Persistent Vomiting Research Articles

Treatment of children with incomplete duodenal membrane

BACKGRAUND: An incomplete or perforated duodenal membrane is a rare developmental pathology of the gastrointestinal tract.
 AIM: This study aimed to analyze the diagnostic and treatment results of children with an incomplete duodenal membrane in the Republican Childrens Clinical Hospital in Ufa.
 MATERIALS AND METHODS: This study retrospectively analyzed case histories of 34 children who underwent surgery for incomplete duodenal membrane from 2005 to 2020. Features of the life history of the children, clinical picture of the disease, presence of concomitant developmental anomalies, laboratory and instrumental examination data, surgical correction methods, and postoperative period were analyzed. All children underwent ultrasound examination of the abdominal organs and contrast-enhanced radiography of the upper gastrointestinal tract with barium sulfate. Esophagogastroduodenoscopy was performed in 17 cases.
 RESULTS: Antenatally, the diagnosis was made in 21 cases. Patients age at the time of hospitalization was 9.7 2.7 days. Children were presented with symptoms such as persistent regurgitation or vomiting of curdled milk, which was sometimes mixed with bile (22 cases). Bloating in the epigastric region, retraction of the lower abdomen, and low weight gain after birth were found in nine children, and in five children, no weight changes were observed. Moreover, 13 (38.2%) children had concomitant developmental anomalies; 4 (11.7%) children had Down syndrome. Surgical treatment of 10 children was performed laparoscopically. Of the 24 children, three received laparotomic access, including conversion. The procedures included duodenotomy, partial excision of the membrane, and suturing of the duodenum. Enteral feeding was started 4.9 0.6 days after surgery. The average duration of hospitalization was 27 1.4 days.
 CONCLUSION: Vomiting or frequent regurgitation in infants and low-weight gain should alert pediatricians and pediatric surgeons. Malformation of the duodenal membrane in combination with other malformations necessitates a comprehensive examination. Laparoscopic excision of the duodenal membrane is the preferred treatment.

Chylomicron retention disease caused by a new pathogenic variant in sar1b protein: a rare case report from Syria

BackgroundChylomicron retention disease (Anderson disease) is a result for variant of the SAR1B gene. It is a rare autosomal recessive hereditary disorder with most incidence in infant. It is characterized by lipid malabsorption syndrome with fatty, chronic diarrhea, and growth retardation.Case presentationWe report a case of a 19-month Syrian boy who presented with vomiting, growth failure, and chronic, fatty diarrhea. Upper gastrointestinal endoscopy showed whitish appearing duodenal mucosa and small intestinal biopsies revealed steatosis of enterocytes. Genetic testing confirmed chylomicron retention disease with the first description of variant located in the fourth helix of sar1b protein. The patient is treated with nutritional supplements and fat-soluble vitamin supplementation resulting in significant improvement.ConclusionEarly endoscopy is recommended in infants with persistent vomiting and failure to thrive due to high suspicion for a disorder of hypocholesterolemia. Early diagnosis and treatment are essential to avoid serious clinical complications, especially neurological impairment.

1517 Case Report: Concomitant Superior Mesenteric Artery and Nutcracker Syndrome

Abstract Background Superior mesenteric artery (SMA) syndrome is a rare1 upper gastrointestinal emergency and diagnosis is reached by a high clinical suspicion and confirmed on CT scan. It classically occurs from the compression of the third part of the duodenum (D3) due to a reduced aorto-mesenteric angle2. Case report A 28-year-old Caucasian female presented with a 4-day history of persistent vomiting, generalised abdominal pain, distension and absolute constipation for 3 days. She has no previous past medical history. On examination, she had a BMI of 17. Her abdomen was distended with generalised tenderness on palpation. Her routine blood results showed stage 2 acute renal failure. CT abdomen and pelvis showed a grossly dilated stomach and part 1& 2 of duodenum. She underwent an emergency Roux-en-Y duodeno-jejunostomy and end-side jejuno-jejunal anastomosis. Operative findings were of a grossly distended stomach and D1/2 with superior mesenteric vessels impinging on D3 and on left renal vein. Conclusions SMA syndrome is a rare cause of gastric outlet obstruction and following initial hydration and correction of electrolytes a definitive procedure should be considered. Many surgeons favour a conservative approach with a period of ‘fattening’ to increase the aorto-mesenteric angle prior to surgical management. We believe that this only delays the inevitable and patients are best serviced with early surgical bypass.

