Paed Mag Jan to March 2014.p65 - CiteSeerX

Karnataka Paediatric Journal Vol. 29, No. 1 Jan - March 2014

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Journal of the IAP Karnataka State BranchCONTENTS

1. Presidents Message 3

2. Oral Care Practices In Intensive Care Units - Dr.Aswathy Rajan 4

Dr.Ashivj Shriyan

3. Ellis Van Creveld Syndrome With Hydrocephalus- A Rare Association 8

Dr. Palled V Dr. Pujar M S

4. Infective Tropical Acute Kidney Injury In An Adolescent From 11

Rural Coastal Karnataka - A Case Report.

Dr Sandeep Kumar Dr Shrikiran Aroor, Dr Suneel Mundkur, R. Dr Maneesh Kumar

5. Vaccine Preventable Disease Death: Tip Of The Iceberg. 14

Dr.Ramya Bandi Dr. Ramesh H

6. Study Of Correlation Of Low Birth Weight With Selected 17

Anthropometric Variables

Dr Anil Narayanan, Dr Prakash Saldanha, Dr Mithun

7. Neumann�s Tumor - A Rare Dental Tumor In Newborn 23

Dr.Venkatesh. H.A

8. Correlation Of Clinical And Radiological Findings In The Children With 25

Lower Respiratory Tract Infections.

Dr.Ansar Murtuza Hussain, Dr.Prakash Saldanha, Dr.Shamshad Khan

9. Serum Creatinine Monitoring In Birth Asphyxiated Newborns 31

Dr. Shamim Amanulla Khan, Dr. Shyam Sudhir, Dr. Faheem

10. Rickettsial Fever- An Incidence Study In A Tertiary Care Centre In South India 36

Dr.Nirmalavineethapinto Dr.Sudharudrappa Dr.Suresh R.

.EDITORIAL BOARD

Editor in Chief : Editor

Dr. B. Sanjeev Rai Dr. Sudharshan SE-mail : [email protected] E mail: [email protected]. : 94481-33494 Mob: 9880008471

EDITORIAL OFFICEMedicare Centre, Karangalpady, Mangalore - 575 003

MEMBERS : Dr. Santhosh Soans Dr. Sridhar Avabratha Dr. Kamalakshi Bhat

Dr. Vijay Kulkarnia Dr. Basavaraj Dr.Mahendrappa Dr. G K Gupta Dr.A N Tobbi

Dr. Veerashanker Dr. Amarnath K Dr. Srinivasa S

PAGE No.


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INDAN ACADEMY OF PAEDIATRCSKarnataka State BranchSociety Reg No: EKM � S460-2006-2007

Dr. NARAYANAPPA D. Dr. GHFTAK K.B. Dr. P. SUBBARAO

President Secretary Treasurer

M:9845112560 M : 9844778712 M :9845872653

Dr. SANTOSH SOANS Dr. KIRAN BALIGA Dr. B. SANJEEV RAI

President Elect-2015 & Historian Joint Secretary Editor in Chief K.P.J.

M:9886332179 M:9886198991 M:9448133494

Executive Board Members

Bagalkot Dr. Ramesh Pattar

Bangalore Urban Dr. Ravishanker M

Belgaum Dr. Tanmaya Metgud

Bellary Dr. B K Srikanth

Bidar Dr.Sanjeev Biradar

Bijapur Dr Sadashiv Ukkali

Chikkamagalur Dr.Ramesh.M.B.

Chitradurga Dr. Basanth P

Dakshina Kannada Dr. Ashv�rl Shriyan

Davangere Dr. Madhu Pujar

Dharwad Dr. Fateppur

Gadag Dr.Shivkumar I Manvi

Gulburga Dr. Rohit Bandari

Hassan Dr. Prasanna Kumar

Haveri Dr.Anand Ingalgavi

Kodagu Dr. Krishnananda

Kolar Dr.Arun

Kollegal Dr.Sridhar M

Koppal Dr. Anand Kumar.

Mandya Dr.G K Gupta

Mysore Dr. Cherak K.B.

Raichur Dr. Vijay Sukhani

Address for Correspondence:

Dr. CHETAK. K.B.# 1409, Navagraha Temple Road, K.R. Mohalla, Mysore

Mob. : 9844778712, Email : [email protected]

Shimoga Dr. Yateesh

Tumkur Dr. Kumar

Udupi Dr. Leslie Lewis

Uttar Kannada Dr Anrita D'Souza.

Yadir

Ex . Officio�s

Dr. Mrs. N.S. MahantashettiDr. Babanna K. Hukkeri

Central IAP Executive Board Members

Dr. Srinivasa S. Mob:9341 288129

Dr. Basavaraja. G.V. Mob:9448 1 53754

Dr. Deepak Chiradoni Mob:9880629906

Zonal Co-ordinators

Bangalore Dr. Venkatachalapathy

Dharwad Dr. Vijay Kulkarni

Gulbarga Dr. M.M. Patil

Davanagere Dr. Madhu Pujar

Mysore Dr. Prashanth S.N.


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DR.D.NARAYANAPPA, MBBS, MD, FIAP

Dear Fellow Pediatricians of Karnataka state,

Greetings from the IAP Karnataka State Branch. I Sincerely thank all our fellowpediatricians for having faith in me and electing me for this prestigious post. We as a team are readyto shoulder the responsibility bestowed on us and would like to keep up the standards setby our peers. Hope the co-operation, advice and suggestion continues in the future.

Inspite of being advanced in technology and one of the largest countries for humanresources, India contributes to nearly one fifth of the child mortality in the world. As a driveto reduce the Infant mortality rate and Under 5 mortality rate, IAP in collaboration withGovernment of Karnataka has implemented several programs like IYCF, public privatepartnerships and has been conducting regular workshops, CMEs.

As the antibiotic resistance is on the rise in our country, there is an urgent need tospread awareness regarding the rational antibiotic policy and rational investigation practices.This is also one of the action plans of central IAP and we plan to implement it effectively inour state.

To reduce the Neonatal mortality Rate, Central IAP has adopted a perfect publicprivate partnership - NSSK and NRPFGM. We need to strengthen these programs by regulartraining at all district places. Our team plans to work towards the same with active supportof state NNF members. Central IAP has very high regards about our state branch for itsexcellent academic activities. I extend full co-operation from our team to all the presidentsand secretaries of the district branches to continue to hold regular academic activities andupdate the knowledge. I also request to enroll maximum members from your districts so thatthe number of our state pediatricians in Central IAP increases and remains a great asset.

With the continued support and co-operation from Central IAP, fellow pediatriciansand our enthusiastic team members, I plan to achieve all our goals for this year. We believein unity is the strength and wish to take the standards of our state to the highest level withthe aim of� Moving towards ��..comprehensive care preventive, promotive, curative�To conclude.......Team work - a fuel that allows common man to achieve uncommon results

JAI IAPJAI KARNATAKA

DR. NARAYANAPPA. D,PRESIDENT, IAPKSB,PROF & HOD OF PAEDIATRICSJ.S.S. MEDICAL COLLEGE,J.S.S. UNIVERSITY,MYSORE.

Presidents Message


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*Dept of Pediatrics ,AJ Institute of Medical Scinences, Kuntikana Mangalore

ORAL CARE PRACTICES IN INTENSIVE CARE UNITSDr.Aswathy Rajan, Dr.Ashivj Shriyan*

ABSTRACT

Background � Oral hygiene is essential

to minimize the risk of infection and

significantly affects the child�s well-being.

Although nurses recognize the oral hygiene

as an integral part of the care in the ICU,

the relationship between oral hygiene and

reduction of VAP is less recognized.

Aim of the study � The study has

aimed to evaluate nurse�s opinions on oral

hygiene in mechanically ventilated ICU

patients.

Methods � A prospective, cross sectional

study was conducted on 50 ICU nursing

staff in A. J. Institute of Medical Sciences,

Mangalore. A five-part questionnaire filled in by

the same was assessed.

Results � Methods of providing oral

care and frequency varied in the same unit.

Nurses did not hold oral care as a priority

amongst their nursing interventions. Only

32% (n=16) of the nurses are aware that the

goal of providing oral care is to prevent

ventilator associated pneumonia. A total of

18% (n=9) of the participants have identified

oral care as the first priority in comparison

with other nursing care provided to ICU

patients, third to tracheal suctioning opined

by 46% (n=23) of them.

Conclusions � This survey helps to

bring to light the current oral care practices

in our institution and should be a step

towards improving the practices in ICU.

Keywords � Oral care, nursing

opinions, ventilator associated pneumonia

INTRODUCTION

Oral hygiene is essential to minimize

the risk of infection and significantly affects

the child�s well-being.1 Oral care has been a

low priority intervention in the intensive

care unit (ICU).2 In the critical care setting,

poor oral hygiene is associated with higher

nosocomial infection rates.2 The oro-

pharyngeal colonization with pathogenic

organism contributes to development of

ventilator associated pneumonia (VAP)3

which delays recovery and increases

patient�s mortality rates.4

Although nurses recognize the oral

hygiene as an integral part of the care in the

ICU, the relationship between oral hygiene

and reduction of VAP is less recognized.

Blamoun et al4 have shown that the

application of ventilator care bundle, oral

care protocol and subglottic suctioning

together significantly reduce the rate of VAP.

MATERIALS AND METHODS

The study has aimed to evaluate

nurse�s opinions on oral hygiene in

mechanically ventilated ICU patients. A

prospective, cross sectional study was

conducted on 50 ICU nursing staff in A. J.

Institute of Medical Sciences, Mangalore. All

nursing staff working in neonatal and

pediatric ICU, medical ICU and cardiac ICU

of the institute were included. A two part

questionnaire was prepared after appropriate

approval from the institution, which was

reviewed by one anesthesiologist, two pediatric/

neonatal intensivists and two nurses with

post basic critical care qualification.


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The questionnaire (Annexure 1)

consisted of five parts. The first part had

questions regarding the qualification of the

participants and their training in oral care.

Second part consists of questions on oral

care protocol in the institution and the

frequency and goal of providing oral care to

mechanically ventilated patients. Third part

asked the participants to grade from 1 to 4,

a list of 4 essential nursing care parameters

(tracheal suctioning, eye care, oral care and

writing reports), where 1 was given to the

one with most importance. Fourth part

assesses the nurse�s attitudes toward oral

care in mechanically ventilated patients.

They were asked to score from 1 to 4,

keeping 1 as the most likely cause for

ineffective oral care being provided to

patients. The questions assessed the basic

barriers nurses come across in the ICU

including documentation work, lack of time,

presence of the endotracheal tube and

difficulty to clean. The last part asks them to

score the most commonly used material for

providing oral care in the ICU (plain cotton

swab/gauze, chlorhexidine, physiological

salt solution, toothbrush/paste, betadine).

RESULTS

Among a total of 50 nurses, 84%

(n=42) have a bachelor degree, while 10%

(n=3) have a diploma in nursing and only

6% (n=5) have a master�s degree in nursing.

38% (n=19) of the nurses responded they

have had specialized training other than

their basic nursing training in oral care/

hygiene. 92% (n=46) of them understood

the importance and requirement of an oral

care protocol in the institution. A study

found that without a protocol for oral

hygiene, oral care was performed infrequently.

Here, majority of the nurses support the

provision of oral hygiene in ICU twice a

day, which accounts for 66% (n=14) of the

total participants. 28% (n=14) provide oral

care only once a day while 4% (n=2)

provide care thrice a day and 2% (n=1)

more than 3 times a day (Graph 1).

Graph 1. Frequency of oral care

Only 32% (n=16) of the nurses are

aware that the goal of providing oral care is

to prevent ventilator associated pneumonia

while 68% (n=34) assume that it is done to

provide comfort to the mechanically

ventilated patient. A total of 18% (n=9) of

the participants have identified oral care as

the first priority in comparison with other

nursing care provided to ICU patients, third

to tracheal suctioning opined by 46%

(n=23) of them. A high percentage of nurses

voted writing reports (32%) as their first

priority while eye care again was a priority

only for 4% (n=2). Oral care was second

priority again only to 12% (n=6) as writing

reports was a high second priority for them

(56%). Majority of nurses voted oral care as

only a third priority with 58% of them

voting for the same. Eye care remained a 4th

priority for 72% of the nurses (Graph 2).

Graph 2. Knowledge of goal of oral care


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80% (n=40) of the nurses reported

spending time in documentation was the

main barrier to providing oral care. 8%

(n=4) of them claimed lack of time as a

hindrance to oral care only second to

documentation, while 6% (n=3) of them

voted the simultaneous presence of an

endotracheal tube as a major factor to not

provide oral to the children and another 6%

(n=3) claimed they find provision of oral

care a difficult task (Graph 3).

