Dr. Manish Pruthi, Dr Ahmad Quazi, Dr Tanu Singhal: Allograft-vascularized fibula composite for infected non union femur

XDR tuberculosis in a 16 year old boy

A 16 year old boy presented with fever and cough for 1 month duration. The CT was suggestive of pulmonary tuberculosis with a pleural effusion. Culture samples confirmed the presence of mycobacterium tuberculosis, which was resistant to all first line drugs, quinolones and even 2^nd line injectable agents. The child was started on a 2^nd line drug regime with quinolones, aminoglycosides, QPAS, clofazimine and linezolid, coamoxiclav, clarithromycin and he improved. 4 months later he developed thrombocytopenia so linezolid was withdrawn. Three months later he developed tubercular meningitis. He was admitted to the hospital and treatment continued with the same drugs and meropenem and amoxiclav was added. He did not improve and then again linezolid was restarted. He developed peripheral neuropathy that was managed with coenzyme Q and drugs were continued. Effort was made t procure bedaquiline which failed. Injectable capreomycin was also started. After about 6 months he started to improve and 18 months later treatment was stopped. He is asymptomatic over the past 6 months. The predicted mortality of XDR tubercular meningitis is in excess of 80% and it was gratifying to save this child

Severe mycobacterium abscessus infection following liposuction

A 23 year old model developed multiple skin abscesses soon after liposuction surgery. She presented to another hospital where was advised radical debridement surgery for her entire back and thighs which would have been associated with very high mortality and morbidity. She took discharge from that hospital and presented to us. Here we sent her pus samples for analysis and detected infection due to mycobacterium abscessus. She was managed conservatively with repeated incision, drainage, and antibiotics including clarithromycin, linezolid and amikacin. She finally recovered after 6 months with very small residual scars and has resumed her modelling career. Mycobacterium abscessus is a rapidly growing mycobacteria that is associated with laparoscopic and cosmetic surgeries and can be managed conservatively with the right combination of antibiotics.

Unusual cause of Aseptic Meningitis in a 5-month-old infant

A 5-month-old infant presented with history of fever for 10 days. She was investigated on day 5 of fever and due to associated irritability a CSF analysis was done which showed around 100 cells predominantly lymphocytes. She was treated with IV ceftriaxone but her fever persisted and antibiotics were upgraded to piperacillin tazobactam. Fever persisted and the WBC and platelets kept rising and she was referred to us. At the time of presentation, she was extremely irritable but there were no other findings. In view of high WBC and platelet counts and high CRP and mild elevation of AST and ALT and also aseptic meningitis, Kawasaki disease was suspected and a 2D ECHO was done. It showed coronary artery aneurysms and the baby was treated with IVIG following which the fever subsided and the aneurysms have lessened over the past few years. Kawasaki disease a medium vessel vasculitis is an unusual cause of fever in children. Infants are unique that they may have none of the tell tale signs such as red lips and tongue and rash. If the diagnosis is delayed there is a 20% risk of coronary artery aneurysms with associated risks of myocardial infarction in later life. Use of IVIG in the first 10 days cuts down this risk to around 1%

Why babies are not small adults?

A 4-month-old infant had history of fever with no focus. A CBC showed high WBC count with predominant polymorphs. His CSR, urine routine and USG abdomen was normal. He was prescribed coamoxiclav with which the fever resolved. Three days later a repeat CBC showed a count of 36,000. The baby presented to the ER of our hospital and was admitted. On history taking, it revealed that the baby was finding it difficult to suck on the breast and lost neck control. An urgent MRI was done which showed a large retropharyngeal abscess that was impinging the airway for which urgent surgical drainage done. Retropharyngeal abscess is one of the occult sites of infection in infants and children along with brain abscess/ sinusitis, osteomyelitis etc. Diagnosis is delayed since the infant cannot localise the infection and are unable to communicate. This makes pediatric practice so challenging and different from adult medicine

Are we in Africa?

A 6-week-old baby presented from a small village near Amreli with fever for 10 days duration. A CBC was done and the PS showed trypomastigotes .This was shocking since trypanosomiasis is unheard of in India unlike Africa where it is fairly common and known as sleeping sickness. The parasite was sent for identification to a higher centre, which identified it, is Trypanosoma lewisi, an animal trypanosome. Review of literature revealed scattered cases in India due to close contact between animals and humans. The baby probably acquired it from contaminated rat excreta which is known to contain this trypanosomes. Since the baby was well and treatment is very toxic, treatment was deferred and the baby recovered spontaneously.

This was followed 1 year later by another case in an adult this time. He was a 48 year old African male residing in Lusaka, Zambia presenting with a progressive neurodegenerative disorder. He came to Kokilaben for neuro rehabilitation. Review of MRI was suggestive of trypanosomiasis. During an acute worsening event, PS for trypomastigotes was sent which was positive. Antimony based treatment was procured from Africa but the patient died. It was indeed surprising that the diagnosis of a disease endemic to Africa was not made there and made here. With increasing international travel and medical tourism it is important to be aware of world wide epidemiology of infectious diseases.