Applied Basic Sciences in Paediatrics Second Edition 2023 by Alfred Thomas Mario

Contents
S. No. Chapter Page number
1. Anatomy 1
2. Physiology 7
3. Biochemistry & Genetics 16
4. Microbiology & Immunology 26
5. Pharmacology 45
6. Nephrology 55
7. Cardiology 90
8. Hepatology 108
9. Gastroenterology 116
10. Haemato-oncology 125
11. Neurology 139
12. Pulmonology 160
13. Endocrinology 169
14. Critical Care 180
15. Feedback received for the first edition 186
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ANATOMY
1. Deciduous and permanent teething

● Deciduous teeth are 20 in number (2102 : 2 incisors, 1 canine and 2 molars in each
quadrant).
● Permanent teeth are 32 in number (2123 : 2 incisors, 1 canine, 2 premolars and 3 molars
in each quadrant).
Eruption of deciduous teeth
● Central incisor 7 months (keep adding 4)
● Lateral incisor 11 months
● First molar 15 months
● Canine 19 months
● Second molar 23 months
Eruption of permanent teeth
(Memory aid : Mama Is In Pain Papa Can Make Medicine)
● Molar I 6 years (keep adding 1 till 12)
● Incisor central 7 years
● Incisor lateral 8 years
● Premolar I 9 years
● Premolar II 10 years
● Canine 11 years
● Molar II 12 years
● Molar III 18 years
Applied aspects
● Anodontia can be seen in ectodermal dysplasia and cleft palate.
● Supernumerary teeth can be seen in cleidocranial dysplasia and cleft palate.
● Amelogenesis imperfecta and dentinogenesis imperfecta are hereditary conditions with
enamel and dentin defects.
● Fluorosis (mottled enamel) occurs in areas with high fluoride content of drinking water
(> 2 ppm).
● Delayed eruption of deciduous teeth is defined as no teeth erupting till 13 months of age.
It may be familial or can indicate systemic disturbances like hypopituitarism,
hypothyroidism, cleidocranial dysplasia and trisomy 21.
● Natal teeth are present at birth whereas neonatal teeth erupt in the first month of life.
These occasionally result in pain and refusal to feed and may also cause maternal
discomfort because of abrasion during nursing. If the tooth is mobile, there is a danger of
detachment and subsequent aspiration and hence it may be extracted.
2. Bone age in the assessment of growth

● Bone age radiographs may be indicated for evaluation of short stature and precocious
puberty. It may also be used in age assessment for legal purposes.
● Assessment is performed with a radiograph of the non-dominant hand PA view that
includes the distal radius and ulna and all the fingers. Appearances of the bones are
traditionally compared to the standardised atlases eg. the Greulich and Pyle Atlas.
Applied aspects
● Distinguishing between constitutional delay of growth and puberty (CDGP) and
pathological causes of short stature
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Applied Basic Sciences in Paediatrics Second Edition (2023) Alfred Thomas Mario
○ Bone age delayed by more than two years from the chronological age indicates a
pathological cause. For example, chronological age 10 years and bone age 7 years
○ Bone age delayed within two years from the chronological age indicates CDGP.
For example, chronological age 10 years and bone age 9 years
● Distinguishing between true precocious puberty and precocious puberty due to
hypothyroidism
○ Advanced bone age suggests true precocious puberty and delayed bone age
suggests precocious puberty due to hypothyroidism
3. Types of body build

The state of nutrition depends mainly on the distribution of adipose tissue in the body. On this
basis, individuals can be classified as normal, overweight and underweight. Mention about
obesity and malnutrition
4. Little’s Area
● It is a highly vascular area located in the anteroinferior part of the nasal septum just
above the vestibule.
● Five arteries anastomose here to form a vascular plexus called Kiesselbach’s plexus.
● The participating arteries are :
1. Septal branch of anterior ethmoidal artery (a branch of ophthalmic artery)
2. Septal branch of posterior ethmoidal artery (a branch of ophthalmic artery)
3. Septal branch of sphenopalatine artery (a branch of maxillary artery)
4. Septal branch of greater palatine artery (a branch of maxillary artery)
5. Septal branch of superior labial artery (a branch of facial artery)
Applied aspects
It is exposed to the drying effect of inspiratory current and to finger nail trauma and is the usual
site for epistaxis.
5. Cleft lip and palate

