and weighing greater than 6kg were to be included in the study. The indication, intraoperative details, operative approach, conversion to open, esophageal substitute, postoperative ventilation, ICU and hospital stay, time to solid foods, morbidity and mortality were recorded. Informed consent was obtained from all the parents and ethical clearance was obtained for the study from the hospital ethical committee. Postoperatively babies were followed up monthly for first six months, 3 monthly for next six months and annually thereafter. Results Between January 2012 and December 2013, in the two year period six infants were admitted for laparoscopic gastric transposition. In five patients the procedure was completed by the laparoscopic approach and one required conversion to open surgery owing to dense adhesions. The age range at the time of surgery was from 8months to 12months with a mean age of 10months. Four patients had pure esophageal atresia (type A) and two had wide gap esophageal atresia with distal tracheoesophageal atresia (type C). Five had primary esophagostomy and gastrostomy as a newborn, the sixth had postoperative anastomotic leak and required subsequent diversion. The mean operating time was 194minutes (range 170–210minutes). The mean stay in ICU was 7days with a range of 4–12days. All patients were ventilated in the postoperative period for an average of 5days with a range of 4–7days. One patient had prolonged gastric ileus which delayed the oral feeds by 14days. The mean time to start the oral feeds was 8days with a range of 6–14days. The mean hospital stay was 19.6days (range 16–23days). Early complications were pneumonia and pleural effusion in one patient. One patient developed anastomotic stricture which was amenable to dilatation. One patient had leak from esophagogastric anastomosis which healed spontaneously. All children are now orally fed, swallow without difficulty, and parents report an excellent cosmetic outcome. The follow-up ranges from 12 to 36months. Conclusion The initial results of endoscopic esophageal substitution are encouraging and easily comparable to the outcome of open surgery with all the attendant benefits of minimally invasive approach.

To study the clinical, biochemical profile and outcome of patients with biliary atresia (BA) who underwent living related liver transplantation (LRLT) at authors’ institute in the last 5 y (2008–2013). Case records of the 20 patients diagnosed with biliary atresia who had undergone living related liver transplantation at authors’ centre in the last 5 y were analysed. Eighteen patients with BA with a failed Kasai procedure and 2 without a prior Kasai's portoenterostomy received a liver transplant. At a median follow up of 2 y and 6 mo, both the patient and graft survival rates were 90 %. The median age of the recipients at the time of LRLT was 8 mo and 12 (60 %) of the transplanted children were less than or equal to 1 y of age. The male–female ratio was 1.8:1. The median weight was 7.3 kg (5.8–48 kg); two thirds were less than 10 kg. The median pre-transplant total serum bilirubin (TSB) and international normalized ratio (INR) were 12.98 (0.5–48.3) mg/dl and 1.3 (1.0–3.9) respectively. All patients received a living related graft and there was no donor mortality. The median duration of postoperative ventilation was 14 h. The post-operative complications were infection (30 %), vascular complications (20 %) and acute rejection (20 %). The median duration of postoperative hospital stay was 21 d (17–42). Two patients died of combined hepatic and portal vein thrombosis in the early postoperative period. Late rejection was encountered in 1 patient and another developed chronic kidney disease necessitating a renal transplant. There were no late vascular occlusions or development of post transplant lymphoproliferative disease. Thus, LRLT for BA with or without a prior portoenterostomy, is a feasible and successful treatment modality with good outcomes attained despite the challenges of age and size. This treatment modality is now well established in India.

The successful development of pediatric liver transplantation (LT) over the past four decades has dramatically changed the prognosis for children dying of acute and end-stage liver failure. Over the past two decades survival post transplantation has improved because of better preoperative management, optimal nutritional support, innovative surgical techniques, and improvements in immunosuppressive medications. The ensuing improvement in survival rate has extended the range of indications for LT in children to include transplantation for metabolic liver disease and unresectable hepatic tumors.