Value of age and alarm features for predicting upper gastrointestinal malignancy in patients with dyspepsia: an endoscopic database review of 4664 patients in Thailand

ObjectiveAge and alarm features are commonly used as indicators for endoscopy in dyspeptic patients; however, the age cut-off and the predictive value of these parameters for identifying upper gastrointestinal (UGI)...

Ventriculoperitoneal Shunt versus Endoscopic Third Ventriculostomy in the treatment of Obstructive Hydrocephalus in Pediatric Midline Posterior Fossa tumors

Abstract Background Treatment of secondary hydrocephalus due to posterior fossa tumors in these children is still a matter of controversy, although preoperative ventriculo-peritoneal shunt (VP shunt) insertion before tumor excision is widely accepted among neurosurgeons but many attempts are rising to minimize permanent VP shunt insertion and associated complications and introducing third endoscopic ventriculostomy (ETV) as one of the options of 2ry hydrocephalus. Objectives Comparing the post-operative clinical success with resolution of the manifestations and post-operative complications between endoscopic third ventriculostomy and ventriculoperitoneal shunt as different modes of CSF diversion in children with 2ry hydrocephalus due to midline posterior fossa tumors. Methods The following electronic databases were searched from June 2009 to june2019: PubMed, Google scholar search engine. Cochrane database of systematic reviews, EMBASE and science Direct, using the keywords ―hydrocephalus; posterior fossa tumors; pediatrics; ventriculoperitoneal shunt; endoscopic third ventriculostomy‖. Studies were eligible if they contain the target keywords in title or abstract, addressing the Pediatric age group with 2ry hydrocephalus due to de novo posterior fossa tumor manifested by signs of increase the intra cranial tension including persistent headache and vomiting, blurred vision, 6th nerve palsy, papilledema in fundus examination, acute DCL and 2ry hydrocephalus confirmed by brain imaging. Exclusion criteria included studies including age group below 1yr or above 18 yr, or patients with recurrent post fossa tumors and operated before or patients presented by failed previously attempt of CSF diversion. Results: A total of 1255 citations were screened for eligibility,6 studies were included in our systematic review discussing, comparing and evaluating the durability of ETV versus VP shunt in treatment the 2ry hydrocephalusdue to pediatric posterior fossa tumor.. Overall study population reached 474 patients. the overall clinical findings at presentation and postoperative outcomes regarding the clinical findings improvement, radiological improvement and postoperative complications between ETV and VP shunt are compared and showing that ETV should be considered as an alternative procedure to VP shunt in controlling severe hydrocephalus related to posterior fossa tumors to relieve symptoms quickly during the preoperative period when patients should wait for their definite tumor excision. Conclusion The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure of endoscopic third ventriculostomy as compared to ventriculoperitoneal shunt, and the significant advantage of not becoming shunt dependent make endoscopic third ventriculostomy to be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to posterior fossa tumors. It is a preliminary, simple, safe, effective, physiological, minimally invasive procedure for the relief of elevated intracranial pressure before direct tumor removal.

Failure to Thrive and Vomiting in a 32-day-old Girl.

Failure to Thrive and Vomiting in a 32-day-old Girl.

Tra reflussi e torcicolli

The paper descibes the cases of a 10-year-old girl and a 3-year-old boy with CNS neoplasia. The girl presented with acute vomiting and cervicalgia while in the boy vomiting persisted for three months as the only symptom and was iniatially misinterpreted as due to gastroesophageal reflux. The authors stress that in very young children (< 4 y) persistent vomiting may be the only symptom of a CNS neoplasia.