Face develops from the following
● Eye
● Olfactory pit
● Globular arch
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● Mandibular arch
● Maxillary process
● Median nasal process
● Lateral nasal process
Any defect in the fusion of these arches leads to formation of cleft lip and palate
Classification system
L/l : denotes lip
A/a : denotes alveolus
H/h : denotes hard palate
S/s : denotes palate
Capital letter : signifies complete cleft
Small letter : signifies incomplete cleft
Examples of this classification system
● LAHS : unilateral complete type cleft of lip, alveolus, hard and soft palate
● lahs : unilateral incomplete type cleft of lip, alveolus, hard and soft palate
● LAHSHAL : bilateral complete clefts of lip, alveolus, hard and soft palate
● lahSh : unilateral incomplete cleft lip and alveolus and complete cleft soft
palate which incompletely extends to hard palate bilaterally
Associations of cleft lip and palate
● Pierre Robin sequence
● Apert syndrome
● Treacher Collin syndrome
● Stickler syndrome
Incidence
1 in 1000 live births
Problems of cleft lip and palate
Difficulty in sucking and swallowing
Defective speech
Altered dentition
Recurrent respiratory tract infections
Cosmetic disfigurement
Timing of surgical repair
● Cleft lip alone : 4-6 months
● Cleft palate
○ involving Soft palate alone : Six months
○ involving soft and hard palate : two staged operation
● soft palate correction at six months
● hard palate correction at 18 months
● Combined cleft lip and palate : two staged operation
○ lip and soft palate correction at six months
○ hard palate correction at 18 months
6. Cervical nodes
Levels
Level I
Ia – submental nodes
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Ib – submandibular nodes
Level II – upper cervical modes
Level III – middle cervical nodes
Level IV – lower cervical nodes
Level V – posterior triangle nodes
Level VI – pretracheal and prelaryngeal nodes
Level VII – mediastinum
Applied aspects
● Kawasaki disease
● Tuberculous lymphadenitis
● Hodgkin lymphoma
● Reactive lymphadenopathy
● Head and neck cancers - Nodal staging of metastases
○ N0 – No nodal involvement
○ N1 – Single node involvement < 3 cm
○ N2a – Single node involvement 3 – 6 cm
○ N2b – Multiple nodes involved 3 – 6 cm
○ N3 – Any node > 6 cm
7. Development of tongue
Anterior ⅔ tongue
From first pharyngeal arch
One median swelling (tuberculum impar) and two lateral lingual swellings
Posterior ⅓ tongue
Cranial part of hypobranchial eminence (mesoderm of 3rd and 4th pharyngeal arches)
Posterior most tongue
Caudal part of hypobranchial eminence
Muscles of tongue
All muscles of tongue arise from occipital somites, except palatoglossus (derived from
4th pharyngeal arch)
8. Development of spleen
● Lymphoid organs develop from mesoderm
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● Spleen develops from mesoderm in the dorsal mesogastrium, close to the developing
stomach
● It develops as a collection of mesenchymal cells, which forms small lobular masses of
splenic tissue (spleniculi) in the dorsal mesogastrium
● These lobules later fuse to form a single mass (spleen)
● Due to the splenic projection, the dorsal mesogastrium is divided into an anterior part
(gastrosplenic ligament) and a posterior part (lienorenal ligament)
Applied aspects
● Presence of splenic notch is an evidence of development of spleen from lobules
● Splenic agenesis
● Accessory spleen - It can be located in gastrosplenic ligament, lienorenal ligament and
along splenic artery
● Situs inversus
9. Pharyngeal arches
Arch Skeletal derivatives Muscle derivatives Arteries Nerves
1st Malleus Mastication muscles Maxillary V3
Incus Ant belly digastric
Maxilla
Mandible
2nd Stapes Stapedius Stapedial VII

