Dr. Rohan Malik MD, PDCC, DM | All India Institute of Medical Sciences, New Delhi (original) (raw)

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Papers by Dr. Rohan Malik MD, PDCC, DM

Acute pancreatitis is a rare diagnosis in pediatrics. Valproic acid has been known to trigger thi... more Acute pancreatitis is a rare diagnosis in pediatrics. Valproic acid has been known to trigger this catastrophe in occasional young patients as an idiosyncratic reaction [1]. We describe a typically developing eight-year-old boy who presented to emergency department with acute abdomen (se-vere, diffuse non-radiating abdominal pain with non-bilious vomiting) and fever for 48 h. He was on oral valproate (30 mg/kg/d), phenobarbitone (3 mg/kg/d) and clonazepam (0.04 mg/kg/d) for his underlying epilepsy. He was diagnosed with super-refractory status epilepticus of unknown etiology nine months back and has been receiving antiepi-leptics since then. There was not any history of recent change in antiepileptic dosages. On examination, there was tachy-cardia (pulse rate = 120/min), tachypnea (respiratory rate = 38/min), diffuse abdominal tenderness and guarding. His hemogram revealed leukocytosis (12,760/cumm with 60% neutrophils) and low platelet count (118,000/cumm). Ultrasound abdomen and chest revealed mild ascites and bilateral minimal pleural effusion with non-visualization of pancreas. A working diagnosis of valproate induced acute pancreatitis was considered. Raised serum amylase (647 SU, normal = 28-100 SU) and serum lipase (514 SU, normal = 0-190 U/L) confirmed the presence of pancreatitis. Serum Valproic acid (VPA) level was within therapeutic range (56.68 mcg/ml, normal = 50-100 mcg/ml). Work up for infective etiology (dengue, rickettsia, chikungunya, coxsackie, cytomegalovirus) was negative. Child was made nil-per-oral and started on intravenous hydration with antibiotics (piperacillin tazobactam and metrogyl), proton pump inhibitors and opioids for pain relief. VPA was immediately stopped and replaced with levetiracetam. On day 2 of hospitalization he developed hypoxia with increased pleural effu-sion, ascites and loose stools which responded to conservative management within 48-72 h. Child did not have any neurological issues during the stay and was discharged after 1 wk. Amylase levels got normalized (0.5 SU). In any child on valproate therapy presenting with acute abdomen, pancreatitis should be suspected and investigated. The underlying mechanism of valproate induced pan-creatitis is elucidative and may possibly be associated with free radical injury [2]. Pancreatitis can develop after weeks to years of initiation of VPA [3]. Majority of children will respond to timely withdrawal of valproic acid and conservative management [4]. However, occasional fatality is also reported [5]. Pediatricians should be aware of this sinister adverse reaction of VPA.

Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy, was first de... more Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy, was first described by Davidson et al. in 1978. Till date, only a handful of cases with MVID have been described in English literature. It is an autosomal recessive disorder with no sex predisposition and more commonly noted in countries with prevalent consanguineous marriages. These patients usually present with intractable secretory diarrhea in early days of life. The pathognomonic findings of MVID are villous atrophy along with the formation of intracellular microvillous inclusions on electron microscopy. Till date, no curative therapy exists, and prognosis mainly depends upon parenteral nutrition. Small bowel transplantation is one of the treatment options. Clinician and pathologist should consider the possibility of MVID in the differential diagnosis of chronic intractable diarrhea in an infant. Herein, authors are describing a case of intractable diarrhea with MVID phenotype diagnosed in a 3-mo-old male child who presented with intractable diarrhea in an outside hospital, and the diagnostic workup was performed by the authors on endoscopic biopsy sample.

Liver biopsy is a valuable tool. Even though outpatient liver biopsies are routinely performed in... more Liver biopsy is a valuable tool. Even though outpatient liver biopsies are routinely performed in
adults, there are no clear recommendations on its safety and feasibility in children. We reviewed
the records of children who underwent a percutaneous liver biopsy at our institution between
January 2005 and June 2015. 626 biopsies were performed on 497 patients (250 boys, median
age 6 (0.2–19.3) years). Abnormal liver function tests for investigation 288(46%) was the most
common indication. 30(4.8%) biopsies had complications, most common being sub-capsular
hematoma 14/30 (46.7 %). Complications were identified within 8 hours of the biopsy in all
patients. Approach, needle–size or number of passes did not affect the complication rate.
Bleeding-related complications were not related to the INR. Performing liver biopsies on an outpatient
basis would have saved 60 beds/AU$ 80,000/year. This study suggests that if an
observation period of 8 hours is instituted, outpatient liver biopsies can be performed safely in
children.

