Clinical Presentation of Congenital Adrenal Hyperplasia in Children: Experience in a Tertiary Care Hospital of Bangladesh

This cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with congenital adrenal hyperplasia (CAH) from January 2005 to December 2018. The study was aimed to find out the clinical and laboratory profile of all patients at presentation diagnosed with CAH during the study period. Data were obtained by reviewing the medical records of the patients. Total 102 children with CAH were diagnosed during the study period. Among them 68 were female and 34 were male (female to male ratio of 2:1). Median age was 3.5 month (range 0.2-158 month) and 5.5 month (range 1-108 month) in female and male respectively (p=0.42). Family history was available in 93 patients. Consanguinity was present in 16(17.2%), history of sib death in 12(12.9%), other family members were affected in 8(8.6%). Sixty patient (58.8%) had salt-wasting (SW), 39(38.2%) had simple virilizing (SV) and 3(2.9%) had non- classic form of CAH. Median age of presentation was 2 month (range 0.2-70 month) and 42 month (range 0.8-158 month) in SW and SV group respectively (p=0.001) and 119 month (range 108-152 month) in non- classic group. Common presentations were: genital ambiguity (64.7%), vomiting (46.5%), failure to thrive (41.6%), features of early puberty (precocious pseudopuberty) (24.5%), diarrhea (12.0%). Hyperpigmentation was noted in 49.0% of patients. Among the salt-wasting type in male failure to thrive (FTT) was the most common presentation (83.3%), followed by vomiting (75.0%). In female genital ambiguity was the commonest presentation (97.2%), followed by vomiting (77.1%). Among the simple virilizing type in male early puberty was the commonest presentation (100%) and genital ambiguity was the presenting feature in all the female (100.0%).

Hypertriglyceridemia associated with eruptive xanthomas and lipemia retinalis in newly diagnosed diabetes mellitus

Severe hypertriglyceridemia can cause the deposit of lipids in the dermis (eruptive xanthomas) and in the retina (lipemia retinalis). Lipemia retinalis and eruptive xanthoma are occasionally seen in patients with diabetes mellitus and are thought to be due to abnormalities in the serum lipid fractions. Here a 15 year's old girl presented with typical symptoms of diabetes with skin lesions over hands and feet. On examination skin lesions were non-tender yellow papules with creamy-colored centers on extensor surfaces of the arms, hands and feet. Ophthalmoscopic examination showed creamy white retinal vessels with a faded pinkish white retinal back ground both in the periphery and posterior pole of the retina. Laboratory findings showed a grossly lipemic serum with markedly elevated serum levels of triglycerides 8869mg/dl cholesterol 498mg/dl. Her fasting blood glucose was 20.8mmol/l, 2 hours after breakfast was 50.5mmol/l and HbA1c was 14.6%. Eruptive xanthomas and lipaemia retinalis can occur in primary and secondary hyperlipoproteinemias, therefore a careful personal and family history as well as laboratory investigations is recommended in order to detect an underlying cause.

Cataract in children and adolescents with fibrocalculous pancreatic diabetes

Cataracts have been infrequently reported in Fibrocalculous pancreatic diabetes (FCPD) which is a form of diabetes secondary to chronic, non-alcoholic pancreatitis in tropical countries. A retrospective study was carried out to find out frequency of cataracts in children and adolescents with FCPD admitted in the Paediatric Unit at Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic disorders (BIRDEM). A total of 83 patients with FCPD were admitted during the study period of 2000 to 2007. Among them twenty patients (24%) had bilateral cataracts who were enrolled in the study. Mean age at the onset of diabetes was 13.9±1.7 years. There was female preponderance. Ninety percent patients were girls. There was longer duration of symptoms in all patients. Mean duration of symptoms before diagnosis was 15.0±10.2 months. All patients had hyperglycaemia, mean HbA1c value was 18.4±5.1. Most of the patients had snowflake type cortical deposits and posterior subcapsular cataract.