Hyoid body sup ½ Facial muscles
Hyoid lesser horn Post belly digastric
3rd Hyoid body inf ½ Stylopharyngeal CCA, ICA IX

Hyoid greater horn muscle
4th Thyroid cartilage Cricothyroid# Arch of aorta Sup laryngeal (X)

All pharynx muscles
All palate muscles
6th Cricoid cartilage All larynx muscles PA Rec laryngeal (X)

Arytenoid cartilage (except#)
Corniculate cartilage
Cuneiform cartilage
Tips on how to remember most of the table for the exam

1. The students would remember from their MBBS days that the muscles of mastication are
supplied by V3 (mandibular nerve) and the muscles of facial expression are supplied by
VII nerve.
2. The students would also remember that V3 is the first arch nerve and VII nerve is the
second arch nerve.
3. Because the mandibular nerve and the muscles of mastication in the maxilla belong to the
first arch, the related structures (maxilla, maxillary artery and mandible) also belong to
the first arch.
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4. Second arch is all about S. So we have stapes, stapedius and stapedial artery belonging to
the second arch. Since stapes is in the second arch, the other two ear ossicles are present
in the first arch.
5. Digastric muscle is unique because it has two bellies belonging to different arches. The
word ‘posterior’ has the letter ‘s’ in it. Second arch is all about S. Hence, the posterior
belly belongs to the second arch. So, the anterior belly is placed in the first arch.
6. Hyoid bone is also unique because it has two horns and two halves which belong to
different arches. Superior half and lesser horn have the letter ‘s’ in them. So they are
placed in the second arch (Second arch is all about S). The inferior half and greater horn
belong to the third arch.
7. Stylopharyngeal rhymes with glossopharyngeal. Hence, both stylopharyngeal muscle and
glossopharyngeal nerve (IX) remain together in the third arch.
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PHYSIOLOGY
1. Sleep
Types of sleep
REM
● 20-30% of sleep duration
● Dreams occur in REM sleep
● Deep sleep occurs in REM sleep
NREM
● No movement of eyeballs
● No dreams
● 70-80% of sleep
● Stages
○ NREM I – Drowsy
○ NREM II – Light sleep
○ NREM III – Medium sleep
○ NREM IV – Deep sleep
Centres of sleep
● Raphe nucleus (pons and medulla)
● Locus coeruleus of pons
● Inhibition of Ascending Reticular Activating System (ARAS)
Sleep disorders
● REM disorders
■ Nightmare – frightening dreams with vivid recall
■ Narcolepsy – Cataplexy + muscle paralysis + dream like hallucinations +
excessive daytime sleepiness
● NREM disorders
■ Sleepwalking – Most common in children
■ Sleep terrors – Child sits up and screams in between sleep; does not
remember this when asked about it the next day
■ Bruxism – occurs due to psychological reasons or stress
■ Enuresis
2. Hormones of lactation
A. Hormones of milk secretion
○ Lactogenesis
■ Initiation of milk secretion
■ Prolactin
○ Galactopoiesis
■ Maintenance of milk secretion
■ Prolactin, T4, GH, cortisol
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B. Milk ejection reflex

Hypothalamus
Pituitary Mother thinks of baby
Spinal cord stimulation Oxytocin
Contraction of myoepithelial cells
Chest wall stimulation Release of milk
Baby
3. Principle behind ORS