Background & Aims: Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed t... more Background & Aims: Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. Methods: We evaluated 67 children with CLD (38 boys; age 13 [7–18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spec-troscopy (1 HMRS), diffusion tensor imaging (DTI) derived met-rics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-a]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. Results: Thirty-four (50.7%) children with CLD had MHE on neu-ropsychological tests. MHE patients had higher BA (30.5 [6–74]

India contributes significantly to the global burden of HCV. While the nucleoside NS5B inhibitor ... more India contributes significantly to the global burden of HCV. While the nucleoside NS5B inhibitor sofosbuvir became available in the Indian market in March 2015, the other directly acting agents (DAAs), Ledipasvir and Daclatasvir, have only recently become available in the India. The introduction of these DAA in India at a relatively affordable price has led to great optimism about prospects of cure for these patients as not only will they provide higher efficacy, but combination DAAs as all-oral regimen will result in lower side effects than were seen with pegylated interferon alfa and ribavirin therapy. Availability of these newer DAAs has necessitated revision of INASL guidelines for the treatment of HCV published in 2015. Current considerations for the treatment of HCV in India include the poorer response of genotype 3, nonavailability of many of the DAAs recommended by other guidelines and the cost of therapy. The availability of combination DAA therapy has simplified therapy of HCV with decreased reliance of evaluation for monitoring viral kinetics or drug related side effects. (J CLIN EXP HEPATOL 2016;6:119–145)

The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in... more The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in the past decade. Although children with these infections are usually asymptomatic with normal liver function, their evaluation and management can often involve complex issues and require specialized expertise. Here the authors review the common clinical scenarios which might be encountered by a general pediatrician, explain the various tests available for diagnosis , and provide practical guidelines for managing these children.

Objective Childhood abdominal tuberculosis may be difficult to diagnose with certainty. Drug resi... more Objective Childhood abdominal tuberculosis may be difficult to diagnose with certainty. Drug resistance adds to the challenge. We present our experience in children with this condition.

Journal of Tropical Medicine, 2011

Parvovirus B19 is the etiologic agent of erythema infectiosum (fifth disease), a fever-rash illne... more Parvovirus B19 is the etiologic agent of erythema infectiosum (fifth disease), a fever-rash illness occurring in childhood. We present a 10 month old child with high grade fever for 10 days, generalized tonic-clonic seizure, bilateral cervical lymphadenopathy, generalized maculopapular rash, hematemesis and malena. Bone marrow aspiration and liver biopsy were done. EBV serology and parvovirus PCR were also performed. Bone marrow aspiration and biopsy showed giant pro-erythroblast consistent with parvovirus infection. PCR showed amplification of parvovirus genomic sequences. Present case highlights an atypical presentation of Parvovirus B19 infection as fever, rash and hepatosplenomegaly.

Annals of Pediatric Surgery, 2013

Journal of Gastroenterology and Hepatology, 2015

Disorders of gastric emptying constitute an important group of conditions in children. The diagno... more Disorders of gastric emptying constitute an important group of conditions in children. The diagnostic gold standard is scintigraphy and recommendations for standardization have been published with adult normative data. Pediatric literature lacks standardized age specific normative values. Our aim was to establish normal values of solid phase gastric emptying utilizing scintigraphy in children (5 to 18 years) using the recommended imaging protocol and standardized meal. Gastric emptying was assessed by scintigraphy of a (99m) Tc-labeled vegetarian meal. Image acquisition was dynamic for first hour and static at 2,3 and 4 hours. Results were reported as percent intragastric retention; lag phase defined as time to 5% emptying. Thirty(17 boys) healthy children, mean ages of 9.5 ± 3.1 (range 5 to 16) years were enrolled. Median values (5(th) and 95th percentile) for percent gastric retention at 30 min, 1, 2, 3 and 4 hours were 90% (76 and 100%), 77% (56 and 96%), 33% (10 and 71%), 16% (3 and 44%) and 7% (0.5 and 22%). The median (5(th) and 95(th) percentile) lag phase was 18 min (6 and 60 minutes). Lag phase had no correlation with gastric retention at 4 hours. This study provides valuable normative ranges for solid phase gastric emptying in children. Using adult normative data in children may be inappropriate. This article is protected by copyright. All rights reserved.