Graph 3. Nursing attitudes

None of the participants opine that

cotton swabs and gauze are materials for

providing oral care. Unfortunately, only 42%

(n=21) use chlorhexidine for the same.

Physiological salt solution (normal saline)

was voted for by 46% (n=23) of them, while

8% (n=4) use betadine. Toothbrush and

toothpaste are used by only 4% (n=2) of

them (Graph 4).

Graph 4. Use of equipment by the nurses

DISCUSSION

This survey aimed to assess the

quality, knowledge and practices of oral care

in mechanically ventilated patients in the

ICU. The results revealed that the frequency,

method and attitude toward oral care

differed widely among nurses. Thereby,

successfully analyzing and identifying areas

for improvement.

Many nurses showed that the only

training that they had received in oral care

had been their basic training. Oral care for

mechanically ventilated patients requires

specialized skills and knowledge. Many of

the nurses in this study believed that oral

care was provided to promote patient�s

comfort rather than to prevent VAP. This is

consistent with previous studies, that

suggests that nurses do not have up-to-date

knowledge of oral care for ICU patients and

the educational course has not prepared

them for providing quality oral care.4

A study found that approximately

93% of nurses practice oral care more than

four times per shift after the implementation

of a new oral care protocol showing the

importance of the presence of a standard

protocol which can be established by the

institution to guide the nurses and provide

better oral care.4

Tracheal suctioning was given the

most importance amongst nursing

interventions in this study. Provision of oral

care was given only a third priority

probably due to the false perception that

oral care is less contributory to the patient�s

health than other nursing care activities for

the mechanically ventilated patients.5

ICU nurses were found to have too

much of documentation work and lack of

time assumed due to staff shortage as the

main obstacles for oral care. In a study


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done by Schwartz and Powell6, nurses also

fear dislodgement of endotracheal tube and

are therefore hesitant to provide a variety of

oral interventions.

Foam and cotton swabs generally are

not effective for removing debris and

plaque.3 Physiological salt solution (normal

saline), because of its tendency to cause

drying, has limited use as a mouth rinse in

critical care settings.3 Toothbrush was used

only in 4% of the cases despite the

recommendation that it is the best method

for removing plaques in the ICU patients. A

reason for not using toothbrushes could be

the nurses� lack of knowledge of up-to-date

research findings. Chlorhexidine gluconate

is a commonly used broad-spectrum anti-

bacterial mouth rinse that decontaminated

the oropharynx and reduces dental plaque.

The anti-plaque activity of chlorhexidine is

superior to that of other antiseptic

mouthwashes. It has better antibacterial

properties as once it fixes to the oral

surfaces, chlorhexidine gluconate is released

between 8 to 24 hours. Therefore, a twelfth

hourly chlorhexidine gluconate use is

recommended.1

CONCLUSION

Oral care is an essential nursing

intervention in the ICU. The existence of

various oral care practices indicates that

there is a need of a standardized oral care

protocol. Providing protocol based oral care

may decrease the incidence of VAP in

mechanically ventilated patients in the ICU.

Nurses seem to lack evidence based

knowledge of the importance and correct

manner of oral care. This survey helps to

bring to light the current oral care practices

in our institution and should be a step

towards improving the practices in ICU.

REFERENCES

1. Johnstone L, Spence D, Koziol-McLain

J. Oral Hygiene Care in the Pediatric

Intensive Care Uint: Practice

Recommendations. Pediatric Nursing

2010; 36(2):85-96

2. Perrie H, Windsor S. A survey of oral

care practices in South African

Intensive care units. South Asian J Crit

Care 2011; 27 (2): 42-6.

3. Berry AM, Davidson PM, Masters J,

Rolls K. Systematic Literature Review of

Oral Hygeine Practices for Intensice

Care Patients Receiving Mechanical

Ventilation. Am J Crit Care 2007;

16:552-562.

4. Soh KL, Ghazail SS, Soh KG, Raman

RA, Abdullah SSS, Ong SL. Oral care

practice for the ventilated patients in

intensive care units: a pilot survey. J

Infect Crit Ctries 2012; 6(4):333-339.

5. Munro CL, Grap MJ. Oral Health and

Care in the Intensive Care Unit: State of

the Science. Am J Crit Care 2004; 13:25-

34.

6. Adib-Hajbaghery M, Ansari A, Azizi-

Fini I. Intensive care nurses� opinions

and practice for oral care of

mechanically ventilated patients.

Indian J Crit Care Med 2013; 17:23-7


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ABSTRACT

Ellis van Creveld syndrome is a

chondroectodermal dysplasia with autosomal

recessive inheritance characterized by short

ribs, polydactyly, growth retardation,

ectodermal and heart defects. We report

a stillborn baby with Ellis van Creveld

Syndrome with hydrocephalus which is an

unusual feature and briefly review the

literature.

KEY WORDS: Ellis van Creveld

Syndrome, Hydrocephalus

INTRODUCTION


chondroectodermal dysplasia with autosomal

recessive inheritance characterized by short

ribs, polydactyly, growth retardation, ectodermal

and heart defects[1]. It is a rare disease

first described in 1940 by Richard W.B.

Ellis and Simon van Creveld [2], with more than

200 cases reported worldwide till now [3]. We

present a stillborn baby with features

suggestive of Ellis van Creveld Syndrome

with hydrocephalus which is an unusual

feature.

CASE REPORT

A single stillborn term female

baby was delivered via naturalis at CG

Hospital, Davangere, Karnataka with

birth weight 2.5kgs and length 45cms.

Head circumference could not be

measured at birth as craniocentesis was

done during labour to facilitate vaginal

delivery due to which skull bones had

collapsed. But antenatally measured

Ellis Van Creveld Syndrome With Hydrocephalus-

A Rare Association

Dr. Palled V Dr. Pujar MS*

JJM Medical College, Davangere. *1955, �Madhumann�, MCC �A� Block, Davangere.

Email- [email protected]

head circumference at 39wks through

ultrasonography was 42.7cms. Placental

calcification was seen.

Clinically, baby had collapsedskull bones, large clover shaped head,hypertelorism, wide nasal bridge, cleftlip and cleft palate, neonatal tooth,short bilateral upper and lower limbs,polysyndactyly in all 4 limbs,hypoplastic nails, saddle gap in rightlower limb and bilateral great toe stood

out[Fig1, 2].

Fig1- Large head, hypetelorism, short

broad nose, cleft lip, short limbs

Fig2- Nail hypoplasia, Polysyndactyly,

Standing out of great toe.

Infantogram revealed two neonatal

teeth, narrow thorax, shortened long

bones, bowing of bilateral radii and left

ulna, polydactyly, shortening of middle


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and distal phalanges of hand, pubic

diastasis, short and squared iliac wings,

horizontal acetabulum[Fig3].

Fig3- Short humeri and femurs, Short

ribs and Narrow thorax

Autopsy findings were as follows- heart

showed atrial septal defect 0.6 x 0.6cm,

small intestine showed 2.5cm constriction

at 5cm distance from ileoceacal junction,

Microscopy of laryngeal and thyroid cartilage

showed >3 cells in single lacuna, vesicular

nuclei, large chondrocytes and irregularly

spaced lacunae[Fig4] suggestive of

chondrodysplasia.

Fig4- Abnormally large chondrocytes, large

lacunae with 2-3 chondrocytes in single

lacuna

DISCUSSION


rare autosomal recessive disorder which

affects the ectodermal, mesodermal and

endodermal derivatives [4], characterized

by short ribs, short limbs, postaxial

polydactyly, and dysplastic teeth and

nails [1]. In Amish population its prevalence

is 1 in 5000 live births whereas in

non-Amish population it occurs in 1 in

1,000,000 live births [5]. It occurs in

two thirds [6] of the patients due to

mutations in the EVC1 and EVC2

genes located on chromosome 4p16 [1, 3]

lying in a head to head configuration[7].

In the first trimester scan, at 13th

week of gestation, there is increased

thickness of fetal nuchal translucency[1,8]. After 18th week, narrow thorax,

marked shortening of the long bones,

hexadactyly of hands and feet and

cardiac defect can be identified.

Clinical features include small

stature, neonatal teeth, small teeth,

delayed eruption, short upper lip bound

by frenula to alveolar ridge, irregularly

short extremities, polysyndactyly in all 4

limbs, hypoplastic nails, cardiac defects

(approx. 60%) most commonly atrial

septal defect, often with single atrium

(40%) [1, 2]. Cardiac defect is the main

determinant of longevity. Although most

patients have normal intelligence and

normal head circumference, occasional

CNS anomalies and hydrocephaly have

been noted with Dandy-Walker malformation

in some rare cases [2].

Histologically cartilaginous changes

include irregularly spaced lacunae,

abnormal chondrocyte nuclei, islands of

cartilage in metaphyseal bone, protrusion

of bone into the epiphyseal cartilage.

Chondro-osseous tissue from supernumery

digits show irregular column formation

and vascular invasion, concavity of the

epiphyseal line protruding into the

cartilage, and islands of cartilage along

the periosteum and within the metaphyseal

bone. In rib and iliac crest, the resting

cartilage contains abnormally large

chondrocytes, often with several cells

per lacuna (normally 1-2), increased


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vascularity of the cartilage, and a

particularly fibrous-appearing matrix with

areas of degeneration [9].

Radiological features include

postaxial polysyndactyly, short ribs,

short iliac wings, horizontal acetabulum

with medial and lateral spurs (trident

pelvis), premature ossification of femoral

capital epiphyses, proximal tibial

epiphysis is hypoplastic laterally with

dome shaped metaphysis, medial tibial

diaphyseal exostosis, genu valgum and

fibular shortening may be seen at knee.

Carpal development is delayed and

carpal fusions are seen especially

between capitate and hamate. In

addition, polycarpyly with ninth carpal

bone may appear in distal row in

some [10].

Prognosis: Approximately 50%

babies die in early infancy due to

cardiorespiratory problems [3].

fWHAT IS THE SIGNIFICANCE OF

THIS REPORT?

Hydrocephalus in Ellis van Creveld

syndrome is a rare entity. This report adds to

the list of such cases.

REFERENCES

1. Baujat G and Merrer ML- Ellis van

Creveld syndrome, Orphanet Journal

of Rare Diseases 2007, 2:27.

2. A. Amin, T. Ahmed, M. Ashraf, Z.

Lone, I. Wani: Chondroectodermal

Dysplasia (Ellis-van Creveld Syndrome):

A case report. The Internet Journal

of Pediatrics and Neonatology. 2009

Volume 10 Number 1.3.

Jones KL.

Smith�s recognizable patterns of

human malformation. 6th ed. Elsevier

Saunders ; chapter J p422.

4. Hegde K, Puthran RN, Nair G,

Nair PP. Ellis van Creveld syndrome�

a report of two siblings; BMJ Case

Reports 2011.

5. KM Veena, H Jagadishchandra, Rao

PK, Chatra L. Ellis van Creveld

syndrome in an Indian child: a case

report. Imaging Sci Dent. 2011

December; 41(4): 167�170.

6. Tompson SW, Ruiz-Perez VL, Blair HJ,

Barton S, Navarro V, Robson JL,

Wright MJ, Goodship JA: Sequencing

EVC1 and EVC2 identifies mutations

in two-thirds of Ellis van Creveld

syndrome patients. Hum Genet 2007,

120:663-670.

7. Ruiz-Perez V, Tompson S, Blair H,

Espinoza-Valdez C, Lapunzina P, Silva

E, Hamel B, Gibbs J, Young I,

Wright M, Goodship J: Mutations in

two nonhomologous genes in a

head-to-head configuration cause Ellis

van Creveld syndrome. Am J Hum

Genet 2003, 72:728-732.

8. Venkat-Raman N, Sebire N, Murphy

K: Increased first-trimester fetal nuchal

translucenty thickness in association

with chondroectodermal dysplasia (Ellis

van Creveld). Ultrasound Obstet

Gynecol 2005,25:412-414.

9. Sillence DO, Horton WA and Rimoin

DL. Morphologic Studies in the

Skeletal Dysplasias: A Review, Am J

Pathol 96:811-870, 1979.

10. Haque F, Ahmed SA: Ellis van

Creveld Syndrome- Letter to the

editor, Indian Pediatrics, Vol41, 867-

868.

AKNOWLEDGEMENTS

We thank the baby�s family for

handing over the baby to the

Department of Pediatrics, JJM Medical

College, Davangere for academic study.

We also thank the Department of

Pathology, JJM Medical College,

Davangere for actively participating in

establishing the diagnosis by autopsy

and histopathologic study.