Absorption of one molecule of glucose drags sodium and water along with it, thereby
replenishing fluid and electrolyte. That is why ORS has 1 : 1 glucose and sodium osmolar
concentration.
4. Physiology of pancreas
A. Endocrine pancreas
Source of pancreatic hormones
● Alpha cells – Glucagon
● Beta cells – Insulin, Amylin
● Delta cells – Somatostatin
● Epsilon cells – Ghrelin
● F cells – Pancreatic polypeptide
Role of pancreatic hormones
Glucagon
● Glycogenolysis
● Gluconeogenesis
● Lipolysis
● Ketogenesis
Insulin
● Glycogenic
● Anti gluconeogenic
● Antilipolytic
● Antiketogenic
Amylin
● Delays gastric emptying
● Reduces food intake
● Reduces glucagon secretion
● Delays appearance of glucose in the blood
Somatostatin
● Inhibits GH secretion
● Inhibits insulin and glucagon secretion
● Decreases GI motility and secretions
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Ghrelin
● Inhibiting insulin secretion
● Increases glucagon secretion
● Stimulates release of Growth Hormone
Pancreatic Polypeptide
● Slows down absorption of nutrients from GIT
Applied aspects
1. T1DM
2. Hypoglycemia is seen in ABCC2 defect (persistent hyperinsulinemic hypoglycemia of
infancy). Somatostatin analogue (octreotide) is used to manage hypoglycemia in these
children.
3. Amylin analog (Pramlintide) is an anti diabetic medication
4. Glucagon injection is used in diabetic patients who present with severe hypoglycemia
B. Exocrine pancreas
Enzymes for protein digestion
● Trypsin
● Chymotrypsin
● Elastase
● Carboxypeptidase A & B
Enzymes for fat digestion
● Lipase
● Colipase
● Cholesteryl ester hydrolase
● Phospholipase
Enzymes for starch digestion
● Amylase
Enzymes for nucleic acid digestion
● Ribonuclease
● Deoxyribonuclease
Storage and activation
● All enzymes are stored as zymogens (inactive form)
● Enterokinase converts trypsinogen to trypsin, which then activates all other
enzymes
Nature’s antacid
● 1500 mL pancreatic juice is secreted per day with a high concentration of
bicarbonate (pH 7.8 – 8.4)
Applied aspects
Exocrine pancreatic insufficiency is seen in conditions like Shwachman Diamond
syndrome, cystic fibrosis, and chronic pancreatitis and it manifests as malabsorption.
5. Regulation of respiration
A. Neural regulation
● Pre-Botzinger complex
○ Initiates the respiratory rhythm (pacemaker)
● Dorsal respiratory group
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○ Concerned with Inspiration

● Ventral respiratory group
○ Concerned with Expiration, but is active only in forceful expiration eg.
during exercise (because expiration is a passive process)
(DIVE : Dorsal Inspiration Ventral Expiration – memory aid)
● Pneumotaxic center
○ Limits inspiration by inhibiting apneustic center (“switches off”
inspiration)
● Apneustic center
○ Increases the firing of inspiratory neurons in the medulla
B. Chemical regulation of respiration

● Peripheral chemoreceptors – located in carotid bodies and aortic bodies
Hypoxia (decrease in PaO2)
Peripheral chemoreceptors stimulated
Tachypnoea, tachycardia, dilation of upper airway
● Central chemoreceptors
Located in ventral medulla, nucleus tractus solitarius, locus coeruleus,
hypothalamus
Increase in PaCO2
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CO2 crosses BBB

CO2 is converted into H2CO3 and then split into H+ and HCO3- (Enzyme CA)
H+ stimulates central chemoreceptors
Hyperventilation to expel CO2
6. Abnormal breathing patterns
● Cheyne Stokes respiration
Periods of apnoea and hyperpnoea
● Biot’s (ataxic) breathing
Highly irregular inspiration separated by long periods of apnoea
● Apneustic breathing
Prolonged inspiratory spasm
● Kussmaul respiration
Hyperventilation characterised by regular, deep, fast breathing
● Ondine’s curse (Central congenital hypoventilation syndrome)
Loss of involuntary control of breathing during sleep (PHOX2b mutations)
7. Starling forces
● Forces that govern fluid movements in capillaries are called Starling forces
● The major Starling forces are
○ Capillary hydrostatic pressure (Pc) favours filtration
○ Interstitial oncotic pressure (πi)
○ Plasma oncotic pressure (πc) opposes filtration and