Prevalence of impaired glucose tolerance among children and adolescents with obesity

The study was undertaken to see the prevalence of impaired glucose tolerance among children and adolescents with obesity, attending the Paediatric Endocrine OPD, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders (BIRDEM), Dhaka, Bangladesh. A cross sectional study from January 2006 to December 2008 was conducted among obese children and adolescents (6-18 years). Children with any other endocrine disorder, dysmorphism/syndrome were excluded. Obesity was defined as BMI ≥ 95th percentile for age and sex using CDC growth chart. Children underwent two hours oral glucose tolerance test with 1.75 gm/kg or 75 gm of glucose, anthropometric and blood pressure measurement. Fasting serum insulin and lipid profile were measured. Impaired glucose tolerance (IGT) was defined as fasting plasma glucose (FPG) <7 mmol/L and 2 hours post glucose load ≥ 7.8 mmol/L to <11.1 mmol/L. Diabetes mellitus (DM) was defined as FPG ≥ 7 mmol/L or 2 hours post glucose load ≥ 11.1 mmol/L. Homeostasis model assessment was used to estimate insulin resistance. A total of 161 children presented with obesity. Male to female ratio was 1.3:1. Mean age was 10.3 ± 2 .5 years. Mean BMI was 27.86 ± 4.1 kg/m². IGT was found in 16.9% of children and adolescents. In children aged 6-10 years IGT was detected in 16.1% and in adolescents aged 11-18 years IGT was detected in 20%. Diabetes mellitus was detected in 2.1% of subjects, all were adolescents. Serum fasting insulin and hip circumference were significantly higher among children and adolescents with IGT compared to that of normal glucose tolerance. The high rate of IGT among obese children and adolescents is of concern. Factors contributing towards obesity needs to be identified and strategies should be planned for prevention and management of this health problem.

Prevalence of obesity among affluent school children in Dhaka

A cross sectional study was conducted in September 2006 in one of the private schools in Dhaka, Bangladesh to see the prevalence of obesity among affluent school children and adolescents. Informed consent was taken from school authority to take anthropometric measurement of all school children. Standing height was measured with a stadiometer and weight with a bathroom scale. Waist and hip circumference were measured with a measuring tape. The body mass index (BMI) was calculated using weight in kilogram/(height in meter)2 formula. Obesity was defined as BMI≥95th percentile for age and sex, over weight as BMI≥85th percentile for age and sex, normal weight as BMI between 5th and 84th percentile and underweight as BMI <5th percentile. Official centers for disease control (CDC) growth chart for boys and girls age 2-20 years was used. Children and adolescents were divided into group 1(3-5 years), Group 2(6-9years), group 3(10-13 years) and group 4(14-18 years). There were a total of 468 children and adolescents (male 266, female 202). In group 1 there were 110 children, in group 2 there were177 children, in group 3 and 4 there were 149 and 32 adolescents respectively. The prevalence of obesity was 17.9%, higher among males (19.9%), compared to females (15.3%). Obesity was highest (27.7%) in group 2, 14.5% in group 1, 10.7% in group 3 and 9.4% in group 4.

Erratum to "Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver" [International Health 2 (2010) 87-98]

The Publisher regrets that an error occurred in the name of the 6th listed co-author for this paper. B. Matthias was listed in the original paper instead of M. Borchert; the correct listing can be seen above.

Cleidocranial dysplasia

Cleidocranial dysplasia (CCD) is a disorder that affects mostly those bones which derived from endochrondal and intramembranous ossification, such as the cranium and the clavicles. CCD is present at a frequency of one in one million individuals. Over 500 cases have been reported. A 13 years old boy reported in the Paediatric Endocrinology outpatient department, Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic Disorders (BIRDEM) on 6th April 2006 with complaints of not growing according to his age, a wide gap over the head since birth and delayed shedding of primary teeth and also eruption of secondary teeth. The boy had elongated facies with midfacial hypoplasia, depressed nasal bridge with hypertelorism. His anterior fontanelle was open about 3/1.5 cm. He had short clavicle and his shoulders could be easily apposed. Radiological findings showed anterior fontanellle and sutures were open and widened, all decidual teeth were intact and all secondary teeth were impacted beneath the primary teeth and hypoplastic clavicle. He was diagnosed as a case of Cleidocranial Dysplasia on the basis of history, clinical examination and investigation.