Acute pancreatitis is a rare diagnosis in pediatrics. Valproic acid has been known to trigger thi... more Acute pancreatitis is a rare diagnosis in pediatrics. Valproic acid has been known to trigger this catastrophe in occasional young patients as an idiosyncratic reaction [1]. We describe a typically developing eight-year-old boy who presented to emergency department with acute abdomen (se-vere, diffuse non-radiating abdominal pain with non-bilious vomiting) and fever for 48 h. He was on oral valproate (30 mg/kg/d), phenobarbitone (3 mg/kg/d) and clonazepam (0.04 mg/kg/d) for his underlying epilepsy. He was diagnosed with super-refractory status epilepticus of unknown etiology nine months back and has been receiving antiepi-leptics since then. There was not any history of recent change in antiepileptic dosages. On examination, there was tachy-cardia (pulse rate = 120/min), tachypnea (respiratory rate = 38/min), diffuse abdominal tenderness and guarding. His hemogram revealed leukocytosis (12,760/cumm with 60% neutrophils) and low platelet count (118,000/cumm). Ultrasound abdomen and chest revealed mild ascites and bilateral minimal pleural effusion with non-visualization of pancreas. A working diagnosis of valproate induced acute pancreatitis was considered. Raised serum amylase (647 SU, normal = 28-100 SU) and serum lipase (514 SU, normal = 0-190 U/L) confirmed the presence of pancreatitis. Serum Valproic acid (VPA) level was within therapeutic range (56.68 mcg/ml, normal = 50-100 mcg/ml). Work up for infective etiology (dengue, rickettsia, chikungunya, coxsackie, cytomegalovirus) was negative. Child was made nil-per-oral and started on intravenous hydration with antibiotics (piperacillin tazobactam and metrogyl), proton pump inhibitors and opioids for pain relief. VPA was immediately stopped and replaced with levetiracetam. On day 2 of hospitalization he developed hypoxia with increased pleural effu-sion, ascites and loose stools which responded to conservative management within 48-72 h. Child did not have any neurological issues during the stay and was discharged after 1 wk. Amylase levels got normalized (0.5 SU). In any child on valproate therapy presenting with acute abdomen, pancreatitis should be suspected and investigated. The underlying mechanism of valproate induced pan-creatitis is elucidative and may possibly be associated with free radical injury [2]. Pancreatitis can develop after weeks to years of initiation of VPA [3]. Majority of children will respond to timely withdrawal of valproic acid and conservative management [4]. However, occasional fatality is also reported [5]. Pediatricians should be aware of this sinister adverse reaction of VPA.

Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy, was first de... more Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy, was first described by Davidson et al. in 1978. Till date, only a handful of cases with MVID have been described in English literature. It is an autosomal recessive disorder with no sex predisposition and more commonly noted in countries with prevalent consanguineous marriages. These patients usually present with intractable secretory diarrhea in early days of life. The pathognomonic findings of MVID are villous atrophy along with the formation of intracellular microvillous inclusions on electron microscopy. Till date, no curative therapy exists, and prognosis mainly depends upon parenteral nutrition. Small bowel transplantation is one of the treatment options. Clinician and pathologist should consider the possibility of MVID in the differential diagnosis of chronic intractable diarrhea in an infant. Herein, authors are describing a case of intractable diarrhea with MVID phenotype diagnosed in a 3-mo-old male child who presented with intractable diarrhea in an outside hospital, and the diagnostic workup was performed by the authors on endoscopic biopsy sample.

Liver biopsy is a valuable tool. Even though outpatient liver biopsies are routinely performed in... more Liver biopsy is a valuable tool. Even though outpatient liver biopsies are routinely performed in
adults, there are no clear recommendations on its safety and feasibility in children. We reviewed
the records of children who underwent a percutaneous liver biopsy at our institution between
January 2005 and June 2015. 626 biopsies were performed on 497 patients (250 boys, median
age 6 (0.2–19.3) years). Abnormal liver function tests for investigation 288(46%) was the most
common indication. 30(4.8%) biopsies had complications, most common being sub-capsular
hematoma 14/30 (46.7 %). Complications were identified within 8 hours of the biopsy in all
patients. Approach, needle–size or number of passes did not affect the complication rate.
Bleeding-related complications were not related to the INR. Performing liver biopsies on an outpatient
basis would have saved 60 beds/AU$ 80,000/year. This study suggests that if an
observation period of 8 hours is instituted, outpatient liver biopsies can be performed safely in
children.