11

Abstract:Tropical acute kidney injury

refers to acute kidney injury secondary to

diseases prevalent in the tropical region.

Factorsthat contribute to poor outcome of

tropical AKI include low socioeconomic

status, poor access to treatment, and delay

in seeking medical attention. Early clinical

diagnosis and appropriate treatment can

minimize fatal outcome. We report an

adolescent with leptospirosis who presented

with non-oliguricrenal failure requiring

hemodialysis and he recovered.

Key words:Tropical infection, acute

kidney injury, Leptospirosis, Adolescent

Introduction:

Tropical infectious diseases in

association with acute kidney injury (AKI)

are given importance during recent years in

the era of enormous expansion of travel and

immigration [1]. The epidemiology of

community-acquired AKI in developing

tropical countries is markedly different from

AKI in developed countries with a temperate

climate. Leptospirosis is a common etiology

of tropical AKI in Indian subcontinent. We

report an adolescent with leptospiral

nephropathy with class 3 AKI and

recovered completely.

Case report:

A 14-year-old boy hailing from rural

village of coastal Karnataka presented with

fever for 10 days, vomiting for 4 days and

gum bleedingalong with altered sensorium

noticed since 2 days. There was no oliguria

or hematuria. His father was an

agriculturist. His past history was not

significant.

His height was 163cm, weight was

40kg. He had a pulse rate of 110 beats /

min, respiratory rate 20 cycles/min and a

blood pressure of 122/70 mmHg. Examination

revealed moderate pallor, icterus and diffuse

conjunctival suffusion with evidence of

glossitis and oral mucosal bleed.Abdominal

examination revealed tender hepatomegaly.

Examination of other systems was unremarkable.

Investigations showed anemia and

thrombocytopenia with hemoglobin of 9.7

gm/dl and platelet count of 70,000/cmm

respectively. He had leukocytosis with

raised ESR and CRP.There was no evidence

of hemolysis in peripheral smear. He had

grossly elevated renal function tests

(creatinine � 14 mg/dL; urea 810mg/dl)

with hyperkalemia.He was categorized to

class 3 AKI (failure) as per modified

pediatric RIFLE (risk,injury,failure,loss, end

stage) criteriabut without oliguria.Urine

analysis revealed microscopic hematuria

and proteinuria (1+) with granular casts.

His serum LDH and complement level was

normal. Liver function tests were deranged

withhyperbilirubinemia(Total bilirubin: 31.7

mg/dL, Direct: 23.5 mg/dL), marginally

INFECTIVE TROPICAL ACUTE KIDNEY INJURY IN ANADOLESCENT FROM RURAL COASTAL KARNATAKA -A CASE REPORT.Dr SANDEEP KUMAR *Dr SHRIKIRAN AROOR, Dr SUNEEL MUNDKUR, r.

Dr MANEESH KUMAR

Department of pediatrics, Kasturba Medical College, Manipal University, Manipal.

Email: [email protected].


12

elevated liver enzymes,hypoalbuminemia,

and coagulopathy (INR-1.9).Urine dark

ground microscopy for leptospira was

negative. IgM Leptospira test by enzyme

immune assay (EIA) was positive. Abdominal

ultrasonography showed hepatomegaly with

bilateral grade I renal parenchymal changes.

Workup for malaria, dengue and rickettsial

infections were negative. Blood and urine

cultures were sterile. Serological markers of

hepatotrophic viruses were negative.

He was treated with IV crystalline

penicillin for 10 days, along with anti-hyperkalemic

measures and fluid management as per AKI

protocol. He required 4 cycles of hemodialysis.

He responded clinically and renal

parameters were normalized over next

9days as depicted in line diagram (fig 1 and

2). He was followedup for next 3 months

and he remained asymptomatic with normal

blood count, renal and liver function tests.

Discussion:

Tropical nephropathies causing AKI

are broadly classified as infective or

toxic.The infective nephropathies that are

commonly prevalent in Indian subcontinent

include diarrheal diseases, bacterial sepsis,

malaria, leptospirosis, dengue fever, enteric

fever, kalaazar and rickettsial fever [2].

Factors that contribute to poor outcome

include to low levels of income, poor access

to health care, and social or cultural

practices leading to delay in seeking

medical intervention.The incidence of

tropical glomerulonephritis is found to be

up to 4% of pediatric hospitaladmissions [3].

Leptospirosis is a zooanthroponosis

caused by a spirochete of genus Leptospira,

the species being L. interrogans and

L.biflexa. Leptospira infect many species of

domestic animals including pets, livestock,

birds and fish. Rat is the principal source

of human infection. Occupational groups

with a high incidence of leptospirosis

include agriculturists and others that require

contact with animals. Leptospira enter

humans through abrasions and cuts in the

skin or through mucous membranes.The

incidence of AKI in adults with severe

leptospirosis as per literature varies from

40% to 60% [4].Renal involvement is

predominantly a result of tubular damage

and interstitial nephritis is the basic lesion

reported in leptospirosis.However rarely

renal involvement may be attributable to

widespread vasculitis and hypovolemia

secondary to myocarditis[5].

Clinical manifestations are classically

biphasic, with an initial septicemic phase

lasting for 3 to 7 days followed by an

immune phase, during which nephropathy

occurs. In its mild formoften referred to as

anicteric leptospirosis seen in majority of

cases, presents as any acute febrile illness

with headache and myalgia.Severe form as

in our case is characterized by jaundice,

renal dysfunction and hemorrhagic diathesis

referred to as hepatorenal syndrome or

Weil�s syndrome that accounts for only 5-10

% [6].The diagnosis of leptospirosis should

be considered in febrile patients with evidence


13

ofrenal, hepatic and mucous membrane

changes. AKI in leptospirosis is primarily

non-oliguric, as in the present case.

Clinical features compatible with

Leptospira along with positive serological

test usually establish the diagnosis [6]. It

was the typical ocular manifestation of

icterus along with conjunctival suffusion

which gave us a clue to suspect leptospirosis.

AKI in Leptospirosis usually leads to rapid

elevation of renal parameters often to high

levels. Conjugated hyperbilirubinemia in the

present case is explained by the frequent

association of intrahepatic cholestasis in

leptospirosis. Less frequently diagnosis is

done by demonstration of organism in urine

by phase contract or dark field microscopy,

but is less sensitive [6]. Serologic tests like

microscopic slide-agglutination test (MAT),

dipstick ELISA and dot ELISA for IgM

antibodies are available. Antibody titers

usually appear by the 12th day of illness

and reach a maximum by the 3rd week.

General management principles of

AKI with careful fluid and electrolyte

balance along with specific antimicrobial

therapy is the cornerstone of management

[7]. Intravenous penicillin Gin the dose of 6-

8 millionU/m2/day every 4-6 hours for

duration of 7-10 days remains the drug of

choice [8]. Treatment initiated before the 7th

day of illness is shown to shorten the

clinical course and complications. Other

antimicrobials include 3rd generation

cephalosporins, amoxycillin, doxycycline

and erythromycin [8]. Poor prognostic

factors include oliguric renal failure,

pulmonary complications, hypotension and

serum creatinine more than 3 mg/dL,

requiring dialysis [9, 10]. Complete recovery

from renal failure is typical among

survivors.

This case has been reported to

highlight the importance of tropical AKI

where early intervention often prevents the

progression of AKI and long term renal

damage.Most causes of tropical AKI are

preventable and strategies to reduce the

burden of tropical AKI require both

improvements in basic public health,

achieved through effective interventions, and

increased access to effective medical care.

REFERENCES:

1. Barsoum R, Sitprija V. Tropical Nephrology.

In: Diseases of the Kidney, Schrier

RW,Gottaschalk CW, Eds, 6th Edn, Boston,

Little,Brown & Co. 1997; 2221-2268.

2. Banerjee S. Tropical acute kidney injury -

Recognition and management. Indian J

PractPediatr 2012; 14:133-142.

3. Herberg J, Pahari A, Walters S, Levin

M.Infectious Diseases and the Kidney. In:

Pediatric Nephrology, Avner ED, et al.

Eds, 6th Edn,Berlin: Springer Verlag 2009;

1235-1274.

4. Andrade L, Daher EF, Seguro AC.

Leptospiral nephropathy. Semin Nephrol.

2008; 28:383�94.

5. Lai KN, Aarnos I, Woodroffe AJ, Clarkson

AR.Renal lesions in Leptospirosis. Aust N

Z M Med1982; 12:276.

6. Sunil Karande, Hemantkulkarni, Madhuri

Kulkarni, Anuradha De, Ami Varaiya.

Leptospirosis in children in Mumbai slums.

Indian J Pediatr 2002; 69 (10): 855-858.

7. Abboud O. Tropical renal failure. J

TroNephro-Urol 2007; 5:11 -13.

8. H. Dele Davies and Melissa Beth

Rosenberg.Leptospira.In Behrman RE,

Kliegman RM et al. Nelson Textbook of

Pediatrics, 19thedn. Philadelphia: W.B.

Saunders Company; 2011; p 1023-1026.

9. Ricaldi JN, Vinetz JM. Leptospirosis in the

tropics and in travellers.Curr Infect Dis

Rep.2006; 8:51�8.

10. Covic A, Goldsmith DJ, Gusbeth-Tatomir P,

Seica A, Covic M. A retrospective 5 year

study in Moldova of acute renal failure

due to leptospirosis: 58 cases and a review

of the literature.Nephrol Dial Transplant.2003;

18:112


14

Abstract

Diphtheria is one of the vaccine

preventable disease for which effectiveness

of vaccine exceeds 95% after three doses.We

report an unimmunized case who died

due to complications of diphtheria. There is

a huge disparity between the reported

figures and WHO estimated figures of DPT3

coverage in India and reflects the poor

immunization coverage status in our

country responsible for such deaths.

Introduction

Diphtheria is one of the vaccine

preventable disease for which effectiveness

of vaccine exceeds 95% after three doses[1].

We report an unimmunized case who died

due to complications of diphtheria and the

current state of immunization coverage in

our country.

Case Report

A 4 year old boy was referred to our

hospital with fever since 8 days and pain

and swelling of neck since 4days.He was

the third child of non consanguineousparents.

Mother had no antenatal checkups done. He

was delivered normally at home by an

untrained dhai. He had normal developmental

milestones. He was never immunized since

birth. His elder sibling, 6year old female

child also had similar complaints of fever

and pain in the throat. On examination

there was bull neck and dirty white

membrane over the tonsils extending into

soft palate and posterior pharyngeal wall.

Child was suspected to havetonsillar and

pharyngeal diphtheria was investigated

VACCINE PREVENTABLE DISEASE DEATH: TIP OF THE ICEBERGDr.RAMYA BANDI* Dr. RAMESH H

Department of Pediatrics,JJM medical college,Bapuji Child Health Institute and Research Centre,Davangere, Karnataka-577004. Email:[email protected].

accordingly. A throat swab was taken which

was positive for albert�s stain and bacilli

with metachromatic granules were seen. He

was treated with crystalline penicillin and

antidiphtheric antitoxin. His blood counts

revealed leukocytosis. On second day of

admission diagnosis was confirmed as the

culture grew corynebacterium diphtheria

bacillus(sub species: intermedia).Child also

had stridor and arrhythmias with heart

blocks and t wave abnormalities after 48

hours of admission. Later for the worsening

respiratory distress he was ventilated with

endotracheal tube. There was no evidence of

laryngeal membrane as observed during

intubation. Child developed congestive heart

failure, pulmonary odema and despite of

supportive care succumbed to death after six

hours of ventilation.His final diagnosis was

Pharyngeal and Tonsillar diphtheria with

myocarditis and congestive cardiac failure.

Fig 1: Bull neck appearance

Fig 2 : Heart block recording due to myocarditis


15

DISCUSSION

Diphtheria is an acute toxic infection

caused by Corynebacteriumdiphtheriae, an

aerobic, non-encapsulated, gram positive

bacillus. It is an endemic disease in India[2].

Diphtheria occurs by entry of C. diphtheriae

into the nose or mouth and after a 2-4 day

incubation period, toxins are secreted which

leads to toxin-mediated tissue necrosis. This

coupled with local inflammatory response

produces patchy exudates which later forms

fibrinous exudates and a tough adherent

membrane. In tonsillar and pharyngeal

diphtheria, sore throat is a universal early

symptom. Underlying soft tissue edema and

enlarged lymphnodescan cause a bull-neck

appearance. Respiratory embarrassment may

follow extension of disease into larynx or

tracheobronchial tree. The main complications

of the disease are toxin mediated.Toxin is

distributed via blood stream &lymphatics

throughout the body. Major respiratory

complications like airway obstruction,

stridor are due to pseudomembrane

formation while the toxin mediated effects

are seen mainly on the heart and nervous

system[3]. Toxic cardiomayopathy occurs in

10-25% of cases with respiratory diphtheria.

