A previously healthy 12-year-old boy presented to the emergency department on the seventh day of illness with classical symptoms of postinflammatory multisystemic syndrome in children temporally associated with SARS-CoV-2 (fever, vomiting, loose stools and rashes all over the body) with COVID-19 seropositivity, high inflammatory markers and elevated cardiac enzymes with cardiogenic shock with multiple organ dysfunction syndrome. After having improved over the first 48 hours following intravenous immunoglobulin and pulsed steroids, this young boy developed sudden cardiac arrest and died. No reversible cause could be identified at the time of resuscitation. Despite an apparent clinical recovery in the myocardial function, it is likely that the myocardium remains arrhythmogenic due to cytokine-induced myocardial inflammation. There are several reports in the literature of fatality in multisystemic inflammatory syndrome in children (MISC) due to cardiovascular complication during the acute phase of the illness. To the best of our knowledge, this is the first report of sudden cardiac death in a child with MISC days after recovery from critical illness, suggesting that fatal outcome remains a potential risk during follow-up, even when there is no evidence of coronary aneurysm. Further studies are needed to identify clinical characteristics of such high-risk children presenting with MISC. We will need to follow these children closely to understand what implications they may have in the long term, and this helps in raising awareness among families of such children.

Justification The unprecedented COVID-19 pandemic has had a formidable impact on Indian health care. With no sight of its end as yet, various establishments including the smaller clinics and nursing homes are restarting full operations. Hence, there is the need for recommendations to allow safe practice ensuring the safety of both the heath care worker (HCW) and patients. Process Indian Academy of Pediatrics organized an online meeting of subject experts on 27 July, 2020. A committee was formed comprising of pediatricians, pediatric and neonatal intensivists, and hospital administrators. The committee held deliberations (online and via emails) and a final consensus was reached by November, 2020. Objectives To develop recommendations to provide a safe and practical healthcare facility at clinics and small establishments during COVID times. Recommendations The key recommendation to practise safely in this setting are enumerated. Firstly, organizing the out-patient department (OPD). Secondly, appropriate personal protective equipment (PPE) to provide protection to the individual. Thirdly, decontamination/disinfection of various common surfaces and equipment to prevent transmission of infection from fomites. Next, maintaining the heating ventilation and air conditioning (HVAC) to provide a stress-free, comfortable, and safe environment for patients and HCWs. Finally, steps to effectively manage COVID-19 exposures in a non-COVID-19 facility. All these measures will ensure safe practice during these unprecedent times in clinics and smaller establishments.

Sir, Organophosphate poisoning [OP] is a potentially fatal but completely treatable condition that is still very prevalent in our country. Early recognition is paramount in preventing fatality. Although rarely reported, it does occur in infants, where history may not be forthcoming and initial presentation often misleading. We report a case of aspiration pneumonia whose evolving symptomatology made us diagnose OP poisoning. A previously healthy baby presented with vomiting whilst breast feeding followed by respiratory distress and altered sensorium. No prior history of fever, respiratory illness, seizures or drug intake. On examination he was a well thriving infant, who was afebrile with severe respiratory distress. He had altered sensorium and was markedly hypotonic with small sluggishly reacting pupils. Emergency management was given and baby was intubated and ventilated. Empirical antibiotics for possible aspiration pneumonia and other supportive treatment was started. Blood counts, chest radiograph and metabolic profile were normal. In the next few hours his sensorium worsened, pupils became pin pointed and unreactive to light. Copious oropharyngeal secretions and diarrhea were also noted. This constellation of symptoms made us suspect cholinergic hyperactivity and a large dose of atropine was given, which did not produce pupil dilatation, suggesting OP poisoning [1]. To confirm cholinesterase [ChE] level [2] was done and was found to be less than 25% reference range. Atropine infusion was immediately instituted at 0.02 mg/kg/hour [5], titrated to drying of secretions. As the nature of OP compound unknown empirical dose of pralidoxime, 25 mg/kg was given to reactivate ChE enzyme [5]. In next 24 h baby showed good improvement in motor tone and power with drying of secretions, and was subsequently extubated. Retrospectively parents revealed that insecticide was sprayed around the house on that day and child most likely got exposed by inhalation. Atropine was continued for 3 days and then weaned over 24 h. Serial monitoring of ChE levels showed a steady rise in titers to normal. The baby was discharged after a week and parents were counseled on the hazards of environmental exposure to OP compounds.

Introduction: Empyema thoracis (ET) is an accumulation of pus in the pleural space. Considering the advantages of Video Assisted Thoracoscopic surgery (VATS), including reduced length of hospitalisation, lower postoperative morbidity and mortality, VATS is the treatment of choice for cases of stage 3 empyema. The objective of this study was to study the age-sex profile, clinical presentation, etiologic agents, management and the overall treatment outcome of empyema thoracis after early VATS in children. Methods: This was a retrospective observational study, conducted in the Department of Paediatrics, Rangadore Memorial Hospital, Bangalore, from November 2018 to March 2020. All children in the age group of 0 to 18 years diagnosed to have pyogenic empyema and presenting in stage 1 and 2 during the study period were included in the study. In the present study, 15 children were found to be having empyema (stage 1 and 2). Results: Majority of patients (66.6%) were seen in the age group of one to five years. Fever (100%), breathlessness (66.66%), and cough (80%) were the commonest presenting features. Bacteriological isolation was possible only in three cases (20%). Patients were treated with antibiotics and primary VATS in majority of cases (55.33%). Average duration of hospital stay in VATS group was 12.11 days. Conclusions: Empyema thoracis mainly affects younger children. Common presenting features are fever, difficulty in breathing and cough.  Appropriate antibiotics and early VATS may be acceptable modality for management of pyogenic empyema thoracis in children.

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