A Clinical Conundrum with Diagnostic and Therapeutic Challenge: a Tale of Two Disorders in One Case

Living organisms are exposed to exogenous and endogenous agents that affect genomic integrity by creating DNA double strand breaks (DSBs). These breaks are repaired by DNA repair proteins to maintain homeostasis. Defects in DNA repair pathways also affect lymphocyte development and maturation, as DSB sites are critical intermediates for rearrangements required for V(D)J recombination. Recent classifications for inborn errors of immunity (IEIs) have listed DNA repair defect genes in a separate group, which suggests the importance of these genes for adaptive and innate immunity. We report an interesting case of a young female (index P1) with mutations in two different genes, DCLRE1C and FANCA, involved in DNA repair pathways. She presented with clinical manifestations attributed to both defects. With the advent of NGS, more than one defect is increasingly identified in patients with IEIs. Familial segregation studies and appropriate functional assays help ascertain the pathogenicity of these mutations and provide appropriate management and genetic counseling.

Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

JUSTIFICATION

Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia.

OBJECTIVE

To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children.

PROCESS

These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members.

RECOMMENDATIONS

We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

The Spectrum of Clinical, Immunological, and Molecular Findings in Familial Hemophagocytic Lymphohistiocytosis: Experience From India

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of immune dysregulation characterized by hyperactivation of the immune system, excessive cytokine secretion and severe systemic inflammation. HLH is classified as familial (FHL) when associated with mutations in PRF1, UNC13D, STX11, and STXBP2 genes. There is limited information available about the clinical and mutational spectrum of FHL patients in Indian population. This study is a retrospective analysis of 101 molecularly characterized FHL patients over the last 10 years from 20 different referral centers in India. FHL2 and FHL3 together accounted for 84% of cases of FHL in our cohort. Patients belonging to different FHL subtypes were indistinguishable based on clinical and biochemical parameters. However, flow cytometry-based assays viz. perforin expression and degranulation assay were found to be specific and sensitive in diagnosis and classification of FHL patients. Molecular characterization of respective genes revealed 76 different disease-causing mutations including 39 (51%) novel mutations in PRF1, UNC13D, STX11, and STXBP2 genes. Overall, survival was poor (28%) irrespective of the age of onset or the type of mutation in our cohort. Altogether, this article sheds light on the current scenario of FHL in India. Our data reveal a wide genetic heterogeneity of FHL in the Indian population and confirms the poor prognosis of FHL. This study also emphasizes that though mutational analysis is important for diagnostic confirmation of FHL, flow cytometry based assays help significantly in rapid diagnosis and functional validation of novel variants identified.

Chromobacterium violaceum diarrhea

This is the first case of Chromobacterium violaceum diarrhoea from coastal Karnataka reported in a 2 year 10 months old girl. Stool culture yielded Chromobacterium violaceum and was sensitive to ampicillin, gentamicin, chloramphenicol, erythromycin and septran. Patient completely recovered with ampicillin and gentamicin.

Noninvasive imaging and analysis of skin lesions for early detection of cutaneous malignant melanoma

Knowledge of the depth of invasion and three-dimensional (3D) characteristics of skin lesions is crucial to the early diagnosis and prognosis of malignant melanoma. These parameters are currently available only after biopsy. A clinical prototype of an optical imaging instrument, called a nevoscope, has been developed to noninvasively image skin lesions. The nevoscope provides multiple views of a transilluminated skin lesion. These views provide a three-dimensional perception of the lesion. In addition, image-analysis techniques are applied to these images to quantify various diagnostic parameters, such as 3D geometric features and surface texture and pigmentation characteristics. Clinical trials are under way to evaluate the utility of the nevoscope as a diagnostic tool for early detection of melanoma. The construction of the clinical prototype and the integrated clinical imaging environment are described. The development of iterative reconstruction techniques suitable for nevoscopy data is also described. Experimental reconstructions of a physical tissue-like phantom and an in-vivo lesion are presented. The phantom is recovered effectively. Thus, nevoscopy is of potential diagnostic value.

Three-dimensional imaging and reconstruction of skin lesions

An optical instrument called a "nevoscope" is used to image skin lesions by transillumination with visible light. The lesion is transilluminated by a fiber-optic annular ring light source that directs light into the skin area surrounding the lesion, forming a virtual source just beneath the lesion. Mirrors uniformly spaced around the lesion and tilted at various angles provide orthographic projections of the skin lesion. Additional views are obtained by rotating the mirror assembly. These multiple views are used in a direct three-dimensional (3D) reconstruction of the lesion using a filtered backprojection method. In this paper, we discuss the methodology of direct 3D reconstruction from 2D views of a transilluminated skin lesion as obtained using the new prototype nevoscope. We present the results of direct 3D reconstruction of a simulated phantom and a test object imaged using the nevoscope. In addition, a skin lesion was scanned in situ using the new prototype nevoscope. Results of the reconstruction of this lesion are also presented.

Chronic utero-rectal fistula with menochezia and amenorrhea

Utero-intestinal fistulas are commonly acute in nature and usually follow malignancies of the intestines. Here we report a chronic uterorectal fistula with uncommon symptom of cyclical rectal bleeding (menochezia) and amenorrhea.

Single coronary artery: right coronary artery originating from distal left circumflex

This report describes a patient with single coronary artery, in whom the right coronary artery originated from the distal left circumflex. However, this anomaly was not of clinical significance based on atypical nature of chest pain, negative thallium exercise test and absence of coronary obstruction.