○ Interstitial hydrostatic pressure (Pi) favours reabsorption
Arterial end Venous end
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● Starling’s hypothesis states that the net filtration pressure (NFP) through the capillary
membrane is proportional to the hydrostatic pressure difference across the membrane,
minus the oncotic pressure difference. In other words,
NFP ∝ (Pc – Pi) – (πc – πi)
● If NFP is positive, then fluid filtration is favoured. If NFP is negative, then fluid
reabsorption is favoured.
● At the arterial end of the capillary, fluid filtration occurs. At the venous end of the
capillary, fluid reabsorption occurs. The filtered fluid is not entirely reabsorbed in the
capillaries. The filtered fluid, which is not reabsorbed, is known as “interstitial fluid”.
The interstitial fluid is returned to circulation as “lymph”.
Applied Aspects
Causes of oedema
● Due to increased capillary hydrostatic pressure – CCF, DVT
● Due to reduced plasma oncotic pressure – nephrotic syndrome, SAM
● Lymphatic obstruction - filariasis
8. Sham feeding
● A hole is made in the neck of an anaesthetised dog. The oesophagus is transversely cut
and brought out through the hole in the neck. When the dog then eats food, it comes out
through the cut end of the oesophagus. But the dog has the satisfaction of eating the food.
This is called sham (false) feeding.
● Subsequently, a fistula is created from the stomach to the exterior. When the dog now
feeds, even though the food does not enter the stomach, the gastric secretion is initiated
and it is measured through the fistula created.
● Finally, a vagotomy is performed. When the dog now feeds, gastric secretion is not
induced. This series of experiments proves the role of the vagus nerve during cephalic
phase of gastric secretion.
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Phases of gastric secretion

Phase % of gastric secretion Initiated by (stimuli)
Cephalic 30% Sight/smell/taste/thought of food
Gastric 50% Distension of stomach by food
Intestinal 10% When chyme enters duodenum
9. Clubbing
● It is a selective bulbous enlargement of the distal portion of the digit due to increased
subungual soft tissue.
● Grading
○ Grade I : Softening of the nail bed
○ Grade II : Obliteration of the angle between the nail and nail bed and positive
fluctuation test
○ Grade III : Parrot beak appearance, drumstick appearance
○ Grade IV : Hypertrophic osteoarthropathy
● Pathogenesis
Clubbing occurs as a result of peripheral deposition of megakaryocytes which are usually
sequestered by pulmonary vasculature. The increased release of platelet-derived growth
factor (PDGF) from peripheral megakaryocytes leads to increased vascularity,
permeability, and ultimately connective tissue changes. The release of PDGF is enhanced
by hypoxia.
● Causes
Pulmonary
● Bronchiectasis
● ILD
● Lung abscess
● Empyema
● TB in later stages
● Mesothelioma
Cardiac
● Cyanotic congenital heart diseases
● Infective endocarditis
● Eisenmenger syndrome
Abdomen
● Chronic liver disease
● Inflammatory bowel disease
● GI malignancy
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Unilateral clubbing
● AV malformation
● Aneurysms of any major vessel
Unidigital clubbing
● Trauma
Pseudoclubbing
● Hyperparathyroidism due to excessive bone resorption
10. Hearing assessment

A. Oto acoustic emissions (OAE)
● Due to biological activity of the outer hair cells of cochlea, some sound is generated. This
sound is known as OAE and can be picked up and recorded by placing a microphone
deep in the external auditory meatus.
● Interpretation of results
○ Pass – Indicates that hearing is within acceptable parameters
○ Refer – Indicates that the child needs additional testing
● It is easy to perform, less time consuming and cost-effective; so it is considered as the
best audiometric test to screen hearing in neonates, infants and small children
B. Brainstem Evoked Response Audiometry (BERA) / Auditory Brainstem Response

(ABR)
● BERA tests the electrical activity occurring in the auditory pathway.
● In a normal child, 5-7 electrical waves are recorded. The sites of origin of these waves are
○ Wave I – Cochlear nerve in the inner ear (distal cochlear nv)
○ Wave II – Cochlear nerve in the brainstem (proximal)
○ Wave III – Cochlear nucleus
○ Wave IV – Superior olivary nucleus
○ Wave V – Lateral lemniscus
○ Wave VI – Inferior colliculus
○ Wave VII – Medial geniculate body
● It is the best audiometric test to confirm hearing loss in neonates, infants and small
children
● The babies need to be sleeping or sedated for this procedure; technically more
challenging than OAE.
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11. Leukotrienes
Leukotrienes are produced from arachidonic acid
Lipoxygenase
Arachidonic acid LTA4 LTB4, LTC4, LTD4 & LTE4
● LTB4 is produced in neutrophils. It is the most potent chemotactic agent.

