SUMMARYA developmentally normal infant presented with repeated episodes of afebrile status epilepticus following nutmeg ingestion. He had developed two episodes of afebrile status epilepticus and had received different treatments earlier, but the details of treatment were not available. On admission, he redeveloped convulsions and loading doses of phenytoin, phenobarbitone and midazolam were administered. However, seizures persisted and extrapyramidal movements, nystagmus and visual dysfunction were noted. Iatrogenic phenytoin toxicity was considered and confirmed by drug levels. His symptoms completely disappeared after discontinuation of phenytoin therapy. The initial seizures were attributed to myristicin, an active component of nutmeg, because of the temporal association. However, the subsequent seizures were due to phenytoin toxicity caused by administration of multiple loading doses. This case highlights that nutmeg, a spice, can cause serious toxic effects like status epilepticus. Furthermore, treatment of status epilepticus with phenytoin can cause iatrogenic seizures due to its narrow therapeutic range. BACKGROUND

Despite resurgence in the number of Scrub typhus cases, it still poses a diagnostic challenge as there is no prototype presentation. We report a case of a child with Scrub typhus who developed a massive consolidation. Despite such an extensive consolidation, respiratory symptoms such as cough and breathlessness were inconspicuous thereby posing a diagnostic dilemma. Upon serological confirmation, doxycycline therapy was initiated with a rapid and complete resolution of the pneumonia, both clinically and radiologically. The case is being reported to highlight this unusual presentation of Scrub typhus in children.

A two-month-old male infant presented with a clinical picture suggestive of fever without focus. Treatment was initiated with broad spectrum intravenous antibiotics. The infant subsequently developed septic shock, hepatosplenomegaly and tachypnoea with oxygen dependency. There was laboratory evidence of anemia, thrombocytopenia and a leukemoid reaction. Infection induced hemophagocytic lymphohistiocytosis with a leukemoid reaction was suspected because of fever, splenomegaly and bicytopenia in conjunction with elevated serum triglycerides and ferritin. Empiric therapy with doxycycline caused a rapid resolution of the fever, and the diagnosis of scrub typhus was confirmed by a positive scrub IgM ELISA. HLH with a leukemoid reaction secondary to scrub typhus has not previously been reported in early infancy.

Background: Dengue fever is endemic to most parts of India and the clinical recognition of progression to severe dengue may become difficult in the absence of classical findings. Early recognition of shock or hemorrhage and appropriate management with fluids prevents morbidity/mortality to a great extent. In this study, we attempted to evolve a simple hematological prognostic marker for prediction of severe dengue.Methods: This retrospective descriptive study of 67 children was conducted in the Paediatric Department of a Government Medical College. The case records of all the patients with a diagnosis of dengue fever and Severe Dengue were analysed using a preset proforma. Besides the demographic and clinical findings a detailed analysis and comparison of hematological profile was done between cases of dengue fever and severe dengue. The data obtained was analysed statistically in order to arrive at a hematological marker to predict severe dengue. Results: Study population consisted of 67 children with 44 children with dengue fever,12 with DSS and 11 cases with DHF. Detailed analysis of hematological profile of severe dengue showed striking neutrophilia and monocytosis besides thrombocytopenia. Neutrophilia was seen in 78% and monocytosis was prevalent in 91% of cases of severe dengue. Monocytosis with thrombocytopenia was consistently seen during shock/hemorrhage. During recovery the fall of monocytes was accompanied by simultaneous increase in platelets in this group. This inverse relation was found to be statistically significant (p <0.05) Such a significant inverse correlation was not seen in dengue fever group (p >0.05).Conclusions: Monocytosis and neutophilia are consistent features of dengue fever. There is an inverse correlation of monocytosis with thrombocytopenia in severe dengue during shock/hemorrhage which recovers on clinical improvement. Thus monocytosis with thrombocytopenia can be used as a prognostic marker to predict severe dengue.