DAIq-A : INqESTINAL AMOEBIASIS AND GIARDIASIS CHILDREN 185

of diagnosis e.g. small intestinal biopsy specimen for giardiasis and serological tests for amoebiasis are not commonly available in practice. Infestations or in- fections by giardia lamblia or entamoeba histolytica undoubtedly though not always cause symptoms in good number of child- ren and jeopardise their well-being; there- fore all symptomatic cyst passers, irres- pective of number of cysts per high pow- er field in respective stool specimens, should be treated. Asymptomatic carriers may remain symptom free at the time of examination, but who can guarantee that they will not turn symptomatic in cottrse of time particularly in a stressful situation. Moreover asymptomatic car- riers may act reservoirs and spread the disease to other members of the family or community; and the new infestants may not remain symptom free. The symp- toms are although generally mild, but often become exacerbated with all sorts of complications. In chronic cases the growth and development of the child may also be hampered. Therefore to curb the incidence and spread of the disease in the family or community all the carriers of the cysts (giardia or E.H.),

symptomatic or asymptomatic, should be treated with simple easily available and low-cost drugs. Metronidazole--20 mgm/per kg/per day for giardiasis and diiodohydroxyquin-40mgm/per kg per day for amoebiasis, in three divided doses orally for 10 days are quite useful. Metro- nidazole-benzoate preparations are not as effective. Child may be declared free of organisms if three serial samples of stool 2 to 3 wk after the treatment do not show cysts or trophozoites; often this is also a difficult proposition in practice. If stool examination cannot be done a second course of treatment may be hope- fully given after 2 to 3 wk.

It is well known that giardiasis and amoebiasis occur in children through contaminated food and water; therefore the adult members of the family of the index case who handle food and water should also be checked and treated. Habit of eating prepared food from the 'Bazaar' must be given up. Some hygienic sense should be evoked in the people of the community by the custodians of health of the countrymen; and the society must have the sense of responsibility to ensure pure drinking water supply to all.

Management of mammal bite Manju Sharma M.D.,

Mammal bites is an important hazard faced by the society, especially the child- ren. The majority of these bites are trivial but fatalities do occur.

Incidence: Nearly I-2 million people are bitten by the animals in the U.S. each

Consulatant Pediatrician New Delhi

year and children account for 86 per cent of them. In India there are no definite figures, yet it can be said that 96 per cent of all bites are dog bites and 4 per cent are all others. Mortality per year due to tables in India is 25,000 per year. About 30 million people receive the anti-rabies vaccine per year in India. ~

186 FILE INDIAN JOURNAl.. OF PEI)IAI-RICS Vol. 52, No, 415

The physician rarely deals with the acute life threatening effects of the animal bite itself, but mostly the medical concern is centred around the infections associated with the bite.

The wide range of animals which bite the humans are, domesticated; dogs and cats, Wild; rodents of various types, monkeys, horse, bat, fox, lion, stumk, bear, leopard. Human bite is important because of the frequency and severity. Infections associated with the bite : A wide range of infections such as cellulitis and lymphangitis are common but abscess (especially after the cat bite), osteomye- litis, tularmia, subcutaneous gas collec- tions, meningitis, endocarditis and syphi- lis may occur. Fulminent gram negative bacteremia has been reported after dog bite in splenectomised or immunocom- promised host. Syndrome resembling generalized schwartzman reactions or thrombotic thrombocytopenic purpura have also been described as sequelae to bites.

Microbiology and clinical manifestations of bites

Dogs and cats : Pastcurella multocide is responsible for 50 per cent of infections for dog bites and 80 per cent from cat bitesl,3, 4 within 48 h the wound becomes inflammed, one third develop regional lymphadenopathy and a fourth develop low grade fever. Tenosynovitis, septi- cemia and osteomyelitis can occur. It responds well to penicillin.

Other organisms involved are gram negative rods classified as CDC group 111 (associated with meningitis and septi- cemia) Streptococcus viridans, Staphylo- coccus ato'eus, Bacteroides and Fttsohac- tc, rium species.