● SRS-A contains LTC4, LTD4 & LTE4 and it causes smooth muscle contraction,
bronchoconstriction and mediates asthma attacks.
● Applications
○ Leukotriene antagonists (eg. montelukast) are used to treat allergic rhinitis and
asthma
12. Surfactant
● Surfactant reduces surface tension in alveoli and prevents alveolar collapse
● Constituents
○ Dipalmitoyl lecithin
○ Phosphatidyl glycerol
○ Cholesterol
○ Surfactant proteins A, B & C
● Source
Type 2 granular pneumocytes
● LS ratio
Before 28 weeks GA, the lung synthesises sphingomyelin. As the foetus matures,
more lecithin is synthesised. Lecithin – sphingomyelin ratio of 2 indicates lung
maturity
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BIOCHEMISTRY & GENETICS
1. Homocystinuria
Cystathione Beta Synthase
Homocysteine Cystathionine
(cofactor is vitamin B6)
● This pathway is affected in homocystinuria

● Clinical features
○ Thromboembolism (prothrombotic state)
○ Ectopia lentis
○ Mental retardation
○ Marfanoid habitus
● Investigations
○ Elevated homocysteine and methionine levels (TMS)
○ UMS shows cyanide nitroprusside test positive
● Management
○ High doses of Vitamin B6 and Vitamin C
2. Phenylketonuria
Phenylalanine hydroxylase
Phenylalanine Tyrosine
● This pathway is affected in PKU
○ Mousy odour
○ Fair complexion (Tyrosine necessary for melanin production)
● Investigations
○ UMS – FeCl3 test positive
○ TMS
● Management
○ Low phenylalanine diet (tapioca)
○ Sapropterin dihydrochloride to reduce phenylalanine levels
○ Inclusion of large neutral amino acids in diet, which would compete with
○ phenylalanine for transport across BBB
3. Galactosemia
● Deficiency of galactose – 1 – phosphate uridyl transferase
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○ Oil drop cataract

○ Increased risk of E. coli sepsis
○ Vomiting
○ Seizures
○ Failure to thrive
○ Hepatic failure
● Investigations
○ UMS – Benedict’s test positive
○ Enzyme assay
● Management
○ Lactose free diet
4. Serum electrophoresis
● Movement of charged particles through an electrolyte when subjected to an electric field
● The positively charged particles (cations) move to the cathode (negative terminal) and
vice versa.
● Factors affecting electrophoresis
○ Net charge on the particles
○ Mass and shape of the particles
○ pH of the medium
○ Strength of the electrical field
○ Temperature
● Serum electrophoresis patterns :
Normal pattern
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Inflammatory response
(elevated alpha2, beta & gamma)
Multiple myeloma
(highly elevated gamma)
5. Essential amino acids

Their carbon skeleton cannot be synthesised by us and so are to be included in the diet
● Any Arginine*
● Help Histidine*
● In Isoleucine
● Learning Leucine
● These Threonine
● Little Lysine
● Molecules Methionine
● Proves Phenylalanine
● Truly Tryptophan
● Valuable Valine
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(*Arginine and histidine are semi-essential amino acids. They are needed in children, but not
needed in adults)
6. Non essential amino acids

GA GA GA PTSC
Glycine Alanine
Glutamate Aspartate
Glutamine Asparagine
Proline Tyrosine Serine Cysteine
7. Serum amino acid pattern in protein energy malnutrition

In a study conducted by Antener et al, it was found that apart from lysine, the essential amino
acid levels were all below normal.
Reference : Antener I, Tonney G, Verwilghen AM, Mauron J. Biochemical study of malnutrition.
Part IV. Determination of amino acids in the serum, erythrocytes, urine and stool ultrafiltrates.
Int J Vitam Nutr Res. 1981;51(1):64-78. PMID: 6786995.
8. Glucose tolerance test