Vaginal bleeding with multicystic ovaries and a pituitary mass in a child with severe hypothyroidism

A seven year and ten months old girl presented with cyclic vaginal bleeding and a huge abdominopelvic mass. She had clinical features of hypothyroidism. The investigation results were consistent with the diagnosis of primary hypothyroidism with precocious puberty. She also had bilaterally enlarged cystic ovaries on CT scan of abdomen and CT scan of brain showed pituitary macroadenoma. After starting treatment with thyroxine, patient became euthyroid and her general condition improved. Treatment with thyroxine alone halted the cyclic vaginal bleeding, led to rapid resolution of the ovarian cysts and regression of the pituitary mass.

Role of cardiac troponin I in staging and prognosis of congestive heart failure subjects

Congestive heart failure is the one of the major cardiovascular disorder that is increasing in incidence and cause of death globally. Mortality rate has increased 40%-50% in advanced cardiac failure and 15%-25% in mild to moderate cardiac failure within one year of diagnosis. There is no established biochemical marker for the diagnosis, prognosis and staging of heart failure. Cardiac Troponin I may be a novel useful tool in identifying patients with Heart failure who are at increased risk for progressive ventricular dysfunction and death. Thirty six congestive heart failure cases and thirty six healthy controls were included in this study and serum cardiac troponin I and Ejection fraction were measured. All the study subjects were grouped according to the NYHA class they belong. Cardiac troponin I was significantly higher in CHF cases than the controls. Troponin I also significantly differed among groups. EF of cases was significantly lower than the controls and also differed among groups. A significant negative correlation between cardiac troponin I and progressive decline of ejection fraction was evident in this study. Cardiac troponin I increased progressively with progression of heart failure. Thus, Cardiac troponin I could be used to stratify patients undergoing heart failure in to high and low risk groups for future cardiac events. Cardiac troponin I could also be used as a very important marker for the prognosis of the patients with congestive heart failure.

Maternal and newborn-care practices during pregnancy, childbirth, and the postnatal period: a comparison in three rural districts in Bangladesh

The aim of this study was to examine the prevalence of maternal and newborn-care practices among women reporting a birth in the previous year in three districts in different divisions of Bangladesh. In 2003, 6,785 women, who had delivered a newborn infant in the previous year, across three districts in Bangladesh, were interviewed. Overall, less than half of the women received any antenatal care, and 11% received a minimum of four check-ups. Only 18% took iron tablets for at least four months during pregnancy. Over 90% of the 6,785 deliveries took place at home, and only 11% were attended either by a doctor or by a nurse. The mothers reported three key hygienic practices in 54% of deliveries: attendants washing their hands with soap and boiling cord-tie and blade for cutting the cord. Forty-four percent of the 6,785 infants were bathed immediately after delivery, and 42% were given colostrum as their first food. The results suggest that maternal and newborn-care remains a cause of concern in rural Bangladesh. Short-term policies to promote healthy behaviour in the home are needed, in addition to the long-term goal of skilled birth attendance.

Touch detection of neonatal hypothermia in Nepal

The use of touch by health workers to detect hypothermia was examined in 250 newborns in Nepal. Palpation of the feet shows fair interobserver agreement (kappa = 0.4-0.7) and high sensitivity (>80%) but low specificity (36%-74%) compared with axillary thermometry. Traditional birth attendants should feel an infant's feet to detect hypothermia.