Gastric antrum stenosis caused by accidental ingestion of concentrated hydrogen peroxide.

Hydrogen peroxide (HP) is an oxidizing agent that has since long been used for medical purposes, such as wound irrigation, dental irrigation, and enema. However, its routine use is limited by many toxic effects such as portal gas embolism1 and proctitis.2 Accidental ingestion of concentrated HP is not common and has been reported to cause an extensive portal gas embolism, esophagitis, gastritis,3 and even result in death. However, reports of gastric corpus stenosis caused by accidental ingestion of HP are rare. A 60-year-old man ingested a mouthful of HP (30%), thinking it was water after a family member filled the water jar with HP on February 23, 2020, when most households in the region used HP as a disinfectant because of the Covid-19 pandemic. He felt epigastric pain, burning sensation in the chest area, had attacks of persistent vomiting, and non-bloody foaming in the mouth and was immediately presented to a county hospital 30 min later. Upon arrival to the emergency department, his vital signs were stable, the abdomen was soft but tender, and he was neurologically intact. A computerized tomography scan of the abdomen was performed and revealed gas in the portal vein throughout the liver (Fig. 1). After gastric lavage, the patient's symptoms were not relieved, and then he was transferred to a provincial hospital. The patient was then treated with proton pump inhibitors and parenteral nutrition for more than 2 months and was allowed a liquid diet (less than 100 ml). He felt abdominal distension, repeatedly vomited white sticky gastric juice, and lost 11 kg weight. Endoscopy was performed on April 27, demonstrating cardiac stenosis, esophagitis, diffuse gastritis with multiple petechiae, and white exudate; gastric stenosis (Fig. 2) and gastroenterography performed on May 27 revealed gastric antrum stenosis and gastric retention. Jejunostomy was performed on May 12, and the patient was treated with continuous enteral nutrition, which provided 2000 kcal daily, through a jejunostomy tube for the following 3 months, and he gained 5 kg weight. The patient was then readmitted, and gastroenterography (Fig. 3) performed on September 6 indicated gastric retention and gastric antrum stenosis, so gastrojejunostomy (Roux-en-Y) was performed on September 22. The patient was discharged on October 9, when he recovered to a regular diet. The patient remained well during 3 months follow-up. The three main mechanisms involved in HP toxicity damage include oxygen gas formation, corrosive damage, and lipid peroxidation.4 The toxic effect of HP seems to be related to the ingested concentration and quantity. Ingestion of low concentration of HP (3%) has been reported to be usually asymptomatic or resulted in mild symptoms such as nausea and vomiting.5 Complications such as gastritis, hemorrhagic gastritis, gastric ulcers, and gas in the portal vein have also been reported.1-3 Accidental ingestion of concentrated HP (35%) is more likely to result in serious complications such as hemorrhagic gastritis, portal venous gas embolism, acute myocardial infarction, neurological impairment, and death.1, 4, 6-8 Our patient presented with a rare case of accidental ingestion of HP associated with the portal vein gas embolism, gastritis, and gastric antrum stenosis, which hindered the patient's intake of food and resulted in malnutrition. Waiting for a certain period before the surgical treatment of gastric antral stenosis is recommended because the stabilization of the pathological process of gastric injury takes time. Accordingly, appropriate nutrition methods should be adopted to maintain the nutrition of patients during the waiting period. All data generated appear in the submitted article. Shi-lian Le: Data curation; supervision; writing – review and editing. Long-xin Xiong: Resources; validation; writing – review and editing. Peng Deng: Formal analysis; project administration; writing – original draft; writing – review and editing.