This case-series analyzed the outcome of live donor liver transplantation (LT) performed in children7.5 kg from January 2008 to June 2009 at our center. Five patients (3 males, 2 females, mean age, 8.2 ± .4 months; mean weight 6.8 ± 0.4 kg) underwent LT. The indications of LT included biliary atresia (3) and idiopathic neonatal hepatitis (2). Postoperative complications included acute rejection (1), portal venous thrombosis (1), bile leak (1), severe hypertension (1) and bacterial sepsis (4). There were no donor related complications. The median follow-up duration is 11 months with patient and graft survival rates of 100% each, respectively.

Pediatric Liver Transplant (LT) is now an established procedure for End Stage Liver Disease (ESLD) with biliary atresia being the commonest indication. Intensive pre-transplant evaluation, nutritional buildup and immunization are the fundamental pre-requisites of a successful LT. With improvement in surgical micro-anastomotic techniques and superior immunosuppressive regimens the success rate of pediatric LT is in excess of 90%. Most of the transplants in our country however are Living related, due to which a fairly large number of children expire awaiting a donor liver. There should be a concerted effort to evolve the cadaveric donation program, so that majority of the children are benefitted.

Liver transplantation is now an established mode of therapy in children with fulminant hepatic failure and end stage liver disease due to various causes. The indications have evolved over the last few years to include various metabolic disorders. A thorough pre transplant evaluation followed by pre-emptive identification and management of anticipated complications is essential for the success of a liver transplant. Low socioeconomic and educational levels and insufficient social assistance have a considerable impact on practicality of a transplant taking place, the follow up and overall outcome of patients undergoing transplantation in India. Nevertheless, the liver transplant programme in India has come a long way over the past ten years with patient survival rates comparable to the best centers in the world. The improvements in surgical and medical expertise have contributed in a big way to this achievement.

Hypotonic fluids are commonly prescribed for maintenance fluid therapy in children. This has been associated with a higher incidence of iatrogenic hyponatremia, sometimes with significant neurological sequelae including death. The use of isotonic fluid for maintenance therapy is likely to reduce this complication and is strongly recommended.

A 12-year-old boy presented with fever for 3–4 months, abdominal pain, weakness, and mild lower-back pain for 15 days. He had tachycardia, tachypnea (46/min), pallor, edema-feet, and tender hepatomegaly (10 cm below right costal margin). There was no splenomegaly or lymphadenopathy. Rest of the systemic examination was normal. Investigations showed anemia (7.9 g/dL), leucocytosis (19.8 9 10/L, 88% polymorphs), normal platelets (260 9 10/L), hypoalbuminemia (2.4 g/dL), normal AST/ ALT (56/91 U/L), normal blood sugar levels, hyperuricemia (12.3 mg/dL) and elevated alkaline phosphate (346 U/L), lactate dehydrogenase (1956 U/L), ferritin (2973 ng/mL), and fasting serum triglycerides (651 mg/dL). Blood gas showed metabolic acidosis (pH 7.25, pO2 82 mmHg, pCO2 14 mmHg, HCO3 5.2 mmol/L, Base excess 17.1) and elevated levels of serum lactate (21 mmol/L). Computerized tomographic scan revealed hepatomegaly with multiple contrast enhancing nodules, bilateral renal enlargement and multiple lytic areas in skull, humerus, scapula, ribs, vertebrae, pelvis, and femur (Fig. 1). Liver biopsy showed cells containing scanty cytoplasm and pleomorphic hyperchromatic nuclei, with dense chromatin and inconspicuous nucleoli arranged in sheets of small and large clusters (Fig. 2). The tumor cells were positive for surface IgM, CD45, CD20, CD10, Ki-67; negative for cytokeratin, CD3 and terminal deoxynucleotidyl transferase; and MIB 1 index was 99.5%, consistent with Burkitt’s lymphoma (BL). Uninvolved liver parenchyma showed micro and macrovesicular steatosis. Bone marrow revealed nodular infiltration by malignant cells having high nucleo-cytoplasmic ratio, vacuolar nucleus, and prominent nucleoli. Immunohistochemistry markers were consistent with BL. Cerebrospinal fluid examination revealed no malignant cells. Epstein–Bar virus IgM and IgG were negative. Retroviral serology was negative. The child was started on MCP842 protocol for non-Hodgkin lymphoma (NHL). With aggressive bicarbonate therapy and following chemotherapy, the lactic acidosis resolved. The child developed hypocalcemia, hyperphosphatemia, azotemia and hyperuricemia, which were managed conservatively. Subsequently, the child developed febrile neutropenia with catheter-related blood-stream acinetobacter infection, which was managed as per standard protocols. The child had a successful recovery. Appendicular and facial bone involvement has been well described in BL. Only one case of scapular involvement has been reported [1]. Osteolytic lesions predominantly in the axial skeleton in our patient were noteworthy. Such widespread involvement of skull, humerus, scapula, ribs, K. Kulkarni L. S. Arya Division of Pediatric Oncology, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India

