Dr. Ankit Mehta

Dr. Ankit Mehta

Consultant – Paediatrician

MBBS, MD Pediatrics, Fellow Pediatric Critical Care, DM Pediatric Critical Care

A Leaking Lung...

Abdul, 17 month old, Male child was transferred to our Institute from Mombasa through air transport. While he was in Mombasa, Abdul had high grade fever, cough and breathing difficulty before he was admitted in Intensive Care for complicated pneumonia (lung infection). He was also diagnosed with pneumothorax (abnormal collection of air in the lung cavity) along with pneumonia. He required ventilator support as he was not able to breathe properly because of his poor lung condition. He also required a tube in the chest (intercostal drainage tube) to remove the air surrounding the lung and allow the lung to expand.
With ventilator support, he got better with time and started breathing better. He was eventually weaned off the ventilator. However fever spikes, fast breathing and air collection around the lung persisted.
Abdul took treatment for one month in Mombasa. However, since he was not improving further, his parents were asked to shift him to a higher center. That’s when Abdul’s mother decided to bring him to Zydus Hospital.
His transfer from Mombasa to Ahmedabad was an arduous journey. You have to complete many formalities to transfer a sick child in airlines. And to make matters worse, having a poor lung condition, as in Abdul’s case, makes air travel even more difficult. Because there was a tube attached to his chest to drain the air, he was transferred with under the care of a nurse after taking high risk consent from his parents. He landed in Mumbai and came to Ahmedabad by the next flight. His underlying condition, the stress of travel and the tube that got displaced during travel, made it more difficult for him to breathe.
On his arrival to Zydus Emergency, a new tube was inserted. Post stabilization, a CT scan was done. The suggested a necrotizing pneumonia with multiple pneumatocele, hydro-pneumothorax and bronchopleural fistula . Basically it meant that his lung was dying at certain places because of the infection, and it has destroyed many air cavities. Because of being ill for a long time, Abdul had also become malnourished. He had lost 2 kg weight in the last one month.
We first enlisted many of the challenges which are seen in Abdul, than we sought the best way out to help him in this situation. He required help of intensive care, pediatric surgeon, dietician, radiologist and health care back bone nurses. His main issues were despite tube in chest cavity the air around the lung was not getting drained, his fever was persisting, he was losing weight.
With the help of appropriate antibiotics his condition was not improving. As dead tissue doesn’t allow antibiotics to penetrate appropriately, we need remove dead tissue and collected pus in the cavity.
Dr. Parthiv shah operated on him, explaining to parents to remove a part of dead necrotic lung and to heal the bronchopleural fistula. After surgery Abdul fever reduced over 72 hours, however the air persisted in the cavity but his lung expansion was better than before and requirement of oxygen was not there after 3 days of surgery.
His air in the cavity got drained over next 7 days and chest tube was removed on day 10 after operation. Mother and grandmother were very happy as he after 6 weeks he did not have chest tube for last 4 days. However on day 14 he again developed air in the chest cavity secondary to break in one of the pneumatocele for which he required again an reinsertion of chest tube. We as clinical team were very hopeful that this will also heal. After few days complete resolution of air in the chest cavity was resolved, he started eating well. He gained weight and after few days chest tube was removed. After a year they ping me from Africa sending his photo. I couldn’t recognize him. He has grown well and is as normal as any other healthy baby.
Hope he stays blessed.
Scientific view:
Necrotizing pneumonia is the complicated pneumonia which is commonly caused by bacteria. It has a very difficult and stormy course. 7 out of ten children recover from this eventually. It takes 6-8 weeks to recover from such illnesses.

A tale of 2 lethal diseases and the power of faith !