Myocarditis is a poor prognosticating sign

as about 60% of death in diphtheria are due

to it. Myocarditis most commonly occurs in

the second week of the disease but can

appear as early as the first or as late as the

sixth week of illness. In our case myocarditis

presented in second week of illness. . A

prolonged PR interval and changes in the

ST-T wave on an electrocardiographic

tracing are relatively frequent findings.

Single or progressive cardiac dysrhythmias

can occur, including 1st-, 2nd-, and 3rd-

degree heart block. This child also had

progressive cardiac arrhythmias in the form

of varying heart blocks. Specific antitoxin is

the mainstay of therapy and should be

administered on the basis of clinical

diagnosis and dosage depends on the

extent of the membrane. Because it

neutralizes only free toxin, antitoxin efficacy

diminishes with elapsed time after the onset of

mucocutaneoussymptoms. The role of

antimicrobial therapy is to halt toxin

production, treat localized infection, and

prevent transmission of the organism to

contacts. Only erythromycin or penicillin is

recommended; erythromycin is marginally

superior to penicillin for eradication of

nasopharyngeal carriage. Appropriate

therapy is erythromycin (40-50 mg/kg/day

divided every 6 hr by mouth [PO] or

intravenously [IV]; maximum 2 g/day),

aqueous crystalline penicillin G (100,000-

150,000 U/kg/day divided every 6 hr IV or

intramuscularly [IM]), or procaine penicillin

(25,000-50,000 U/kg/day divided every 12

hr IM) for 14 days[3].This child received

crystalline penicillin as antibiotic. Antibiotic

therapy is not a substitute for antitoxin

therapy. The prognosis for patients with

diphtheria depends on the virulence of the

organism, patient age, immunization status,

site of infection, and speed of administration

of the antitoxin. The poor prognosis factors

in this child include age < 5years, unimmunized

status,delay in antitoxin administration. At

recovery, administration of diphtheria toxoid

is indicated to complete the primary series


16

or booster doses of immunization, because

not all patients develop antibodies to

diphtheritic toxin after infection[3].

This case is reported to highlight the

prevailing health system scenario in

India.This child was delivered at home.

Parents were unaware of the immunization

programme and other siblings were also

unimmunized. They were also not registered

in any anganawadicentre. Other siblings

were vaccinated appropriately at our health

service and sent.According to WHO/

UNICEF [4]estimates the national

immunization coverage rate for the year

2011for India was 72% for DPT3. This

coverage rate is a good indicator of the

health system prevailing in a country. It is

expected to be atleast at and above 80%

according to WHO/UNICEF.Our neighbouring

country SriLanka has a coverage of more

than 80%. According to the figures reported

by our country 87% of districts had DPT3

coverage at or greater than 80%. This huge

disparitywould reflect the poor reporting

system in our country which is far from

reality.

According to reported statistics from

all countries WHO[5] has published

incidence time series for all vaccine

preventable diseases. According to that

2,525 cases of diphtheria were reported from

India for the year 2012 ,wherein majority of

the countries have not even reported in

hundreds. According to WHO reported

values are usually underestimates of actual

cases. So the burden of these vaccine

preventable diseases in our country is large

and masked. The health system and the

immunization coverage is not �good

enough� at the grass root level for which

may lives are lost, otherwise could have

been saved.This case truly represents the tip

of iceberg because innumerable such

incidents do occur and are undereported.

Strengthening of the health system is the

only solution for such deaths and everyone

should contribute to it with in their scope of

reach.

REFERENCES

1. Vijay Y, Choudhary P, Thacker N. IAP

guide book on Immunization. Indian

Academy of Pediatrics; 2011.p61.

2. Patil Y Diphtheria. In :Parthasarthy A,

Kundu R, Agarwal R. Textbook of

Pediatric Infectious Diseases. Jaypee;

2013.p.225.

3. Buescher ES Diphtheria(corynebacterium

diphtheria). In :Kleigman RM, Behrman

RE, SchorNF,Geme JW, Stanton BF,

editors. Nelson Textbook of Pediatrics.

Philadelphia:Saunders Elsevier; 2011.

p.928.

4. Immunization summary 2013 edition.

Available at http://www.who.int/

entity/immunization_ monitoring/en/

5. Vaccine preventable diseases. Available

at http://www.who.int/immunization

_monitoring/burden/estimates_burden/

en/index.html


17

Abstract

Objective: To study correlation of low

birth-weight with selected anthropometric

measures of newborns, such as mid-upper

arm circumference (MUAC), chest circumference,

head circumference, and crown-heel length

to identify the best predictor among them

and also with its cut off value .

Studydesign: Case control study of

100 in each group of newborn babies were

done in a tertiary referral centre, in Mangalore

city to examine the correlation between

birth-weight and selected anthropometric

parameters of newborns.

Results & Conclusion: The mean

birth-weight of low-birth-weight (<2,500 g)

babies were 2084 ± 265 gms and that of

babies taken as control were 2782 ± 185

gms. All key anthropometric parameters of

low-birth-weight (<2,500 g) babies were

significantly different from those of the

controls (2700g)(p<0.001). Chest circumference

was the best detector of birth-weight with

area under the graph in ROC curve was

0.848, followed by head circumference 0.824

and MUAC 0.823. We found that these

anthropometric variables can easily be used

to identify the low birth babies at the time of

birth.

Key words: Low birth-weight;

Anthropometry

INTRODUCTION

Birth weight is regarded as one of the

most sensitive and reliable predictors of

health of any community. India, a large

number of deliveries take place outside

health facilities. In the absence of adequate

resources and trained man power for timely

diagnosis and management of low birth

babies, there has been a requirement of

simpler method for identification of low

birth-weight babies even by untrained health

personals. Low birth weight has been

defined by the World Health Organization

(WHO) as weight at birth of less than 2,500

grams (5.5 pounds)1 irrespective of

gestational age. It is an important public

health problem because of its association

with poorer outcomes when compared

normal birth weight babies. The national

neonatal perinatal database reported that

nearly about one third of all neonates born

in major hospitals of India every year are

LBW. Of all neonatal death, nearly 82%

occur among LBW, which is highest in the

world. An early identification and

immediate direct interventions, such as

extra nutrition, can result in low-birth-

weight infants catching up with their

heavier contemporaries1. Screening for low-

birth-weight babies warrants proxy

indicators which can be used for low birth-

weight and for preventing infant mortality.

These include the circumferences of the

newborn�s head, chest, and mid-arm, and

crown-heel length. Different studies from

developing countries have suggested

different anthropometric surrogates to

identify LBW babies and recommended

various cut off values19,20. This study was

conducted to indentify appropriate alternate

indices for low birth-weight which can be

used in situations where accurate weight

measurement at birth is not feasible. Aims

Yenepoya Medical College, Yenepoya University, Mangalore

STUDY OF CORRELATION OF LOW BIRTH WEIGHTWITH SELECTED ANTHROPOMETRIC VARIABLESDr Anil Narayanan, Dr Prakash Saldanha, Dr Mithun


18

and objectives of the study was 1) corelating

low birth-weight with selected anthropometric

measures of newborns, such as mid-upper

arm circumference (MUAC), chest circumference,

head circumference, and crown-heel length

and identify the best predictor among them

2)to determine its cut off value to identify

LBW babies.

Materials and Methods: This was a

hospital based prospective, Case Control

Study done in Department of Pediatrics in

the Labour room, Yenepoya Medical College,

Mangalore, India between January 2012 To

December 2012. A simple random-sampling

technique was adopted to recruit the study

subjects. All cases are managed as per the

protocol for treatment of low birth weight

babies. There was no follow-up of patients

for study purpose. A total of 100

consecutive low birth babies(<2500g), were

selected as cases for enrollment in the study.

Still births, patients born elsewhere and

referred to Yenepoya Medical College,

Mangalore, were excluded from the study.

An equal number of normal birth weight

babies (>2700gms) irrespective of gestational

age selected as controls during the period of

study. Accurate weighing of the baby was

done on a regularly calibrated electronic

weighing machine with a sensitivity <5 gm.

The birth weight was recorded up to the

first digit after the decimal. The babies

having their birth weight recorded with

rounding up and down,which produces an

inaccurate birth weight recording were

excluded from the study. The study included

both term and pre-term babies. Gestational

age was calculated as total duration of

pregnancy in weeks from the first date of

the last menstrual period (LMP) to birth of

the baby. Gestational ages of these infants

ranged from 31 to 44 weeks. The

anthropometric parameters of the newborns

recorded were using standard techniques as

described by DB Jelliffe 7. MUAC was

measured at the midpoint between the tip of

acromion process and olecranon process in

the left upper arm with a fibre-glass

measuring tape to the nearest of 0.1 cm.

Head circumference was also measured

with the help of a fibre-glass measuring tape

21 to the nearest of 0.1 cm. Maximum

occipito-frontal circumference of head was

recorded. Crown-heel length was recorded

to the nearest of 0.1 cm on an infantometer

with the baby supine, knees fully extended,

and soles of feet held firmly against the foot

board and head touching the fixed board.

Chest circumference was measured at the

level of nipple by a fibre-glass measuring

tape to the nearest of 0.1 cm at the end

phase of expiration.

Datas were analyzed using standard

statistical methods, which included paired t

test to compare the data among two groups.

Receiver operating characteristic curve

(ROC) was prepared to analyze the validity

of using the anthropometric parameters of

the newborns for diagnosing low birth

weight). Specificity and sentivity of

individual anthropometric parameters of the

newborns for diagnosing low birth weight

was calculated using confidence interval of

10% and confidence limit of 95%. All the

data was analyzed with SPSS 17 software8,9,10 .

Results:

A total of 200 cases inclusive of cases

and controls(49%males and 51% females)

studied of which , the mean birth-weight of

low birth weight babies was 2,084 ± 265 g

and that of controls were 2,782 ± 185 g. All

the mean anthropometric values (Table 1)

were found to be significant differences than

those for the control babies. The mean

MUAC, chest circumference, crown to heel

length and head circumference of the cases

were found to be lower than the mean


19

MUAC, chest circumference, crown to heel

length and head circumference of the

controls. ROC graph (Table 2 and Graph 1)

of the mean MUAC, chest circumference,

crown to heel length and head circumference

of the cases and control showed graphs

skewed to the top left corner.. The area

under the graph for MUAC, chest

circumference, crown to heel length and

head circumference of the cases and control

were 0.848, 0.823, 0.750 and 0.824, which

established validity of anthropometric

values for diagnosis of low birth weight.

Sensitivity and specificity analyses were

carried out with different cut-off points for

MUAC, chest circumference, and head

circumference of the cases to identify low

birth-weight babies (Table 3). The aim of

selecting cut off points was to identify

correctly all the low-birth weight babies

with a least number of false-positive case.

Table 1 the mean anthropometric values of

the newborns.

Table 2 : ROC curve characteristics and

correlation coefficient value for various

variables.

1-chest circumference 2-head circumference

3-mid arm circumference 4-crown heel

length 5-birth weight

ROC Curve for various anthropometric

parameters of low birth weight babies

Table 3: Sensitivity and specificity with

different cut-off points for MUAC, chest

circumference, and head circumference of

the cases to identify low birth weight babies

1-chest circumference 2-head circumference

3-mid arm circumference 4-crown heel

length

Anthropometric variables

Case/ Control Number Mean

Std. Deviation t value

P value

case 100 27.98. 2.78 -9.603 0.00 CC1(mm)

control 100 32.63 3.96

case 100 28.65 2.83 -9.414 0.00 HC2(mm)

control 100 32.91 3.52

case 100 8.65 1.09 -10.641 0.00 MAC3(mm)

control 100 10.51 1.36

case 100 44.37 3.00 -6.902 0.00 CHL4(mm)

control 100 47.45 3.30

case 100 2084 265 -21.559 0.00 BWT5(gms)

control 100 2782 185

Test Result Variables Area

Std. Error

Asymptotic Sig.