Herpetic oesophagitis in an immunocompetent infant with gastroesophageal reflux

A 7-month-old boy presented to our emergency department because of persistent vomiting with streaks of blood despite esomeprazole treatment for gastroesophageal reflux for 3 months. Additionally, he refused solid food and showed failure to thrive (decrease of two standard deviation scores for weight-for-age). The boy's mother was known to have recurrent herpes labialis. Abdominal ultrasound showed no pyloric hypertrophy, but a barium swallow radiogram revealed a dilated distal oesophagus with a pinpoint stenosis (figure A). Oesophagogastroscopy showed extensive inflammation with whitish exudate and friable mucosa of the distal part of the oesophagus (figure B; video), as well as stenosis of the lower oesophageal sphincter. During oesophagogastroscopy, the stenosis was dilated to 8 mm and multiple biopsies were taken. Histopathological examination revealed features typical for herpes simplex virus oesophagitis (HSVE; figure C), which was confirmed by herpes simplex virus (HSV) immunohistochemistry (figure D). Moreover, HSV-1 was detected by PCR analysis. Additional laboratory tests revealed normal levels of T, B, and NK lymphocyte subpopulations and immunoglobulins. The patient was treated with valaciclovir (30 mg/kg per day in two doses) for 10 days, high-dose omeprazole (2 mg/kg per day in one dose), and nasogastric tube feeding. 2 weeks after initiation of treatment, the patient was symptom free and gained weight. 4 weeks after valaciclovir treatment, oesophagogastroscopy showed remarkable improvement with complete disappearance of mucosal inflammation, but clearly visible was a mild sliding hiatal hernia. Nasogastric tube feeding was discontinued after the endoscopy and omeprazole treatment was continued to treat reflux oesophagitis.

Multisystem Inflammatory Syndrome in Children Admitted to a Tertiary Pediatric Intensive Care Unit.

Background Multisystem inflammatory syndrome in children (MIS-C) is characterized by persistent fever, abdominal pain, vomiting, diarrhea, rash, conjunctivitis, headaches, and mucocutaneous manifestations and it can cause circulatory dysfunction, resulting in hypotension, shock, and end-organ injury in the heart and other organs and possibly death. In this study, we aimed to analyze the clinical spectrum, treatment options and outcomes of children with MIS-C who were admitted to our pediatric intensive care (PICU). Materials and Methods Clinical and laboratory findings and treatment of the patients admitted to the PICU with MIS-C between April 2020 and January 2021 were recorded, and their outcomes were evaluated. Results Nineteen patients with a median age of 12.5 years (interquartile range (IQR): 5.8-14.0 years) were admitted. Eleven (57.8%) were males. The most frequent clinical and laboratory features were fever (100%), abdominal pain (94.7%), rash (63.1%), headache (68.4%), diarrhea (47.3%), seizure (10.5%), cardiac dysfunction (52.6%), acute kidney injury (26.3%), lymphopenia (84.2%), and thrombocytopenia (36.8%). However, 8 patients needed mechanical respiratory support, 11 patients needed inotropes, 2 patients needed plasma exchange, and 1 patient needed continuous renal replacement therapy. All patients received corticosteroids, 17 patients (89.2%) received intravenous immunoglobulin, 2 patients received anakinra, 10 patients received acetylsalicylic acid, and 6 patients received enoxaparin. Median PICU length of stay was 3 days (IQR: 2-5) and only one patient died. Conclusion In conclusion, MIS-C may present with a variety of clinical manifestations, and it can lead to life-threatening critical illness. Most children need intensive care and the response to immunomodulation is usually favorable.

Clinical Presentations, Outcome and Cost of Illness of Dengue in a Tertiary Care Hospital of Bangladesh: An Observational Study