Congenital nephrogenic diabetes insipidus is a rare disorder of resistance to Anti Diuretic Hormone (ADH), characterized by polyuria, polydipsia, low urine osmolality and high serum osmolality. Diagnosis is established by measuring serum and urine osmolality, water deprivation test and vasopressin challenge test. This report describes a 4½-year-old boy who presented to us with fever, polydipsia, polyuria and delayed language development and was diagnosed as a case of congenital nephrogenic diabetes insipidus.

Multiple lung abscesses are extremely rare in healthy children. We report a case of polymicrobial bilateral lung abscess in a 9-month-old previously well infant presenting with a short history of fever and respiratory distress. The management options and outcome are discussed.

Tonsillopharyngitis is very common in children, with Group A Streptococci being the most common bacterial etiology. Effective antibacterial treatment is imperative due to risk of rheumatic fever. Cephalosporins have been used successfully for the treatment of Group A beta-hemolytic Streptococcal (GABHS) tonsillopharyngitis. Cefprozil is a novel broad-spectrum oral cephalosporin. Cefprozil is rapidly absorbed from the gastrointestinal tract with high bioavailability. The excellent penetration of cefprozil into tonsillar and adenoidal tissue corresponds well with the clinical outcome. The drug provides excellent coverage against both gram-negative and -positive bacteria that may cause pharyngitis/tonsillitis. The beta-lactamase stability of cefprozil appears to exceed that of other oral cephalosporins for important gram negative pathogens. In clinical trials, cefprozil appears to be at least as effective as commonly used comparison agents such as cefaclor and cefixime. Additionally, cefprozil is better tolerated than the latter, especially with regard to gastrointestinal adverse effects. Thus cefprozil can be considered a safe and reliable drug for the treatment of Streptococcal tonsillopharyngitis in children.

To study effects of vasopressin on hemodynamic, clinical, and laboratory variables in children with advanced vasodilatory shock. Retrospective study in a multidisciplinary tertiary pediatric critical care unit. Patients (n = 117; 32 noncardiac, 85 postcardiac surgery) requiring intravenous vasopressin infusion longer than 60 min for advanced shock (January 2004 to December 2005). Vasopressin infusion (n = 157). Both cardiac and noncardiac patients showed a significant decrease in inotrope requirement without change in central venous saturation or lactate during infusion. Both groups had increased urea and creatinine and decreased urine output with longer duration/higher cumulative dose of vasopressin. There was a significant increase in conjugated bilirubin level in the noncardiac group during vasopressin infusion; noncardiac patients showed higher AST levels with higher cumulative dose or longer duration of infusion. Postcardiac surgical patients showed a trend towards normal INR values which persisted after vasopressin infusion. Platelet counts were significantly lower during infusion in both groups. Vasopressin infusion improved the hemodynamic state in advanced shock without compromising cardiac function. Urine output and creatinine levels were adversely affected but were reversible. This effect was more pronounced with higher dose or duration of infusion. There was no major effect on liver function but a significant reduction in platelet counts. These data suggest that vasopressin is useful in states of vasodilatory shock with limitations regarding to its adverse renal effects and on platelet counts.