Spot morning urine protein creatinine ratio and 24 hour urinary total protein excretion rate

Proteinuria helps to establish the diagnosis of most renal diseases and also to predict the outcome of such diseases. Proteinuria is biochemically represented by measuring the protein concentration in timed collection of 24 hour urine. But, 24-hour timed urine collection is time consuming, cumbersome and often unreliable due to collection errors and also results in undue delay on diagnostic process. An alternate approach avoiding arduous and inaccurate timed urine collection can be the measurement of protein creatinine ratio in spot morning urine. This study was aimed to evaluate whether the spot morning urine protein creatinine ratio can be a reliable alternative to 24-hour urinary total protein (UTP) estimation. The study was carried out in the department of Biochemistry, Bangabandhu Sheikh Mujib Medical University, Dhaka on 50 (fifty) non-diabetic Chronic Renal Disease (CRD) patients with an age ranging from 18 -70 years. The study subjects were grouped into mild, moderate and severe CRD on the basis of GFR. Urinary protein and creatinine concentrations were measured in spot morning urine samples and their ratios were calculated. Urinary protein measured in 24-hour timed collected urine samples gave the 24-hour UTP excretion rate. In our study, spot morning urine protein creatinine ratio significantly correlated with 24-hour UTP excretion rate in all CRD patients. Severe CRD patients gave significant positive correlation (p<0.05), whereas mild and moderate CRD patients gave very highly significant positive correlation (p<0.001). Therefore, it may be suggested that protein creatinine ratio in spot morning urine can be accepted as a reliable and alternative to 24-hour UTP excretion rate in non-diabetic chronic renal disease patients. This simple and inexpensive procedure will thus simplify the way of establishing the severity of renal disease along with its prognosis.

Glycemic status in hyperthyroid subjects

This was an observational case-control study carried out in the Department of Biochemistry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka jointly with the 'Thyroid and Endocrine Clinic' of the same institution during the period of January 2002 to December 2002. Sixty-five (65) newly diagnosed hyperthyroid patients between 20-60 years of age were studied, where forty-five (45) were Graves' disease and twenty (20) were TMNG (Toxic multinodular goiter) patients. Thyrotoxicosis was diagnosed by history, clinical examination and biochemical investigations- FT4, TSH, and Radioactive iodine uptake (RAIU) test. Thirty (30) age and sex matched healthy subjects were taken as control. The mean age was 33.02+/-9.24 years in Graves' disease and 37.55+/-9.49 years in TMNG. Female predominance observed in both the diseases. Glucose intolerance was found in 72.3% of thyrotoxic patients, which is much higher than European population. Our study showed Diabetes mellitus (DM) in 11% of Graves' disease patients. The incidence of DM in Graves' disease was slightly higher in our population. Incidence of DM in TMNG in our study was much lower (5%) than that of Graves' disease (11%) but the incidence of IGT (Impaired glucose tolerance) in TMNG was more (85%) in relation to Graves' disease (54%). Percentage of RAIU was more marked in Graves' disease than TMNG. There is a significant positive correlation (p<0.05) between plasma glucose and FT4 in Graves' disease. Glucose intolerance is frequently found in Thyrotoxic patients.

Use of Wigglesworth classification for the assessment of perinatal mortality in Bangladesh--a preliminary study

The Wigglesworth pathophysiological classification was used to analyse perinatal deaths occurring in 5 health centres in Bangladesh. The aims were to assess the feasibility of this classification, to determine the causes of perinatal deaths and thereby to identify the areas in need of intervention. A total of 8058 births were recorded at 5 centres during the period of 11 months from mid-January to mid-December 2001. There were 1069 deaths in the perinatal period. Stillbirths were slightly more frequent (53.5%) than early neonatal deaths (46.5%). Among the stillbirths, fresh stillbirths predominated over normally formed macerated ones at all centers except BIRDEM, where the majority (52.5%) was macerated. The majority (71.6%) of perinatal deaths were in the groups comprising asphyxial conditions (46.8%), conditions associated with immaturity (13.3%), and normally formed macerated stillbirths (NFMSB, 11.5%). In the group, 'other specific conditions' which was responsible for 9.3% of perinatal deaths, all but one case was attributed to sepsis. When the cases were subdivided by birth groups, asphyxia predominated in all but the <1000g group, in whom immaturity was responsible. Conditions associated with immaturity were second highest in number. The majority of the perinatal deaths (83.4%) was in babies less than 2500g. The study has shown that the Wigglesworth classification can be used in different types of health facilities in Bangladesh by doctors, nurses and midwives. The areas which need intervention are antepartum care, obstetric and newborn care practices, and environmental factors responsible for the high prevalence of prematurity and low birth weight.