Background: Dengue is a fast-emerging viral disease in many parts of the world, having a potential to present with a varied spectrum of clinical manifestations with atypical presentations being more frequent. This study was conducted to evaluate the clinical features, outcome and Cost of Illness (COI) of dengue cases admitted in a tertiary-care government hospital in Chattogram, Bangladesh. Methods & materials: It was a hospital based prospective observational study and was carried out in the Department of Medicine, Chittagong Medical College Hospital. All the consecutive serologically positive (NS1 antigen, IgM, IgG antibodies) dengue cases (age >12 years) admitted in the Department of Medicine of Chittagong Medical College Hospital from 1st August 2019 to 31st July 2020, were enrolled in the study. Severity of each dengue case was determined as per the recent WHO classification (2009) Clinical presentations of the cases were carefully assessed. In-hospital outcomes of the patients in terms of mortality, duration of hospital stay, need for ICU or other support were recorded. The COI questionnaire included three major cost components: direct medical costs (DMC), direct non-xiv medical costs (DNMC), and indirect costs (IC). Data analysis was done on the SPSS 23 version. Results: Out of 425 patients, the maximum number of dengue cases reported were males (76.9%) and belonging to the 21-30 years age group (38.8%). Fever was the main complaint in all the cases followed by headache (78%), myalgia (56%), persistent vomiting (44%). Of the 91.5% Dengue fever cases, 88.2% were classified as Dengue fever without warning signs and 3.3% with warning signs and 8.5% as severe dengue. Thrombocytopenia was present in 53.9% and leukopenia in 42.1% of cases. 3.3% of patients needed ICU admission and the mortality rate was 1.2%. The median total COI was BDT 8703 (IQR: 6240-11795) with median DMC of 3580 (IQR: 2525-4885), DNMC of 2000 (IQR: 1250-3225) and INMC of 2400 (IQR: 1045-4000). Conclusions: Overwhelming number of cases and their varied clinical presentations lead to an increase in hospitalization in this outbreak. Though the outcomes have been mostly favorable, the cost incurred as a result has been immense and has impacted households greatly, since most medical costs in Bangladesh are out-of-pocket expenses.

Dorsal Stomach Perforation by Peptic Ulcer. Case Report and Review the Literature

Background: Dorsal perforation due to stomach ulcer is a rare condition and it should always be included in the differential diagnosis of acute upper quadrant pain. Our report evaluates the presentation, diagnosis, management and outcomes of this uncommon acute surgical condition. Case presentation: The aim of this case report was to review the current literature and report on a case involving a 65-year-old Caucasian female presented to the emergency department with persistent right upper abdominal pain, nause, vomiting and loss of appetite. Contrast-enhanced CT scans of abdomen showed a dorsal stomach perforation with free air and contrast intraperitoneal and in retroperitoneal space. A posterior gastric perforation of peptic ulcer was confirmed by exploratory laparotomy; ulcerectomy with primary suture closure was performed. The patient was discharged 25 days after the operation. Conclusions: When pneumoperitoneum was confirmed by radiological examination, posterior perforation of peptic ulcer should be actively excluded in high risk patients. A high index of suspicion is mandatory.

Overtreatment of Transient Maternal Hyperthyroidism Resulting in Fetal Goiter.

Overtreatment of Transient Maternal Hyperthyroidism Resulting in Fetal Goiter.

Small cell neuroendocrine carcinoma disguised as an external hemorrhoid.

This article describes a patient who presented to the ED with persistent nausea and vomiting, constipation, weight loss, and a new complaint of an external hemorrhoid and hematochezia with stooling. Comprehensive diagnostic evaluation included imaging studies that showed extensive metastatic disease but did not identify a primary neoplasm. Biopsy of the external hemorrhoid revealed small cell neuroendocrine carcinoma of the anal canal.