Correlation coefficient

CC1 0.848 0.031 0.000 0.837

HC2 0.824 0.029 0.000 0.802

MAC3 0.823 0.029 0.000 0.650

CHL4 0.750 0.035 0.000 0.403

Test Result Variable(s)

Positive if Greater Than or Equal To Sensitivity Specificity

Positive likelihood ratio of the

cut off value

27.95 0.820 0.610 2.10

29.35* 0.820 0.873 6.43

29.95 0.780 0.800 3.90

CC1

30.50 0.740 0.840 4.6

29.90 0.800 0.701 2.67

30.15 0.760 0.706 2.58

30.95 0.760 0.820 4.22

HC2

31.60* 0.700 0.870 5.38

9.20 0.800 0.780 6.15

9.55 0.800 0.820 4.44

MAC3

9.85* 0.800 0.880 6.66

40.80 0.970 0.890 8.88

41.25 0.970 0.820 5.38

41.75 0.940 0.800 4.50

CHL4

42.50 0.830 0.690 2.76


20

* cut off values of anthrometric variables for

LBW babies in order of significance

Discussion

Present study is first of its type in

Daksin Kannada with respect to correlation

of low birth eight with anthropometric

variables and predicting the cut off value

for the identification of the same. The

findings of this study are comparable with

the findings of these South Asian countries.

The mean birth-weight of new born normal

birth weight babies was 2,782 ± 185 g

which is comparable to the mean birth-

weight in the multi-centre study was 2,630

g, 2,780 g, and 2,840 g, respectively, for

India, Nepal, and Sri Lanka 11, 12. The present

study revealed that all anthropometric

parameters of the new-borns significantly

correlated with one another. For an early

identification of low-birth-weight babies, we

considered arm, chest and head circumferences

as surrogates and found that all were

significantly linked to birth-weight. Most

studies used cut-off points of 28, 29, and 30

cm for chest circumference for a proxy

indicator for birth-weights 2. A comparative

analysis using these and cut-off values of

27.95, 29.35 and 30.5 cm for this study is

shown in Table 3. The cut off value of 29.35

cm, can identify 87 % low birth babies with

sensitivity of 83% with high accuracy as

shown by positive likelihood ratio of test at

6.43. Results of similar studies in India

also showed a chest circumference of <30

cm, and MUAC of <8.7 cm to have the best

sensitivity and specificity for identifying

low-birth-weight infants 3, 13, 14. In a Brazilian

study, head circumference of 33 cm and

chest circumference of 31 cm had been

identified as cut-off points for identifying

low-birth-weight pre-term babies 15. In Egypt,

two cut-off points of 29 to <30 and <29 cm

were selected for chest circumference to

identify �at-risk� and �high-risk� infants

respectively1. As with other parameters

concerned, high sensitivity, specificity and

high positive likelihood ratio was shown by

MUAC and crown to heel length values

9.85comes and 40.80 cm respectively

Linear Regression analysis found the entire

four variables to independently predict the

occurrence of low birth weight in the babies.

The findings of the present study revealed

that, of four parameters 16, 17, 18, chest

circumference and head circumference have

high correlation coefficient (0.837 and 0.802),

are the best one to identify low-birth-weight

infants. Highest correlation (0.837) was

between chest circumference and birth-

weight. So the chest circumference should be

preferred in most cases; as measurement of

head circumference at birth would not be

accurate due to moulding of head, particularly

in cases of prolonged and obstructed

labour19, 20.

Trained birth attendants and health

and family-planning workers working in

rural areas can easily be provided with a

measuring tape, it would be logical to

assume that these substitute measurements

would be useful in predicting neonatal

outcome. Since it is a simple tool to measure

babies and also to detect low-birth-weight

babies, grassroots-level health and family-

planning workers and trained birth

attendants, can identify infants with low

birth-weight with a fair degree of accuracy

and can play a significant role in

identifying low-birth-weight babies and in

giving proper advice to mothers and other

caretakers21-24. Furthermore, in the certain

religious community, where taboos exist

regarding weighing of newborns, these

measurements can be used without any


21

obstruction from the community to identify

low ¬birth-weight babies. In conclusion, we

recommend the use of chest circumference

rather than mid arm or head circumferences

as a surrogate for birth-weight.25

References

1. Diamond ID, Abd EL-Aleem AM, Ali

MY, Mostafa SAM, El-Nashar SMA,

Guidotti RJ. The relationship between

birth weight, and arm and chest

circumference in Egypt (brief report). J

Trop Paediatr 1991;37:323-6.

2. Use of a simple anthropometric

measurement to predict birth weight.

WHO collaborative study of birth

weight surrogates. Bull World Health

Organ 1993;71:157-63.

3. Bhargava SK, Ramji S, Kumar A,

Mohan M, Marwah J, Sachdev HP. Mid-

upper arm and chest circumferences at

birth as predictors of low birth weight

and neonatal mortality in the

community. Br Med J 1985;291:1617-9.

4. Sharma JN, Saxena S, Sharma U.

Relationship between birth weight and

other neonatal anthropometric

parameters, v Joypur: Department of

Paediatric Medicine, Sir Pandmpat

Mother and Child Health Institute,

SMS Medical College, 1988:244-8.

5. Khanam ST, Shahidullah M. A study of

correlation of thigh and mid-arm

circumference of newborns and birth-

weight. Bangladesh Med J 1990;19: 45-

50.

6. Alves JG, Lima GM, Azevedo GN,

Cabral VB, Moggi RS, Nunes R.

Evaluation of newborn arm circumference

as an indicator of low birth weight.

Bull Pan Am Health Organ

1991;25:207-9.

7. Jelliffe DB. The assessment of the

nutritional status of the community

(with special reference to field surveys

in developing regions of the world).

Geneva: World Health Organization,

1966:64-76. (WHO monograph series

no. 53).

8. Reitsma JB, Glas AS, Rutjes AW,

Scholten RJ, Bossuyt PM, Zwinderman

AH. Bivariate analysis of sensitivity

and specificity produces informative

summary measures in diagnostic

reviews. J ClinEpidemiol. 2005;58:982�

90.

9. Akobeng AK. Understanding diagnostic

test 3: Receiver operating characteristic

curves. ActaPaediatr. 2007;96:644�7.

10. Deeks JJ, Macaskill P, Irwig L. The

performance of tests of publication bias

and other sample size effects in

systematic reviews of diagnostic

accuracy was assessed. J ClinEpidemiol.

2005;58:882�93.

11. Karim E, Mascie-Taylor CG. The

association between birthweight,

sociodemographic variables and

maternal anthropometry in an urban

sample from Dhaka, Bangladesh. Ann

Hum Biol 1997; 24:387-401.

12. World Health Organization. Multicentre

study on low birth weight and infant

mortality in India, Nepal and Sri

Lanka. New Delhi: Southeast Asia


22

Regional Office, World Health

Organization, 1994. 78 p. (SEARO

regional health paper no. 25).

13. Raymond EG, Tafari N, Troendle JF,

Clemens J. Development of a practical

screening tool to identify preterm, low-

birthweight neonates in Ethiopia.

Lancet 1994;344:524-7.

14. Bhargava SK, Sachdev HP, Iyer PU,

Ramji S. Current status of infant

growth measurements in the perinatal

period in India. ActaPaediatrScand

1985;319(Suppl):103-10.

15. Pjoda J, Kelley L. Low birthweight; a

report based on the International Low

Birthweight Symposium and Workshop,

Dhaka, 14-17 June 1999. Geneva:

United Nations Administrative Committee

on Coordination/Sub-Committee on

Nutrition, World Health Organization,

2000:30. (ACC/SCN nutritionpolicy

paper no. 18).

16. Ahmed FU, Karim E, Bhuiyan SN.

Mid-arm circumference at birth as

predictor of low birth weight and

neonatal mortality. J Biosoc Sci.

2000;32:487�93.

17. Ezeaka VC, Egri-Okwaji MT, Renner JK,

Grange AO. Anthropometric measurements

in detection of low birth weight infants

in Lagos. Niger Postgrad Med J.

2003;10:168�72.

18. Fok TF, Hon KL, Wong E, Ng PC, So

HK, Lau J, et al. Trunk anthropometry

of Hong Kong Chinese infants. Early

Hum Dev. 2005;81:781�90.

19. Kulkarni AP, Sathe PV. Relationship

between birthweight and anthropometric

measurement of newborn. Indian J

Community Med. 1993;18:141�8.

20. Mullany LC, Darmstadt GL, Khatry SK,

Leclerq SC, Tielsch JM. Relationship

between the surrogate anthropometric

measurements, foot length and chest

circumference and birth weight among

newborns of Sarlahi Nepal. Eur J

ClinNutr. 2007;61:40�6.

21. Singh M, Paul VK, Deorari AD,

Anandalakshmi PN, Sundaram KR.

Simple tricoloured measuring tapes for

identification of low birthweight babies

by community health workers. Ann

Trop Paediatr. 1988;8:87�91.

22. Arisoy AE, Sarman G. Chest and mid-

arm circumferences: identification of

low birth weight newborns in Turkey.

J Trop Pediatr. 1995;41:34�7.

23. Ngowi JA, Redding-Lallinger R, Hirji

KF. An assessment of the use of

anthropometric measures for predicting

low birth weight. J Trop Pediatr.

1993;39:356�60.

24. Das JC, Afroze A, Khanam ST, Paul N.

Mid-arm circumference: an alternative

measure for screening low birth weight

babies. Bangladesh Med Res Counc

Bull. 2005;31:1�6.

25. Goto E. Meta-analysis to estimate the

correlation coefficients between

birthweight and other anthropometric

measurements at birth. Indian J Pediatr.

2011;78:311�8.


23

Abstract

Neumann�s tumor also called as

Epulis tumor is a rare and benign dental

lesion seen exclusively in newborn. This

tumor arises from mucosa of the maxillary

alveolar ridge and characterized by smooth

surfaced sessile or pedunculated mass with

normal to reddish color. We report a case of

a new born presenting with pedunculated

reddish mass arising from maxillary

alveolar ridge.

Key words: Neumann�s tumor:

congenital Epulis: benign : neonate

Neumann�s tumor, a rare benign

tumor of dental interest is exclusively seen

in new born with preponderance to

females(10:1)1-3 arises from right maxillary

anterior alveolar ridge and rarely from

mandibular area. Its size varies from several

centimeters to few millimeters. Aetiology of

this tumor is unknown but certain theories

like myogenic, neurogenic,odontogenic,

fibroblastic are suggested . This tumor is

usually not associated with any other

congenital malformations4 except mild mid

facial hypoplasia. Bigger masses produce

feeding and breathing difficulties needing

emergency intervention. The diagnosis is

mainly clinical. Histologically it is similar to

granulosa cell tumor. This benign tumor

needs surgical excision as spontaneous

regression is rare

Consultant neonatologist, Manipal hospital, Bangalore

Case report

A term 4 days female neonate

appropriate for gestational age was

presented to out patient department with

complaints of a swelling in the oral cavity.

she was born vaginally to nonconsanguinous

union and hemodynamically stable. Parents

were surprised to look at the mass and they

were very anxious. Weight ,length and

head circumference were at 50th percentile.

Clinical diagnosis of Neumann�s tumor

also called as congenital epulis was made

.The mass was measuring 2.5 cm in length

,reddish and pedunculated (as shown in

picture 1) . This mass was not causing

feeding and breathing difficulties. There

were no other congenital malformations

noted. Dental opinion was sought and

parents were reassured .

Neumann�s tumor in new born

Discussion

Neumann�s tumor also called as

granulosa tumor was first published in

the year 18715 by Neumann. the usual site

of tumor is future maxillary canine area.

The clinical presentation consists of lobular

, sessile or pedunculated mass. some times

presents with multiple tumors covered by a

smooth mucosal surface. when lesion is

NEUMANN�S TUMOR - A RARE DENTAL TUMOR

IN NEWBORNDr. Venkatesh. H.A


24

large unlike in our case as depicted in the

picture 1, it causes feeding and breathing

difficulty warranting immediate surgical

excision. Recurrence following incomplete

excision is not published. some small

lesions will undergo spontaneous

regression6-7 as it has happened in our case

. The mass disappeared slowly with in a

year. The lesion probably develops late in

utero hence not usually picked up by

antenatal ultrasound.The differential

diagnosis of a mass in oral cavity includes

dermoid cysts, haemangioma, lymphatic

malformations.

References

1. Chami RG, Wang HS. Large congenital

Epulis of new born. J pediatr Surg

1986: 21(11):929-30

2. Inan M.Yalcin O.Pul M.Congenital

fibrous epulis in the infant.Yonsei Med

J 2002:43(5):675-7

3. Bernhoft CH,Gihuus-Moe O,Bang

G.Congenital epulis in the new born.Int

J Pediatr otorhinolaryngol 1987;

13(1):25-9

4. Koch BL ,Myer C 3rd,Egelhoff JC.

Congenital epulis. AJNR Am J

Neuroradiol 1997;18(4):739-41

5. Neumann E. Elin fall von congaliter

epulis. Arch Helik 1871;12:189

6. Kusuwaka J, Kuhara S. Koga C, Inoue

T, Congenital granular cell tumor

(congenital epulis) in the fetus : a case

report. J Oral Maxillofacial Surg

1997,55(11):1356-9

7. Bork M, Hoede N, Korting GW,

Burgdorf WH, Young SK. Disease of

the oral mucosa and the lips.