Cat scratch disease is caused by chlar- mydia like organisms, the disease being benign and self limited. Monkey bite may transmit herpes virus siniae which causes potentially fatal myelitis in the humans after one to three weeks of incu- bation period. Human bite : Human dental plaques and gingivae harbour 42 different species of organisms and human saliva has l0 s bacteria per ml. s The predominant or- ganisms are group A and Viridans strep- tococci and Staphylococcus aureus. Others are eikenella conodens, bacteroides melaninogenicus, Proteus species, Eseh. eoli, neisseria species, Klebsiella. Aero- bactes, mycobaeterium-tuberculosis, acti- nomycetes, spirochetes, hepatitis B virus and atypical strains of Pasteurella multi- cida. Human bites are worriesome since the vast majority are on the hand are rapid and extensive spread of infection in various compartments can result in the need for amputation or a permanent decrease in function.

Rat bite fever : Two specific infections that occur are Haverhilfever due to Strep- tobacillus moniliformis and aerobic gram negative organisms.

Spirillal3, rat bite fever or Soduku are due to spirillum minor. Both these infec- tions respond well to penicillin. In all the mammal bites the physician has to be on guard against rabies and tetanus.

Management of bite wounds

This involves care of lacerations, punc- ture wounds, scratches etc, inoculation of infectious bacterial organisms from the animals mouth to man and risk of transmission of rabies from the animal to man. The various components in treat- merit are; (i) meticulous wound toilet,

�9 . iHARMA : M A N A G E M E N T OF M A M M A l . BI ' IE 187

which decreases the infection rate from 69-12 per cent4; wash all lacerations and puncture wounds for at least 15 rain with 20 per cent soap solution. Benzalkonium chloride (Zephiran) aqueous solution is an alternative; (ii) debridement of devi- talized tissue; (iii) complete homeastasis; (iv) Irrigation with one litre of normal saline. (This is the major deterant to sec- ondary infections); (v) suturing of bite wounds is a controversial topic. Large lacerations and facial wounds should be ~utured but hand wounds should not be sutured; (vii) prophylactic antibiotics are not warranted in the routine case and they should be saved till the infection develops except for the hand infections and punture wounds which may benefit from prophylaxis. Penicillin provides a good cover for the dog, cat and human bites till the culture report is available; (vii) capture, isolate and observe domes- tic animals for 10 days. Determine the animals vaccination status. If within this period the animal does not show any illness or dies. then no rabies prophy- ~a• is needed. Animals that trove received rabies immunisation within two years are unlikely to transmit rabies but re- quire observation; and (viii) inamunise all patients with tetanus toxiod.

Rabies vaccine should be given ira ca.~e of :(i) bite by escaped wild animals whether the animal is sick or well (Pre- valence of rabies in wild animals has in- creased in the last three years: The major animals involved are--skunks, foxes, bats, and raccons; these species are con- sidered rabid unless and until proved otherwise. In small rodents and lega- maorphs (rabbits and hare) rabies is extremely rare and the bite by these ani- mals does not require prophylactic vacci- nation) ; (b) bites by the domestic animals :

If the animal is ill or behaving abnor- mally (Furious or paralytic type); (c) bites by stray domestic animals, that is not captured in a community in which the incidence of rabies is high either in that domestic species or in the local wild fauna. A captured stray animal should be evaluated by the Vet; (d) bite by a wild animal sick or well, that is kept as a pet- while dealing with the bite wound it should be kept in mind that rabies virus may be present in the saliva for a variable period of time before the onset of clinical symptoms. The duration of this depends upon the species. Asymptomatic rabid dogs may secrete the virus upto 3 days, cats for 2 days, skunks for 18 days and bats for several months. Also, the incu- bation period of rabies varies from 9 days to 19 y r ( < 2 w k a n d >1 y r i s un- usual). In the humans the incubation period is between 3 wk to 3 months. (average 35 days).

Rabies immunization agents

Passive : Human rabies immunoglo- bulin (HRIG) protects in the initial 1-2 wk before the active anti bodies are pro- duced by the vaccine. The dose is 20 IU/per kg ira single dose, 50 per cent infil- trated around the wound and the rest is given I M.

HRIG is not recommended if there is a history &previous vaccination with HDVC, history of having taken another rabies vaccine and adequate antibody titres are present (1 : 16 by rapid floure- scent inhibition test).

HRIG is not given in the same muscle as tIDCV. I-TRIG can be given within 7 days after" the initial vaccine dose. I f HRIG is not available ARS (enquire antirabies serum) in a single dose of 49IU/

188 ]HE INDIAN JOURNAL OF PEDIATRICS Vol. 52, No. 415

per kg is given but with this there is a risk of anaphylaxis and serum sickness.