A 12 year old boy presented with history of skin lesions for last 12 days. He had no previous health issues. On day 2 of illness parents took him to a doctor who suggested it could be chicken pox but has atypical findings. Doctor asked to start medicines as prescribed by him and follow-up after 48 hours.
After reaching home, patient’s grandmother decided that it’s what they call in folklore - Mata Ji and asked the parents to stop all medicines and keep him in a dark room and pray to God.
As days passed his condition worsened. He lost his appetite and became lethargic. His mother started worrying a little but kept her emotions to herself as she felt that probably in coming days, his sons health would improve. One day, her worst fears turned true. Her kid was not responding to her voice and as she removed the blanket that covered him, she was horrified to see that most of the skin has come out (a scene which no human can bear to see especially a layman). They went to nearby hospital where they were guided to take treatment in a higher medical centre. When the boy reached the higher medical centre, his general condition was very poor and doctors gave them little hope. He was diagnosed with TOXIC EPIDERMAL NECROLYSIS (80 % of body surface area was involved). Around the world only 1 in 10 survive this condition. As his skin was sloughed his natural barrier to infection was gone, he had developed bacterial infection in blood. He was shifted to ICU isolation for further management. His dressing alone used to take 4-5 hours a day with a lot of nursing care. Despite all efforts, his condition kept deteriorating till day 7 of hospital stay.
But as we say, you can’t write anyone off till he is fighting for himself. Slowly his condition improved and his skin condition and infections started getting better. He had to endure excruciating pain while during skin, eye and bowel care, but every painful second was worth it as he slowly improved and was shifted OUT OF ICU after 28 days.
As expected he became great friends with all the nursing staff and doctors. After all the hospital had become his second home now. As he got discharge everyone was elated and we felt as if he was reborn. He gradually was settling in normal life .He had multiple while marks all over his skin, but doctors said that the skin condition would improve over some time.
After 3 months of hospital discharge, he started having some swelling (nodes) in neck and eyes. Doctors looked at common causes and did some blood tests and asked to follow up after 2 weeks. As 2 weeks passed his swelling didn’t subside. He was given an antibiotics course and asked to visit after a week. After discussion doctor asked to him to undergo lymph node biopsy (removing node surgically and send for test).
His parents started getting the same feeling of doom. As they had developed so much faith in the hospital team, they let the child undergo the test with local anaesthesia. Their son underwent the test holding the doctors hand, as he was the closest mate he had in the last few weeks. To everybody’s dismay, he was diagnosed with lymphoma. We couldn’t imagine our ill-luck. After coming out of one serious illness, where chances of survival are very less, he was diagnosed with another potentially lethal illness. He underwent further test for determining the stage of illness. We started his treatment again. Fortunately, he responded well to the treatment and as days passed he started going back to school. At the same time he took his regular chemotherapy session. Every time we came for chemotherapy he brought a big chocolate for his best mate (doctor). As the time elapsed he was declared free of lymphoma.
As a doctor, this episode taught me a lot of things. It taught me to never give up hope. Children are like mirrors. They reflect what they see and experience and also freely express their true feelings. The child had more faith in me and my team that I ever had treating such a difficult disease. No book can teach us the emotional bonding between humans.
His story is more than a miracle and I wish him great health always.
Scientific Insight:
It was not a case of chicken pox, it was Toxic Epidermal Necrolysis right from the beginning. This a rare disease and present with vesicobullous skin lesions along with mucosal (eyes, urinary tract and mouth). It can happen secondary to certain infections and as a reaction to certain medicines. In this child’s case, the cause of the disease, could not be ascertained.

The Beauty of Hope

A 2 year old child was playing alone outside the house. Suddenly she came crying to her mother, complaining of severe pain in the abdomen. She seemed to be in a lot of pain. Her mother gave her home based treatment but she was not relieved of the pain. She was taken to her local doctor who prescribed some medicine. She was still not relieved of pain.
She slept after crying and in unbearable pain. When she woke up after 2 hours, her mother noticed that she was drowsy, couldn’t open her eyes properly and was looking dull. Her mother felt this was not normal. The parents again took her to the paediatric doctor who examined and noticed that the child was not able to breathe properly. Doctor asked parents to immediately taker her to the nearest Intensive Care Unit (ICU). As she reached the ICU she was not able to move her limbs, she could hardly breathe and was put on ventilator. In a matter of hours i.e. from morning 11 am to 6 pm her health deteriorated. Her parents and doctors were not able to understand what was happening to her. She was an absolutely healthy child and Overnight she ended up on a ventilator. When senior doctors came to visit the following morning they explained to the parents that the child’s condition had deteriorated rapidly and she had slipped in to a coma and that her brain was not functioning properly. Under such conditions, it would be difficult for them to save her life.
Her parents wanted to give her the best possible treatment and take 2nd opinion for the baby. The admitting hospital transferred her to Zydus Hospitals, Ahmedabad on a ventilator support. Looking at all her clinic findings, we thought of some poisoning (envenomation) and a remote possibility of bleeding in the brain. We did a CT scan brain which didn’t reveal any bleed. Based on our clinical findings and past experience we thought its likely a neuroparalytic snake bite (neurotoxic snake bite). She was administered supportive care by shifting her to the Paediatric ICU, continuing ventilatory care and rest of the management.
We administered anti dote of snake envenomation. Parents were requested to allow us 3-7 days, as some of such patients may appear to be brain dead during such time period. As time elapsed, the patient started moving her fingers and tried to open her eyes. This raised our hopes of improvement.
There was still no sign of movement in the limbs. However, with time there was improvement in eye movements and eventually she started moving limbs also purposefully. With time she also regained her muscle power. She was taken off from ventilator after 10 days.
She was shifted to the room and discharged after 4 days. She was normal after 4 weeks of discharge.
Scientific Insight :
The child was affected with neuroparalytic snake envenomation. It can be non-painful bite depending on the kind of snake without even a local reaction. This child had classical symptoms starting with no specific symptoms like irritability, abdominal pain followed by paralysis of all limbs, facial and eye muscles. It’s a life threatening condition and if not identified in time child dies of air hunger. Neuroparalytic snake envenomation is a treatable condition with good outcomes as in above case.