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Sirs, While severe malaria is usually associated with infection due to Plasmodium falciparum, there have been recent reports of life-threatening manifestations in patients with P. vivax infection. Acute renal failure (ARF) is reported to occur in 1-30% patients with falciparum malaria but rarely with vivax malaria [1][2][3]. We recently reported a case of P. vivax malaria with acute renal failure [3]. We now describe a boy with vivax malaria complicated by anemia, thrombocytopenia, ARF secondary to thrombotic microangiopathy, and acute respiratory distress syndrome.This 11-year-old boy presented with fever, with chills for 5 days, and abdominal pain, rapid breathing, hemoptysis and anuria for 3 days. There was no preceding history of diarrhea or dysentery. Investigations showed a hemoglobin level of 8.8 g/dl, leukocyte count of 7,800/mm 3 and platelet count of 10,000/mm 3 . A peripheral smear showed red cells parasitized with trophozoites of P. vivax (parasite count 200/μl); there was thrombocytopenia, but there were no fragmented red cells. His blood pressure was 120/70 mmHg, and oxygen saturation was 84%. The ratio of the partial pressure of oxygen in arterial blood to the inspired oxygen fraction (PaO 2 /FiO 2 ratio) was 150; a chest radiograph showed diffuse bilateral alveolar infiltrates, suggestive of acute respiratory distress syndrome. The blood level of urea was 239 mg/dl, creatinine 9 mg/dl, glucose 100 mg/dl, pH 7.12, bicarbonate 15 mEq/l, sodium 136 mEq/l and potassium 5 mEq/l. Urinalysis showed 3+ proteinuria and 80-100 red cells per high-power field; no casts or crystals were seen. Serum complement C3 was 46 mg/dl (normal 77-90 mg/dl); tests for antinuclear antibodies and antineutrophil cytoplasmic antibodies gave negative results. There was no evidence of disseminated intravascular coagulation. P. vivax malaria was confirmed by a specific polymerase chain reaction (PCR). Rapid detection test (Parascreen; Zephyr Biomedicals, Goa, India) and PCR gave negative findings for P. falciparum infection. Blood, urine and bronchoalveolar lavage cultures were sterile. Ultrasonography showed normal-sized kidneys with increased echotexture and ascites.The patient was treated with quinine, parenterally (10 mg/kg intravenously, 8 hourly), ceftriaxone and cloxacillin. He also received transfusions of packed red cells and platelets. Over the next 30 h, he underwent peritoneal dialysis for azotemia and metabolic acidosis. The parasite count dropped to nil, and the thrombocytopenia resolved 48 h after the initiation of intravenous (i.v.) treatment with quinine. While the respiratory distress rapidly improved, he continued to have oliguria and azotemia, requiring maintenance hemodialysis for 3 weeks. Five weeks after the onset of illness, the blood level of urea was 44 mg/dl, creatinine 1.1 mg/dl and C3 was 83 mg/dl.A kidney biopsy, during the second week of hospital stay, showed focal cortical necrosis with cortical edema. There was endothelial swelling and myo-intimal hyperplasia in the arterioles (Fig. 1). Immunoflu...

Though thrombocytopenia is one of the hallmarks of dengue hemorrhagic fever/ dengue shock syndrome, persistence of the same is rare. We report an 11 year-old child with dengue shock syndrome, who developed persistent thrombocytopenia. The possible mechanisms are discussed.

Asthma is a common chronic inflammatory disorder of the airways characterized by recurrent wheezing, breathlessness, and coughing. Acute exacerbations of asthma can be life-threatening; annual worldwide estimated mortality is 250,000 and most of these deaths are preventable. While most of the acute exacerbations can be managed successfully in the emergency room, few children have severe exacerbations requiring intensive care. Mainstay of treatment for status asthmaticus are inhaled β2 agonist and anticholinergic agents, oxygen along with corticosteroids. Children who do not respond well to initial treatment require parenteral β2 agonist and magnesium. Rarely, sick children need parenteral aminophylline infusion and mechanical ventilation. Guidelines for diagnosis, treatment, ventilator management and supportive care for status asthmaticus in children are discussed in the protocol.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are disorders of pulmonary inflammation characterized by hypoxemia and respiratory failure. Children have varying incidence of ALI/ARDS from 2.2 to 16 per 100,000 pediatric population associated with high morbidity, mortality, and financial burden. The diagnostic criteria include: acute onset, severe arterial hypoxemia resistant to oxygen therapy alone (PaO₂/FIO₂ ratio ≤ 200 for ARDS and ≤ 300 for ALI), diffuse pulmonary inflammation (bilateral infiltrates on chest radiograph) and No evidence of left atrial hypertension. Management includes ventilatory therapy including lower tidal volume, relatively high PEEP and supportive care. Guidelines for diagnosis, ventilator management, rescue therapies and supportive care are being discussed in the protocol.