Philadephia, PA: WB Saunders;

1996.p.293

Lakeside Education Trust

and

Rajiv Gandhi Institute of Public health and

Center for Diseases Control

Jointly Organises32nd Annual CME Programme

Sunday 27th July 2014

at

Hotel Atria, Bangalore

Vector Borne Diseases and Food Borne Syndromes

C o - S p o n s o r sIAP Karnataka State Branch IAP Bangalore Branch (BPS)

IMA Bangalore � East Branch Pediatric Association of India (PAI)

Lakeside Medical Center & Hospital Pediatric Allergy Association of India (PAAI)

For further details contact

Dr. H Paramesh

#33/4, Meanee Avenue Road ,Near Ulsoor Lake, Bangalore � 560 042

Phones: Mobile: 098450 22689, Office 080 � 25360823, 25303677, Fax: 080 �25512934


25

ABSTRACT

Objective: To identify differences in

clinical features of children with acute lower

respiratory tract infection between those with

and without radio graphically abnormalities.

Material and methods: It was a

prospective case series conducted on 50

consecutive children aged between 2 and 60

months admitted as cases of acute LRTI who

underwent CXR for diagnosis.

Results: Among the clinical findings,

we observed that there was a statistical

difference in the chest x-ray finding of the

patients with symptoms of wheezing and

refusal to feed, and signs of fever,

tachypnoea, wheezing, crackles and chest in

drawing (Pearson chi square 0.001- 0.01).

Among the clinical signs and symptoms at

the time of admission, we observed that

symptoms of wheezing and refusal to feed

and signs of crackles and chest in drawing

were found to be independently affecting the

presence in the chest x-ray finding of the

patients (Multinomial logistic regression

analysis (0.001- 0.016).

Conclusion: Radiological findings

more accurately correlates with clinical

symptoms like wheezing, refusal to feed,

signs of crackles and chest in drawing,

reflecting a more severe inflammatory

process. Patients in the early stages of acute

lower respiratory tract infections with

clinical finding primarily as cough and

fever may not have specific chest x-ray

findings.

Key Words � LRTI, chest X rays, chest in

drawing

INTRODUCTION

Lower respiratory tract infections

have been identified as a leading cause of

mortality in children in developing countries

and a cause of significant morbidity

worldwide1. The World Health Organization

(WHO) proposed the use of a standardized

management based on the detection of

simple signs2, in clinical and chest X-ray

(CXR) findings on admission.3Particularly in

primary health centres and rural settings,

major difficulty in diagnosing lower

respiratory tract infections promptly, is the

absence of an easily identifiable and gold-

standard diagnostic criterion4. Better

understanding of correlation between

clinical finding and radiological finding of a

case of lower respiratory tract infections, is

extremely helpful in paediatric emergency

set-up5.In this study, we aimed to identify

differences in clinical features of children

with acute lower respiratory tract infection

between those with and without radio

graphical abnormalities.

METHODS: This was a prospective

case series studied on 50 consecutive

Children aged between 2 and 60 months

admitted from January 2013 to June2013, as

cases of acute LRTI who underwent CXR

for diagnosis. The study protocol was

approved by the Ethics Committee of

Yenepoya Medical College. Acute LRTI was

defined as child presenting with symptoms

Yenepoya Medical College, Yenepoya University, Mangalore

CORRELATION OF CLINICAL AND RADIOLOGICAL FINDINGS IN

THE CHILDREN WITH LOWER RESPIRATORY TRACT INFECTIONSDr.Ansar Murtuza Hussain, Dr.Prakash Saldanha, Dr.Shamshad Khan


26

of respiratory complaints and detection of

lower respiratory tract findings and was

diagnosed to have acute LRTI by paediatrician

on duty. Children were excluded if they had

anatomic abnormalities of the respiratory

tract, chronic pulmonary illness, immunological

defects, progressing neurological disorders,

psychomotor retardation, heart disease,

hemoglobinopathy, severe malnutrition, or

history of aspiration. Written informed

consent was obtained from parents or legal

guardians before enrolment. Patients were

treated as per the protocol. A thorough

examination was performed and data on

demographics, clinical history, and physical

examination were recorded at admission.

Patient�s symptoms of cough, fever, difficulty

in breathing, wheeze and refusal to feed

were asked and recorded. Fever, tachypnoea,

crackles, wheeze and chest in drawing were

recorded as signs on structured format.

Fever was defined as axillary temperature

>37.5º C6, and tachypnoea as respiratory

rate =50 breaths/min in children aged 2-11

months and =40 breaths/min in children

from 12 months of age onwards7.

Radiological studies: For the purpose

of this study, digital chest x-ray was done

at the time of admission. Chest x-ray was

read by a team of radiologists who were not

aware of the patients� clinical history and

complains. Radiographic findings were

recorded in a standardized form8. The

radiologists looked for the presence of

pulmonary infiltrate, consolidation, pleural

effusion, atelectasis, hyperinflation, abscess,

peribronchial thickening, pneumatocele and

pneumothorax (Table 1)

Table 1: showing the clinical and radiological

findings of the study patients.

Clinical findings N(%)

Symptoms

Cough 50 (100 %)

Fever 44 (88 %)

Difficulty in breathing 36 (72 %)

Wheezing 17 (34 %)

Refusal to feed 3 (6 %)

Signs

Fever 29 (58 %)

Tachypnoea 33 (66 %)

Wheezing 30 (60 %)

Crackles 15 (30 %)

Chest in drawing 12 (24 %)

Chest x-ray findings

pulmonary infiltrates 23 (46%)

consolidation- 12 (24 %)

Normal 8 (16%)

Hyperinflation 4 (8 %)

Atelectasis 2 (4 %)

Data management and analysis:

Statistical Package for the Social Sciences

(SPSS 17.0) was used for statistical analysis.

The presence of a symptom or sign at least

once during the two daily evaluations was

considered as presence of that finding on

that day of evaluation. Differences in

proportions were assessed by using the

Pearson chi square as all the studied

variables were nominal. Multivariate logistic

regression models were performed to identify

association between radiographic findings

and clinical presentation on admission. The

95% confidence intervals were calculated.

Results: At the time of admission 50


27

(100 %) children had cough and 44 (88 %)

had fever. Difficulty in breathing, wheezing

and refusal to feed was present in 36 (72

%), 17 (34 %) and 3 (6 %) cases. Signs of

fever, tachypnoea, wheezing, crackles, chest

in drawing was present in 29 (58 %), 33 (66

%), 30 (60 %), 15 (30 %) and 12 (24 %) cases

respectively. Chest x-ray findings included

pulmonary infiltrates, consolidation,

hyperinflation, atelectasis, pleural effusion

in 23 (46%), 12 (24 %), 8 (100%), 2 (4 %)

and 1 (2 %) respectively. 4 (8 %) of the

patients had no abnormalities in chest x-

ray.(Table 1)

Among the clinical symptoms at the

time of admission, we observed that there

was a statistical difference in the chest x-ray

finding of the patients with symptoms of

wheezing and refusal to feed (Pearson chi

square 0.001- 0.01). Among the clinical signs

at the time of admission, we observed that

there was a statistical difference in the chest

x-ray finding of the patients with signs of

fever, tachypnoea, wheezing, crackles and

chest in drawing (Pearson chi square 0.000-

0.001). Among the clinical signs and

symptoms at the time of admission, we

observed that symptoms of wheezing and

refusal to feed and signs of crackles and

chest in drawing were found to be

independently affecting the presence in the

chest x-ray finding of the patients

(Multinomial logistic regression analysis

(sig) 0.001- 0.016).(Table 2 and 3)

Table 2: Showing Cross tabulation of the Chest x-ray findings of the patients with the

clinical presentations at the time of admission.

Chest x-ray

findings

Fever (sympto

m)

Cough (symptom) Difficult

y in breathin

g

(symptom)

Wheezing

(symptom)

Refusal to feed

(symptom)

Fever

(sign)

Tachypnoea

(sign)

Wheezing

(sign)

Crackles

(sign)

Chest in drawing

(sign)

pulmonary

infiltrates

23(46%) 20 (45.4 %) 14(38.8

%) 2 (11.7

%) 0 (0.0 %) 8(16 %) 12(36.4

%) 8(26.7

%) 2(13.3

%) 2(16.6

%)

consolidation

13 (26%) 13 (29.5 %) 13 (36.1

%) 8 (47.1

%) 0 (0.0 %) 13(26 %) 13(39.4

%) 13(43.3

%) 6(40.0

%) 3(25 %)

no abnormali

ty detected

7 (14%) 4 (9.1 %) 3 (8.3 %) 0(0.0 %) 0 (0.0 %) 1(2 %) 1(3.03

%) 2(6.7 %) 0(0.0 %) 0(0.0 %)

hyperinflation

4 (8 %) 4 (9.1 %) 3 (8.3 %) 4 (23.5

%) 0 (0.0 %) 4(8 %) 4(12.1

%) 4(13.4

%) 4(26.6

%) 4(33.3

%)

atelectasis 2 (4 %) 2 (4.5 %) 2 (5.5 %) 2 (11.7

%) 2

(66.6%) 2(4 %) 2(6.05

%) 2(6.7 %) 2(13.3

%) 2(16,6

%)

pleural effusion

1 (2 %) 1 (2.3 %) 1 (2.7 %) 1(5.8 %) 1 (33.3

%) 1(2 %) 1(3.03

%) 1(3.3 %) 1(6.7

%)

1(8.3 %)

total 50 44 36 17 3 29 33 30 15 12


28

confirmed that tachypnea and lower chest

in drawing when applied by health workers

and paediatricians as a diagnostic tool had

the sensitivity of 70% and 81% respectively9.

In the Vellore study10 lower chest wall in

drawing correctly predicts 79 percent of

children with LRI who were hospitalized by

a paediatrician. These criteria have proved

effective in reducing ARI mortality in

children below 5 years in community by

56% in Abbottabad, Pakistan11.

We observed that the patients of

acute lower respiratory tract infections the

x-ray finding of the cases with sign and

symptoms like fever cough and difficulty in

breathing were not very different from those

without these signs. This is similar to the

observation in earlier reports that cough or

difficulty breathing plus tachypnea12, are not

always sensitive indicator of pneumonia

has been published13. In a clinical trial of

treatment of non-severe pneumonia

conducted by Hazir T et al14, author

reported that out of 891 cases only 6.8% had

radiographic feature of pneumonia. Similar

finding were reported by Shann Fet al15 use

of radiographs does not have that level of

sensitivity signs like respiratory rate and

Chest x-ray findings

Fever (symptom)

Cough (symptom)

Difficulty in breathing

(symptom)

Wheezing

(symptom)

Refusal to feed

(symptom)

Fever

(signs)

Tachypnoea

(signs)

Wheezing

(signs)

Crackles

(signs)

Chest in drawing

(signs)

Pearson chi square

1.00 0.107 0.060 0.000 0.000 1.00 0.001 0.000 0.000 0.000

Multinomial logistic regression analysis (sig)

0.931 0.845 0.300 0.001 0.010 0.752 0.845 0.821 0.016 0.012

Table 3: Pearson chi square and multinomial logistic regression analysis of study variable.

Discussion:

The clinical presentation of pneumonia

varies with the age of the patient, the extent

of the disease, and the etiologic agent. Non�

specific signs and symptoms include fever,

chills, headache, malaise, restlessness and

irritability. General signs of lower respiratory

tract disease include cough, fever,

tachypnea, refusal to feed and retractions of

the accessory intercostal and abdominal

muscles. Chest in drawing is a particularly

useful sign as it appears early and yet has

a high specificity and a reasonable

sensitivity. Respiratory rates to be measured

in all infants thought to be ill or to have

acute feeding problems. Cough with

expectoration of sputum is more common in

older children. Decreased breath sounds

may be present but the presence of crackles,

characteristic of pneumonia in older

children. Rapid breathing as defined by

WHO, detects about 85 percent of children

with pneumonia, and more than 80 percent

of children with potentially fatal pneumonia

are probably successfully identified and

treated using the WHO diagnostic criteria.

Mulholland et al in Philippines have


29

chest in drawing. Finally, there is a

considerable overlap in the clinical and

radiological features of bacterial and viral

pneumonias15, 16.