A Study of Prognostic Markers for Dengue Infection

Introduction: Early diagnosis and prognostication of infections such as dengue are crucial for better patient outcomes, as they help predict the likelihood of patients developing severe dengue, allowing more comprehensive patient triage and therapeutic interventions. This study aimed to determine clinical, laboratory, and radiological factors predicting prognosis in dengue infection. Methods: This prospective observational study included 250 patients seropositive for dengue. They were classified into dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS); and evaluated both on admission and at the end of their hospital course, the latter was performed for factors responsible for the progression of dengue to severe dengue. Data were statistically analyzed using R 3.6.1, with P<0.05 considered statistically significant. Results: Final diagnosis correlated significantly with systolic blood pressure (P=0.004), lowest platelet count (P<0.001), serum glutamic-oxaloacetic transaminase (P=0.001), urine protein (P<0.001), urine red blood cells (P<0.001), pleural effusion (P=0.0064), serositis (P<0.001), vomiting (P<0.001), rash (P<0.001), restlessness (P<0.001), and bleeding manifestations (P<0.001). Conclusion: The prognosis of dengue is significantly associated with blood pressure, lowest platelet count, serum transaminases, serum creatinine, proteinuria, hematuria, pleural effusion, abdominal pain, persistent vomiting, rash, restlessness, serositis, and bleeding manifestations. Monitoring these parameters is useful for the effective management of dengue.

Cerebral Venous Thrombosis in Nucleophosmin Gene-Mutated Acute Myeloid Leukemia

Association of cancer and thrombotic complications in acute leukemia is not uncommon. The underlying mechanism involved in thrombus formations is largely unknown with limited published data. Our patient was presented with complaints of continuous headache and persistent projectile vomiting. After initial tests, a magnetic resonance imaging of the brain performed revealed cerebral venous sinus thrombosis. Anticoagulant and anticonvulsant prophylaxis was initiated, and further treatment was planned. In such rare cases, early diagnosis and management are desirable. The role of clinicians in identifying the clinically suspicious signs and symptoms can help in identifying such rare conditions before developing severe thromboembolic complications. In the present study, we report a rare case of cerebral venous thrombosis, its associated treatment, and complications in a patient diagnosed with nucleophosmin gene-mutated acute myeloid leukemia. Similar Cases Published: None.

A narrative review of gastroesophageal reflux in the pediatric patient.

Gastroesophageal reflux (GER) is the retrograde passage of gastric contents into the esophagus. It is a physiologic condition that is common in neonates, typically resolves spontaneously, and does not result in clinically significant complications. When pathologic, gastroesophageal reflux disease (GERD) can cause numerous complications including persistent emesis, failure to thrive, aspiration, and respiratory symptoms. While a diagnosis can often be made from a thorough history and physical, some patients may require further testing. In general, many clinicians will reserve extensive investigation such as multiple intraluminal impedance and pH monitoring for patients with a confounding clinical picture or relative contraindications to medical or surgical management. Whereas most pediatric GER resolves spontaneously, medical management including lifestyle changes, changes to feeds, and the use of H2-antagonists and/or proton pump inhibitors (PPIs) can be utilized to alleviate symptoms. Surgical treatment is reserved for patients who are refractory to medical management or have suffered significant complications as a consequence of GER. In this article we seek to provide a concise but detailed review of recent updates in the understanding, work up and management of GER in the pediatric patient. A summary of new technologies used in the diagnostic and therapeutic arms of this disease are included.

A Curious Case of Progressive Respiratory Failure Due to Anterior Spinal Cord Infarction in an Adolescent Boy: A Case Report and Review of the Literature

AbstractClinical features of cervical spontaneous spinal cord infarctions (SSCIs) remain poorly described in the literature. The goal of this article was to improve recognition of cervical SSCI, a rare but life-threatening condition. We presented a 15-year-old adolescent male patient who developed neck pain with weakness and numbness in all four limbs half an hour after returning from a hike in the late afternoon. The next morning, he was brought to the emergency room due to persistent weakness, vomiting, and progressive respiratory distress. He was promptly intubated for airway protection. Pupils were 2 mm, sluggishly reactive, and all four extremities were flaccid. He was found to have anterior spinal cord syndrome. Light touch (brush) was normal down to the posterior aspect of shoulders. Cervical magnetic resonance imaging (MRI) showed increased T2/short-tau inversion recovery and decreased T1 signal of the anterior spinal cord from C3 to C7. Four days later, MRI of the spinal cord showed restricted diffusion of anterior spinal cord consistent with radicular artery territory infarction. The work-ups for infection, thrombosis, and cardioembolism were all negative. Three months later, he still had incomplete Brown-Séquard's syndrome, as position sense was preserved. There was in addition bilateral loss of pain and temperature sensations below the clavicles. MRI showed cervical myelomalacia most severe between C3 and C5. Furthermore, MRI showed changes in C3–C4 intervertebral disc, consistent with a fibrocartilaginous embolism via retrograde arterial route into the anterior spinal artery. This article demonstrates the importance of recognizing subtle clinical clues leading to cervical SSCI diagnosis.