Active immunization

Human diploid cell vaccine : T h e vaccine is currently licensed in the U.S. This is prepared by growing the virus in the human diploid cells. It is a killed virus vaccine. The antibodies are produced in 100 per cent of the vaccinated individuals by the recommended regimen in which 5 doses of 1 ml each of the vaccine given IM over a period of one month. Infants and small children need the same dose as the adults.

The schedule is as follows: First dose of the vaccine is given soon as possible after the exposure. Additional doses are given on each of the days 3, 7, 14, 28 alter the 1st dose. Other volumes and routes of administration riz. intradermal, have not been evaluated and they should not be used for this purpose. If a person has re- ceived the pre-exposure prophylaxis with HDCV previously, then post-exposure prophylaxis consists only of thorough wound cleansing.

Two, one ml doses of HDCV are given IM each on days 0 and 3 either in the deltoid region (for older children) and anterolateral aspect of the thigh in the younger child.

Duck embryo vaccine: It is associated with treatment failures and severe ad- verse reactions sometimes. Routines sero- logic testing after p r e - o r post-exposure prophylaxis is not recommended except in the immuno-suppressed persons where the serum is collected at the time of the last dose of the vaccine to assess the anti- body titre.

Pre exposure immunization: It is recom- mended for those living or visiting coun- tries where rabies is a constant threat. This also reduces the doses of vaccine in post-exposure prophylaxis. Three-1 ml, doses are given IM each oll days 0-7, 21 or 28 days.

Special situations affecting immunization

During pregnancy: There is no untoward effect on the fetus and vaccine can be given. During febrile illness, vaccination should not be delayed because of the fever. Infants, should be given the same quantity as that of the adults. In immuno- suppressed individuals frequent deter- minations of the antibody titre and addi- tional doses of the vaccine are given. There is no contraindication to simul- taneously administering the rabies vac- cine with other vaccines.

Reactions to the vaccine are usually local. Urticaria and anaphylaxis with HDCV has been reported in highly atopic individuals.

l~reventions of bites : Considering the extent of the animal bites in this country, it is important that the physicians educate the children and the families. Vast majo- rity of the bite can be prevented by not leaving the young children or infants un- attended with large, even apparently docile dog. Older children might benefit from creative education about the benefits of letting sleeping dogs lie. Rat extermi- nation also needs to be carried out more vigorously. Human bites especially of the hand are related to interpersonal aggres- sion and it is beyond the scope of this article to elaborate more on the preven- tion of these.

5HARMA MANAGEMENT OF MAMMAL BITE 189

References

I . ])ilc,,.~[ Conmlunication, National In~iitute of Communicable diseases, Delhi.

2. Kizer KW: Epidcmiologic and clinical aspects of animal bite injurics. JACEP 8: 134, 1979

:,. ,\ghababian RV, Conic JE Jr: Mammalian

bite ~ounds. Ann Emerg 3led 9: 79, 1980 4. Callaham ML: Treamaent of common dog

bites. Infection risk factors. ,IACE'P 7: 83, 1978

5. Current pediatric therapy I I, Gc Ills and Kagan ; Rabies, eds. 1984 p 573

DYSENTERY IN CHILDREN WITH ACUTE RENAL FAILURE

Acute renal failure (ARF) has recently been recognised as an important and fre- quently fatal complication of bacillary dysentery in the Indian sub-continent. The patients involved were mostly infants and young children with a rather severe form of the disease. A high proportion showed features of hemolytic uremic syndrome (HUS), viz., microangiopathic hemolytic anemia, thrombocytopenia and uremia. Others had ARF with no detectable evidence of hemolysis.

Acute dysentery was complicated by acute renal failure (ARF) in 20 and by HUS in 21 of 41 children studied. The clinical feature, 'exudative' stools and absence of l-)Ttamoeba histolytica were strongly suggestive of shigellosis. However, shigella was isolated in only eight children. Negativity in the other children was attributed to prior administration of antibiotics. The severity of dysentery, renal impairment, hematological changes and intravascular coagulopathy was more marked in HUS than in ARF. Renal cortical necrosis was seen in 11 patients with HUS and 2 with ARF. This was frequently associated with thrombosis. The characteristic lesions of micro-angiopathy involving the glomeruli and arterioles were seen in only 4 patients of HUS. A high mortality (71 -4%) was observed in HUS and a high recovery (60.%) in ARF.

Abstracted from : U.N. Bhuyan et at. :

hu/ian J Med Res 81, 402-408, 1985