We observed that children with a

clinical diagnosis of lower respiratory tract

infection and having wheezing, refusal to

feed and chest in drawing, crackles were

found to have different radiological finding

as compared to those which lack them.

More over the presence of wheezing, refusal

to feed, signs of crackles and chest in

drawing were found to be independently

affecting the chest x-ray finding of the

patients. The accuracy of the chest

radiograph in predicting the etiologic agent

causing pneumonia has been disputed. The

radiologic pattern has a relation with the

clinical condition and a routine chest x-ray

is necessary at the initiation treatment.

Staphylococcal pneumonia is frequently

associated with pneumatoceles and pleural

effusion that subsequently evolve to

empyema17 these findings might be

explained by the overlap on clinical

presentation of children with bronchiolitis

and pneumonia. Chest radiographs remain

the diagnostic mainstay in childhood

pneumonia providing support to the clinical

impression and defining the extent of the

inflammatory process. Although it is not

possible to decide from a radiograph

whether a child is suffering from a bacterial

or viral infection and intraobserver and

interobserver variation among radiologists is

common, a high quality chest film can be

useful in the differential diagnosis between

these entities.

Conclusion: we concluded that

radiological findings more accurately

correlates with clinical findings like

wheezing, refusal to feed, signs of crackles

and chest in drawing , reflecting a more

severe inflammatory process. Moreover,

patients in the early stages of acute lower

respiratory tract infections with clinical

finding primarily as cough and fever may

not have specific chest x-ray findings.

REFERENCES:

1. Ranganathan SC, Sonnappa S.

Pneumonia and other respiratory

infections. PediatrClin North Am.

2009;56:135-56.

2. World Health Organization. Acute

Respiratory Infections in Children:

Case Management in Small Hospitals

in Developing Countries. A Manual for

Doctors and Other Senior Health

Workers. World Health Organization:

Programme for the Control of Acute

Respiratory Infections. Geneva,

Switzerland: 1990.

3. Puumalainen T, Quiambao B, Abucejo-

Ladesma E, et al. Clinical case review:

a method to improve identification of

true clinical and radiographic

pneumonia in children meeting the

World Health Organization definition

for pneumonia. BMC Infect Dis.

2008;8:95.

4. Wilkins TR, Wilkins RL. Clinical and

radiographic evidence of pneumonia.

Radiol Technol. 2005;77:106-10.

5. Mahabee-Gittens EM, Grupp-Phelan J,

Brody AS, et al. Identifying children

with pneumonia in the emergency

department. ClinPediatr. 2005;44:427-35.


30

6. El-Radhi AS, Barry W. Thermometry in

paediatric practice. Arch Dis Child.

2006;91:351-6.

7. World Health Organization. Integrated

management of childhood illness chart

booklet. (WC 503.2). Geneva: WHO,

2008. Available at: http:// whqlibdoc.

who.int/ publications/2008/9789241

597289_eng.pdf. Accessed on January

15; 2009.

8. Cherian T, Mulholland EK, Carlin JB, et

al. Standardized interpretation of

paediatric chest radiographs for the

diagnosis of pneumonia in epidemiological

studies. Bull World Health Organ.

2005;83(5):353-9.

9. Mulholland EK, Simoes EAF, Costales

MO, McGrath EJ, Manalac EM, Gove

S.Standardized diagnosis of pneumonia

in developing countries.Pediatric Infect

Dis J1992;11(2):77-81.

10. Shan F. Etiology of Severe Pneumonia

in Children in Developing Countries.

Pediatr Infect Dis. 1986;5(2):247-52.

11. Shaikh QamaruddinNizami, Zulfiqar

Ahmed Bhutta, Rumina Hasan, Yousuf

A Husen.Role of Chest X-ray in

diagnosis of lower respiratory tract

infections in children less than five

years of age in Community. Pak J Med

Sci 2005 Vol. 21 No. 4 417-421.

12. World Health Organization. Integrated

management of childhood illness chart

booklet. (WC 503.2). Geneva: WHO,

2008. Available at: http://

whqlibdoc.who.int/ publications/

2 0 0 8 / 9 7 8 9 2 4 1 5 9 7 2 8 9 _ e n g . p d f .

Accessed on January 15; 2009.

13. Shah S, Bachur R, Kim D, Neuman MI.

Lack of predictive value of tachypnea

in the diagnosis of pneumonia in

children. Pediatr Infect Dis J.

2010;29:406-9.

14. Hazir T, Qazi SA, Bin Nisar Y, et al.

Comparison of standard versus double

dose of amoxicillin in the treatment of

non-severe pneumonia in children aged

2-59 months: a multi-centre, double

blind, randomised controlled trial in

Pakistan. Arch Dis Child. 2007;92(4):

291-7.

15. Shann F, Hart K, Thomas D. Acute

lower respiratory tract infections in

children: possible criteria for selection

of patients for antibiotic therapy and

hospital admission. Bull World Health

Org1984;62(5):749-53.

16. Wall RA, Corrah PT, Mabey DC,

Greenwood BM.Theetiology of lobar

pneumonia in the Gambia. Bull World

Health Org1986;64(4):553-8.

17. Caffey�sPediatric Diagnostic Imaging

10th Edition Vol.I, 994-1006.


31

ABSTRACT

Objective: To understand the need for

monitoring creatinine levels in Birth

asphyxiated neonates to evaluate the

possibility of Acute Kidney Injury in them.

Study Design: prospective hospital

based observational study done in

Department of Pediatrics, Yenepoya Medical

College, and Mangalore, India between Jan

2013 � June 2013.

Patients: 25 newborns born with an

Apgar score (A/S) of =5 at 5 min and

admitted in the NICU were studied, renal

function parameters�blood urea, serum

creatinine, serum electrolytes were monitored

initially within 24 hours of birth and then

serially everyday up to day 5 of life.

Results: The newborns were divided

in two groups. Asphyxiated babies with

normal renal functions were selected as

group A and with impaired renal functions,

as Group B. The renal function parameters

of group A did not show any significant

variation in the serial estimation, which

though was elevated on Day 1 of life

became normalised by Day 3, whereas in

group B, renal function parameters exhibited

progressively higher levels in the serial

estimation of the values from day 1 to day 5.

Conclusion: Monitoring of serum

creatinine is recommended in asphyxiated

neonates with altered renal parameters on

day 1 of life to evaluate the possibility of

acute kidney injury in them.

Key Words: Birth Aphyxia, Creatinine,

monitoring

INTRODUCTION:

Asphyxia remains a common problem

in paediatric intensive care. The incidence

of asphyxia is estimated to be between 1

and 10 per 1000 live births and is a

significant cause of morbidity and death in

the term and preterm neonate1. Asphyxia is

known to lead to multi-organ dysfunction

and a redistribution of cardiac output

which compromises renal perfusion 2, 3, 4, 5.

Renal system is involved in about 50% of

the cases of perinatal asphyxia. Perinatal

asphyxia results in fetal hypoxemia and

hypercarbia1 which further contributes to

renal insult. Moreover perinatal asphyxia

producing ischemia is the commonest cause

of neonatal renal failure5, 6. A high incidence

of altered renal function has been reported

in many studies7, 8, 9.There are not many

reports which elaborates on the pattern of

change in routinely measured renal function

in the cases of birth asphyxia. An accurate

estimate of the pattern of variation in

routinely measured renal function

parameters will help us in early diagnosis

and management renal abnormalities in the

cases of birth asphyxia.

METHODS

This was a hospital based prospective,

observational study done in Department of

Pediatrics, Yenepoya Medical College

Mangalore, and India between January 2013

SERUM CREATININE MONITORING IN BIRTH

ASPHYXIATED NEWBORNSDr. Shamim Amanulla Khan, Dr. Shyam Sudhir, Dr. Faheem

Yenepoya Medical College,Yenepoya University, Mangalore


32

� June 2013. Neonates with an Apgar score

(A/S) of =5 at 5 min of life were included

in the study. Neonates diagnosed with

heart disease, congenital abnormality of

kidneys and urinary tract, perinatal

exposure to medicine that might change

renal hemodynamic, polycythemia, and

twins were excluded from the study10. All

cases were managed as per the clinical

condition, and data was recorded by

treating pediatrician blinded for study

outcome. Gestational age, birth weight,

relevant perinatal history, findings on

physical examination and systemic

examination were recorded on a

predesigned proforma. Daily weight

recordings were taken on an electronic scale,

24 hours urine output measurement done by

applying plastic collection bags and urine

examination performed daily. Renal function

parameters�blood urea, serum creatinine,

serum electrolytes were monitored initially

within 24 hours of birth and then serially

everyday up to day 5 of life by drawing 1

mL of blood with aseptic precautions and a

disposable syringe from any large peripheral

vein, for various tests. After 5 days, babies

having abnormal renal functions had their

laboratory parameters monitored and were

managed accordingly till recovery. Twenty

four hour urine output was measured using

self-adhesive plastic urine collecting bags

and sent for routine examination. Neonates

who developed renal failure were managed

conservatively as per the clinical decision of

the paediatrician incharge. Arterial blood

gas analysis was done as and when

required for the management of the

particular case. Criteria adopted for labelling

an asphyxiated neonate as having renal

failure were , serum creatinine >1mg/dL

plus two of the following three (1) urine

output <0.5 mL/kg/hour,(2) blood urea

>40mg/dL,(3) presence of significant

hematuria or proteinuria. These criteria

were, applied on day 3 of life and the

criteria when fulfilled were considered as

indication of renal failure 12. For blood

urea- diacetyl monoxime13 (DAM) Method;

serum creatinine-Jaff�s reaction 13 (picric acid

reaction); and Serum electrolytes (S·Na +

S·K +)-electronic analyzer, were used. Renal

USG was advised if clinically required.

Asphyxiated babies with normal renal

functions were grouped as group A and

babies with birth asphyxia with impaired

renal functions were grouped as Group B.

Stastical analysis

Data was analyzed using SPSS 17

software. The statistical difference in the

mean value of basic demographic factors

was assessed using unpaired t test of chi

square test as per variable. The statistical

difference in the serial values of the serum

parameters were analyzed using one way

ANOVA for confidence level of 95%, p <

0.05 were considered significant.

RESULTS

25 birth asphyxiated newborns were

studied out of which 14(56%) were girls

with a mean birth weight of 2.63 ± 0.43 kg

and mean gestational age of 39.15 ±3.7

weeks. The patients were divided into two

groups: Group A with normal renal function

(n-14) (M/F 8:6) and Group B renal failure

(n-11) (M/F 6:5)(table 1). No statistical

difference in the mean age (p=0.564) and

gestational age (p=0.433) were noted among

the two group of patients.


33

Table 1: showing the basic demographic

parameters of the two groups of study

patients.

Group A

Group B

Statistical method

Significance

N 14 11

Male/female 8/6 6/5 chi-square with one degree of freedom

p = 0.828

Birth weight (Kg) 2.67 ±0.32

2.59 ±0.73

unpaired t test

0.564

Gestational age( weeks)

39.43 ± 3.4

38.79 ± 3.7

Paired t test 0.433

The renal function parameters of

group A with normal renal function were

statistically different from the corresponding

values for group B (p=0.000-0.012). The

renal function parameters of group A with

normal renal function did not show any

variation in the serial estimation of the

values from day 1 to day 5(p=0.32-0.48). In

Group B neonates, renal function

parameters exhibited progressively higher

levels in the serial estimation of the values

from day 1 to day 5, which was statistically

significant (p=0.000-0.0043) (Table 2).

Table 2: showing the serial renal function parameters of the two groups of patients

DAY 1 DAY 2

DAY 3 DAY 4

DAY 5 p DAY 1 DAY 2 DAY 3 DAY 4 DAY 5

P value

Serum urea

23.4±3.8

24.7±2.7

26.5±6.2

24.4±5.

25.3±5.1

0.482

42.4±3.9

44.8±3.6

49.5±4.3

51.1±15.

55.02±5

0.0043

Serum creatinine

0.9±0.64

1.1±0.45

1.2±0.27

1.1±0.7

1.3±0.24

0.728

1.69±1.25

1.93±2.12

2.32±1.4

2.43±2.1

3.11±1.4

0.0023

Urine output(ml/kg/hr)

0.49±0.16

0.45±0.12

0.51±0.06

0.49±01

0.48±0.12

0.793

0.45±0.24

0.39±0.16

0.36±0.3

0.33±0.1

0.37±0.2

0.0012

Urine routine

P �

H -

P �

H -

P �

H -

P-

H-

P-

H-

P +

H -

P +

H -

P �

H-

P �

H -

P �

H -

0.000

Fig 1.Chart showing the variation in the serial serum creatinine levels in the two groups of

patients.