English

BACKGROUND Dengue is a major public health concern in tropical Asian countries and a most rapidly spreading mosquito borne viral disease with a 30 fold increase in global incidence over the last five decades. Dengue is among the ten leading causes of death in children ranging from 1 to 15 years of age in tropical Asian countries. Complications of dengue fever are common in children. But very limited studies are available on paediatric populations. The virus or non-structural protein (NS1) interacts with platelets and coagulation factors. A combined effect of mild disseminated intravascular coagulation, liver damage and platelet dysfunction results in bleeding in dengue fever. With this scientific knowledge background, the present study was undertaken to identify and document the changing pattern of dengue infection in paediatric age group with a special emphasis on laboratory findings of dengue cases in paediatric age group. METHODS The present descriptive study was conducted for two years in a state run paediatric referral hospital. The sample was purposive by design and consisted of patients who have been diagnosed as having dengue fever with warning signs and admitted. RESULTS Fever was typically high grade (> 103 F) and most patients presented with warning signs within 5 days of illness (64.2 % in year 2016 and 76.6 % in year 2017). Persistent vomiting and abdominal pain were the most common warning signs in both the years. Thrombocytopenia was the commonest laboratory finding. Bleeding in study subjects lead to < 50000 / cu mm platelet count. Most common bleeding was gastrointestinal bleeding (39.2 % of study subjects with platelet count < 50000 / cu mm presented with G. I bleeding). CONCLUSIONS Dengue illness comes with varied presentation. Atypical presentations can delay the diagnosis. Early recognition of warning signs keeping the atypical presentation in mind is important. KEYWORDS Dengue Fever, Paediatric Age Group, Non-Structural Protein (NS1), Thrombocytopenia

Cerebellar Stroke in a COVID-19 Infected Patient. a Case Report.

BackgroundRecent studies have reported that COVID-19 infected patients with stroke, who were often in the older age group, had a higher incidence of vascular risk factors, and more severe infection related respiratory symptoms. These observations provided little evidence to suggest that COVID-19 infection is a potential causative factor for stroke. This report describes a young patient with a cerebellar stroke secondary to COVID-19 infection.Case presentation A 45-year old male presented at a hospital, reporting a two-day history of headache, vertigo, persistent vomiting, and unsteady gait. Physical examination revealed gaze-evoked nystagmus on extraocular movement testing, left-sided dysmetria and dysdiadochokinesia. He was diagnosed with a left cerebellar stroke. An external ventricular drain was inserted, and sub-occipital craniectomy was performed to manage the effects of elevated intracranial pressure due to the extent of oedema secondary to the infarct. He also underwent screening for the COVID-19 infection, which was positive on SARS-COV-2 polymerase chain reaction testing of his endotracheal aspirate. Blood and cerebrospinal fluid samples were negative. After the surgery, the patient developed atrial fibrillation and had prolonged vomiting symptoms, but these resolved eventually with symptomatic treatment. He was started on aspirin and statin therapy, but anticoagulation was withheld due to bleeding concerns. The external ventricular drain was removed nine days after the surgery. He continued with active rehabilitation.Conclusions Young patients with COVID-19 infection may be more susceptible to stroke, even in the absence of risk factors. Standard treatment with aspirin and statins remains essential in the management of COVID-19 related stroke. Anticoagulation for secondary prevention in those with atrial fibrillation should not be routine and has to be carefully evaluated for its benefits compared to the potential harms of increased bleeding associated with COVID-19 infection.