Background & Aims: Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed t... more Background & Aims: Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. Methods: We evaluated 67 children with CLD (38 boys; age 13 [7–18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spec-troscopy (1 HMRS), diffusion tensor imaging (DTI) derived met-rics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-a]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. Results: Thirty-four (50.7%) children with CLD had MHE on neu-ropsychological tests. MHE patients had higher BA (30.5 [6–74]

India contributes significantly to the global burden of HCV. While the nucleoside NS5B inhibitor ... more India contributes significantly to the global burden of HCV. While the nucleoside NS5B inhibitor sofosbuvir became available in the Indian market in March 2015, the other directly acting agents (DAAs), Ledipasvir and Daclatasvir, have only recently become available in the India. The introduction of these DAA in India at a relatively affordable price has led to great optimism about prospects of cure for these patients as not only will they provide higher efficacy, but combination DAAs as all-oral regimen will result in lower side effects than were seen with pegylated interferon alfa and ribavirin therapy. Availability of these newer DAAs has necessitated revision of INASL guidelines for the treatment of HCV published in 2015. Current considerations for the treatment of HCV in India include the poorer response of genotype 3, nonavailability of many of the DAAs recommended by other guidelines and the cost of therapy. The availability of combination DAA therapy has simplified therapy of HCV with decreased reliance of evaluation for monitoring viral kinetics or drug related side effects. (J CLIN EXP HEPATOL 2016;6:119–145)

The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in... more The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in the past decade. Although children with these infections are usually asymptomatic with normal liver function, their evaluation and management can often involve complex issues and require specialized expertise. Here the authors review the common clinical scenarios which might be encountered by a general pediatrician, explain the various tests available for diagnosis , and provide practical guidelines for managing these children.

Objective Childhood abdominal tuberculosis may be difficult to diagnose with certainty. Drug resi... more Objective Childhood abdominal tuberculosis may be difficult to diagnose with certainty. Drug resistance adds to the challenge. We present our experience in children with this condition.

Journal of Tropical Medicine, 2011

Parvovirus B19 is the etiologic agent of erythema infectiosum (fifth disease), a fever-rash illne... more Parvovirus B19 is the etiologic agent of erythema infectiosum (fifth disease), a fever-rash illness occurring in childhood. We present a 10 month old child with high grade fever for 10 days, generalized tonic-clonic seizure, bilateral cervical lymphadenopathy, generalized maculopapular rash, hematemesis and malena. Bone marrow aspiration and liver biopsy were done. EBV serology and parvovirus PCR were also performed. Bone marrow aspiration and biopsy showed giant pro-erythroblast consistent with parvovirus infection. PCR showed amplification of parvovirus genomic sequences. Present case highlights an atypical presentation of Parvovirus B19 infection as fever, rash and hepatosplenomegaly.

Annals of Pediatric Surgery, 2013

Journal of Gastroenterology and Hepatology, 2015

Disorders of gastric emptying constitute an important group of conditions in children. The diagno... more Disorders of gastric emptying constitute an important group of conditions in children. The diagnostic gold standard is scintigraphy and recommendations for standardization have been published with adult normative data. Pediatric literature lacks standardized age specific normative values. Our aim was to establish normal values of solid phase gastric emptying utilizing scintigraphy in children (5 to 18 years) using the recommended imaging protocol and standardized meal. Gastric emptying was assessed by scintigraphy of a (99m) Tc-labeled vegetarian meal. Image acquisition was dynamic for first hour and static at 2,3 and 4 hours. Results were reported as percent intragastric retention; lag phase defined as time to 5% emptying. Thirty(17 boys) healthy children, mean ages of 9.5 ± 3.1 (range 5 to 16) years were enrolled. Median values (5(th) and 95th percentile) for percent gastric retention at 30 min, 1, 2, 3 and 4 hours were 90% (76 and 100%), 77% (56 and 96%), 33% (10 and 71%), 16% (3 and 44%) and 7% (0.5 and 22%). The median (5(th) and 95(th) percentile) lag phase was 18 min (6 and 60 minutes). Lag phase had no correlation with gastric retention at 4 hours. This study provides valuable normative ranges for solid phase gastric emptying in children. Using adult normative data in children may be inappropriate. This article is protected by copyright. All rights reserved.