34

DISCUSSION

11 (44%) of the studied newborn with

birth asphyxia had renal failure. Even those

babies who did not qualify the diagnostic

criteria of birth asphyxia had renal function

parameters higher than those for healthy

newborn 8.This reflects a mild injury to the

kidneys in the majority of them14. However,

kidneys are very sensitive to oxygen

deprivation and injury may result in

permanent renal impairment in up to 40%

of survivors7. Hence, renal function should

be closely monitored in all asphyxiated

neonates, as renal dysfunction is the most

common involvement during perinatal

asphyxia15.

Incidence of renal failure was

seen in 44% of the asphyxiated neonates

which is quite comparable to the incidence

of renal failure reported in earlier studies7, 8,

9. However, Dauber et al 16 studied seven

infants born with A/S of =5 at 1 min, for

renal parameters and observed that 57%

developed ARF. Furthermore, Mohan et al 17

reported an incidence of 72% in asphyxiated

neonates with an overall mortality of 36%,

which could be because of employing

highly sensitive tests, such as measurements

of â2 M, fractional excretion of sodium, and

renal failure index along with urine/plasma

ratio of creatinine.

Out of 25 asphyxiated neonates 11

(44%) developed ARF, which showed the

worsening of the renal parameters on serial

estimation. The fact that levels of the renal

function parameters were similar to study

done by Gupta et al 7 , Saili et al 8 and

Dauber et al 16 the latter studies do not

provide the serial profile of five days values

so exact comparison is not possible.

In conclusion, renal function abnormalities

represent a significant problem among

asphyxiated neonates, and these neonates

have a higher risk to develop renal failure.

We recommend kidney functions to be done

routinely in asphyxiated neonates to

evaluate the possibility of acute kidney

injury in them.

REFERENCES

1. Lisa MA, Papile LA., Cloherty JP,

Eichenwald EC, Stark AR (Eds):

Manual of neonatal care, 6 th Ed. New

Delhi, Wolters Kluwer India Pvt Ltd

2008; 518-35.

2. Bhargava M, Bhargava SK. Impairment

of platelet functions in birth anoxia.

Indian J Med Res 1978; 68:976-9.

3. Costello AM, Mananethar DS. Perinatal

asphyxia in less developed countries.

Arch Dis Child 1994; 71:F1-3. Volpe

JJ. Hypoxia ischemic encephalopathy.

In Volpe JJ (Eds): Neurology of

newborn, 3rd Ed. Philadelphia:

Saunders 2000, 217,277,296,331

4. Volpe JJ. Hypoxia ischemic encephalopathy.

In Volpe JJ (Eds): Neurology of

newborn, 3rd Ed. Philadelphia:

Saunders 2000, 217,277,296,331.

5. Chevalier RL, Campbell F, Noorman A.

Prognostic factors in neonatal acute

renal failure. Pediatrics 1984; 74:265-72.

6. Guinard JP. Renal functions in new

born infant. Pediatr Clin Am 1982;

29:777-89.

7. Gupta BD, Sharma P, Bagla J, Parakh

M, Soni J P. Renal failure in

asphyxiated neonates: Indian Pediatr

2005;42:928-34

8. Saili A, Sarna MS, Dutta AK. Acute


35

renal failure in asphyxiated newborns.

Indian Pediatr 1990; 28:19-23.

9. Kojima T, Kobayashi T, Matsuzaki S,

Iwase I, Kobayashi Y. Effects of

perinatal asphyxia and myoglobinuria

on development of acute neonatal renal

failure. Arch Dis Child 1985; 60:908-12.

10. Jenic AG, Cernadas JM, Gorenstein A,

et al. A randomized, double-blind,

placebo-controlled trial of effects of

prophylactic theophylline on renal

functions in term-neonates with

perinatal asphyxia. Pediatrics

2000;105(4): e45-54

11. Costello A, Ellis M. Birth asphyxia.

Apgar score and neonatal

encephalopathy: Editorial. Indian

Pediatr 1997; 34:975-7.

12. Misra PK, Kumar A, Natu SM, Kapoor

RK, Srivastava KL, Das K. Renal

failure in symptomatic perinatal

asphyxia. Indian Pediatr 1991; 28:

1147-1151.

13. Varely H, Gowenlock AH, McMurray

JC. Creatinine, Urate and Urea. In

Practical Clin Biochem, William

Heinemann Med Books 1988:350-67.

14. Martin-Ancel A, Garcia-Alix A, Goya F,

Cabanas F, Buergueros M, Guero J.

Multiple organ involvement in

perinatal asphyxia. J Pediatr 1995;

127:786-93.

15. Sabrine N, Singh J, Sinha SK. Medical

management of birth asphyxia. Indian

Pediatr 1999;36:

16. Dauber IM, Krauss AN, Synchych PS.

Renal failure following perinatal

anoxia. J Pediatr 1976;88:851-5

17. Mohan PV, Pai PM. Renal insult in

asphyxia neonatorum. Indian Pediatr

2000; 37:1102-6.


36

Abstract:

Aim: This study was done to measure

the incidence of rickettsial fever in a tertiary

care hospital in Mysore Karnataka.Settings:

Pediatric ward of Cheluvamba Hospital

Mysore Methods: This study included all

children between the age group 1year to 14

years who were admitted in Cheluvamba

Hospital Mysore from 1st July 2012 to 31st

June 2013 .The Case records of all children

with a clinical diagnosis of rickettsial fever

and who tested positive for Weil Felix

reaction were reviewed. Weil Felix test was

done by the tube agglutination method .A

titre of 1/160 and above was considered

significant. RGA Scoring system for spotted

fever group of Rickettsial fever was used

(Score above 9 was taken as positive).

Statistical Analysis used was SPSS version

17 for windows and data analysis was by

descriptive analysis and chi square

test.Results:In our study a total of 13

children (4.56% of viral exanthematous

fever) were found to have rickettsial fever.

Age ranged from 1 y to 14 years with

maximum incidence below 5 years (46.2%)

and male predominance (M:F = 1.6:1).

Major presenting symptoms were fever (100

% with mean of 8.76 days) and rash (100%),

followed by oedema (38.5%), hepatosplenomegaly

(21%). Conclusions: Rickettsial fever should

to be considered in children with presenting

complaints of fever with rash. A positive

Weil Felix reaction in the presence of clinical

suspicion and the RGA scoring above 9 can

be regarded as diagnostic for rickettsial

fever where facilities for confirmatory tests

are not available. Early diagnosis and

treatment is associated with reduced

morbidity and mortality.Key words:

Rickettsial Fever, RGA scoring system, Weil

Felix reaction.

Introduction:

Rickettsial Fever is an acute febrile

zoonotic illness transmitted by bite of mites

and ticks with varied clinical manifestations

presenting as fever with rash or

accompanied with gastrointestinal

,respiratory orcentral nervous system

involvement.The main agent causing

rickettsial infection in our country is

Orientiatsutsugamushi,which is the

etiological agent for scrub typhus1.Often

labeled as viral �Exanthematous fever��2.

Rickettsial infection can lead onto serious

end organ damage which includes

pneumonitis, ARDS, acute renal failure,

myocarditis, disseminated intravascular

coagulation (DIC)3 and septic shock.4 The

presence of Rickettsial fever and its re-

emergence have been established in various

parts of India- Jammu and Kashmir,

Himachal Pradesh, Uttaranchal, Rajasthan,

Assam, West Bengal, Maharashtra, Kerala,

Tamil Nadu and Karnataka.

Diagnosis of the disease is often

challenging due to non-availability of

confirmatory laboratory tests and cost factor.

Diagnosis and confirmation of this

disease is based on Serological tests like

Micro Immunofluorescence,Latex agglutination,

RICKETTSIAL FEVER- AN INCIDENCE STUDY IN A

TERTIARY CARE CENTRE IN SOUTH INDIADr. NirmalaVineethaPinto, Dr. SudhaRudrappa, Dr. Suresh R.

Department of Pediatrics, Mysore Medical College and Research Institute,Mysore.


37

Indirecthemagglutination, ELISA and

Immunoperoxidase3 .Gold standard test for

diagnosis isimmunofluorescence assay.

The Weil-Felix (WF) test is based on

the detection of antibodies to various

Proteus species which contain antigens

with cross-reacting epitopes to antigens from

members of the genus Rickettsia. Whole cells

of Proteus vulgaris OX-2 react strongly with

sera from persons infected with SFG

rickettsiae,and whole cells of P. vulgaris

OX-19 reacts with sera from persons

infected with typhus group rickettsiae.

The OX-K strain of Proteus mirabilis

was demonstrated to agglutinate with sera

from scrub typhus patients5. By the WF test,

agglutinating antibodies are detectable after

5 to 10 days following the onset of

symptoms, with the antibodies being mainly

of the immunoglobulin M (IgM) type. The

poor sensitivity of the WF test is now well

demonstrated but a good correlation

between the results of the WF test and detection

of IgM antibodies by an immunofluorescence

assay (IFA) is often observed.

The RGA scale was devised by Rathi

GoodmanAghai et al. includes clinical and

laboratory findings in scrub typus6.Total

score is 35 (25 clinical and 10 laboratory).

TABLE 1 shows the RGA scoring system for

spotted fever

Highest accuracy was found at a

score of 14 with a sensitivity and specificity

at 96.15 % and 98.84%. A score of 17 had

100% specificity and score of 9 had 100%

sensitivity

Observations:

In our study from July 2012 to June 2013,

13 children (4.56% of viral exanthematous

fever) satisfied our inclusion criteria. Age

ranged from 1 year to 14 years with

maximum incidence below 5 years age

group (46.2%) and male predominance (M:F=1.6:1).

Major presenting symptoms were fever (100

% with mean of 8.76 days) and rash

(100%), followed by oedema (38.5%),

hepatosplenomegaly (21%).

TABLE- 2 Observations of the study

On Weil Felix test, 8 children showed

titres = 1:160 for OX2 antigen and 8children

for OX-19 antigen = 1:160, while 4children

showed titre =1:320 for both the antigens at

presentation 1child showed a titre of 1:640.

RGA scores had a median of 14.

Discussion:

This study documents that rickettsial

fever is prevalent in Karnataka and needs to

be considered as an essential differential

diagnosis in children presenting with


38

exanthematous fever. In our study 13

children met our inclusion criteria and had

a positive Weil Felix test and RGA scores

were above 9.Incidence being 4.29 % with a

male preponderance and maximum in age

group less than five years. Weil Felix test

even with low sensitivity can be used in a

set up where confirmatory tests are not

available,however it should be correlated

with clinical features and the RGA scoring

system can be applied.

The clinical features indicating strong

suspicion for diagnosis includes rashes

involving palm and soles, edema of hands

and soles, hepatosplenomegaly and

arthralgia.

The importance of rapid diagnosis is

the prompt response to antimicrobial

therapy and reduced mortality in children

with early treatment. The treatment given in

our set up was oral doxycycline 4 mg/kg/

day7till 3 days after being afebrile, to which

all the children responded and there was

no morbidity.

Delay in diagnosis and treatment has

been associated with death and grave

neurological sequelae.

References

1 Isaac R, Verghese GM, Mathai E et al,

Scrub typhus : prevalence and

diagnostic issues in rural southern

India, Clinical Infectious diseases, 2004

Nov, vol 39, pp. 1395 � 1396

2 N.Murali , Swathi Pillai, Thomas

Cherian et al ,Rickettsial infections in

South India- How to spot the Spotted

fever, IndianPediatrics, 2001 ,vol

38:1393-1396

3 Tsay RW, Chang F Y, Serious

complications in scrub typhus, Journal

of Microbiology, Immunology and

Infection, 1998, vol 31(4), pp. 240 - 244

4 Mohd Ashraf, Arshad Farooq,

SaikaBashiaet al, Renal failure

association with scrub typhus, JK

Science, 2010 april-june, vol 12 (2).

5 SK Mahajan*, R Kashyap*, A Kanga**,

V Sharma**, BS Prasher*, LS

Pal;Relevance of Weil-Felix Test in

Diagnosis of Scrub Typhus in India

JAPI � vol. 54 � august 2006

6 Narendra b rathi, *akanksha n rathi,

#michael h goodman, and #zubair h

aghaiRickettsial Diseases in Central

India: Proposed Clinical Scoring System

for Early Detection of Spotted Fever

indianpediatricsvolume 48; November

17, 2011

7 David H. Walker, J. Stephen Dumler,

Thomas Marrie. Harrison�s Principles

of InternalMedicine 18th edition.

McGraw-Hill Companies Inc.; 2012.

Chapter 174 The Rickettsial Diseases.

pp.1407 � 1417

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