TSH assay using dried blood samples: a screening method for congenital hypothyroidism

Capillary blood samples from three hundred healthy, full-term newborn within 48 and 120 hours of delivery, were collected on filter paper for analysis of thyroid-stimulating hormone (TSH). Blood was collected by pricking the heel of the newborn and spotted and dried on filter paper cards. The samples were analysed by immunoradiometric assay (IRMA) to determine the TSH level. Some fifteen percent of a total 1928 deliveries at two hospitals during a period of one year were included in the study. Male:female ratio was 1.1:1. There was no maternal history of thyroid disease. None of the babies had any clinical feature of hypothyroidism. On analysis, TSH level ranged from 0.6-19.3 microU/ml with a mean (SD) of 7.19 (4.21) microU/ml. TSH assay from dried filter paper blood spot is technically possible and is a cost-effective and reliable method for a screening programme. This is the first time in Bangladesh that this method has been successfully carried out.

Circulating lipids and glycaemic control in insulin dependent diabetic children

The prevalence of dyslipidaemia in children with insulin dependent diabetes mellitus (IDDM) and its relation to glycaemic control was studied in a group of 51 diabetic children and a control population of 132 schoolchildren. The prevalence of dyslipidaemia in the fasting state was increased in the diabetic group (39%) compared with control subjects (17%). Serum cholesterol concentration alone was raised in 25% of diabetic subjects while serum cholesterol and triglycerides were raised in 14%, compared with 16% and 0.7% respectively in control subjects. Serum total cholesterol (5.1 v 4.5 mmol/l), low density lipoprotein cholesterol (3.2 v 2.6 mmol/l), non-esterified fatty acids (0.91 v 0.50 mmol/l), and triglycerides (0.94 v 0.76 mmol/l) were higher in diabetic children. Serum total cholesterol, triglycerides, and apolipoprotein (apo)B concentrations increased with worsening control, while serum high density lipoprotein cholesterol and apoA-I concentrations were unaltered. There were also positive correlations between glycated haemoglobin and total cholesterol, triglycerides, and apoB in diabetic children. Thus, abnormalities in circulating lipids are common in young subjects with IDDM but largely disappear if blood glucose concentrations are reasonably controlled.

Lipid levels in schoolchildren in north east England: effects of feeding and age

Serum total cholesterol, high-density lipoprotein (HDL) cholesterol, triglyceride, apolipoprotein (apo) A-I and apoB concentrations were estimated and low-density lipoprotein (LDL) cholesterol levels were calculated in 132 children aged 11.4-17.3 years. The effect of feeding was investigated by estimating postprandial values and also by studying the effects of a test meal. The distribution of all data was consistent with Gaussian apart from triglycerides which was log normal. Overall fasting values were [mean (standard deviation; SD)] cholesterol 4.5 (0.8) mmol/L, HDL cholesterol 1.5 (0.4) mmol/L, LDL cholesterol 2.6 (0.8) mmol/L, apoA-I 1.5 (0.3) g/L, apoB 1.0 (0.4) g/L and triglycerides 0.76 (0.38-1.51) mmol/L, the values for triglycerides being mean (95% confidence intervals). Girls had higher triglycerides than boys [0.82 (0.43-1.54) versus 0.70 (0.36-1.33)] and different effects of age on lipids were found, HDL cholesterol being negatively correlated with age in boys (r = -0.37; P < 0.001), but not in girls, and apoA-I being negatively correlated with age in boys (r = -0.31; P = 0.006), but positively correlated with age in girls (r = 0.32; P = 0.008). Triglycerides rose and HDL cholesterol fell following feeding and inconsistent effects were seen on apoA-I and apoB.