Procedure
● 8 AM – Fasting blood and urine sample collected
● Glucose load – 1.75 gram/kg anhydrous glucose – given in 250-300 mL water
● to be drank in 5 minutes
● Sample collection – 1 hour & 2 hour urine and blood samples
Reference Normal Diabetes Mellitus Impaired glucose tolerance
Fasting < 110 > 126 110 – 126
1 hour (peak) < 160 – –
2 hour < 140 > 200 140 – 200
Indications
● Glucose challenge in pregnancy
● Symptoms of diabetes mellitus are present, but FBS value is inconclusive
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9. HbA1c
● Non-enzymatic addition of sugar to a protein is called glycation. When once attached,
glucose is not removed from haemoglobin. It remains inside the RBC throughout the
lifespan of the RBC (120 days).
● The glycated haemoglobins are together called the HbA1 fraction. Out of this, 80%
molecules are HbA1c. Routine clinical assays are carried out by HPLC. The value of
HbA1c is expressed as a fraction of the total haemoglobin eg. 5%, 10% etc.
● An HbA1c value between 5.7 and 6.4 suggests impaired glucose tolerance and a value >
6.5 suggests diabetes mellitus. This value is also checked after initiating appropriate
therapy to assess the level of glycemic control.
HbA1c value Estimated 3 month average glucose Level of glycemic control
5.5 110 Very good
6 126 Good
7 154 Adequate
8 183 Inadequate
9 212 Poor
10 240 Very poor
10. Urine metabolic screening

● Ketones – Organic acidemias, glycogen storage disorders
● Ferric chloride – positive in PKU, MSUD, tyrosinemia
● Dinitrophenylhydrazine – positive in PKU, MSUD, glycogen storage disorders
● Nitrosonaphthol – Tyrosinemia, hereditary fructose intolerance, galactosemia
● Cetylpyridinium chloride – MPS
● Benedict’s – Galactosemia, hereditary fructose intolerance, diabetes mellitus
● Cyanide Nitroprusside – Homocystinuria
● Gas chromatography – Confirmatory test for aminoacidopathies and organic acidemias
11. Ketone bodies

● The acetyl CoA formed from fatty acids can get oxidised in the TCA cycle only when
carbohydrates are available. During starvation and in diabetes mellitus, acetyl CoA takes
the alternative route – formation of ketone bodies.
● The ketone bodies are formed in the liver, but they are utilised by extrahepatic tissue
● Almost all tissues and cell types can use ketone bodies as fuel, except liver and RBC
Application
○ DKA and starvation ketosis
○ Ketogenic diet
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12. Vitamin A
● It is a fat soluble vitamin
● RDA : 1500 IU
● Foods rich in vitamin A : Green, yellow and orange colour vegetables and fruits, milk,
egg, fish
Vitamin A deficiency
● It manifests as xerophthalmia.
● WHO classification of xerophthalmia
○ XN Night blindness
○ X1A Conjunctival xerosis
○ X1B Bitot spots
○ X2 Corneal xerosis
○ X3A Corneal ulceration involving less than one third of the cornea
○ X3B Corneal ulceration involving more than one third of the cornea
○ XS Corneal scarring
○ XF Fundal changes
● Treatment of vitamin A deficiency
○ <6 month old child - 50,000 IU
○ 6-12 month old child - 1 lakh IU
○ >1 year old child - 2 lakh IU
○ This dose of vitamin A is given on day 0, day 1 and day 28.
● Prevention of vitamin A deficiency
○ 1 lakh IU vitamin A is given at 9 months along with MR vaccine first dose
○ 2 lakh IU vitamin A is given at 18 months along with DPT first booster
Hypervitaminosis A
● Toxicity is noted if >50,000 IU/day of vitamin A is ingested for several months
● It can manifest as pseudotumour cerebri, dermatitis, alopecia, hyperostosis and
hepatosplenomegaly.
● Toxic levels in pregnancy (>10,000 IU/day) can be teratogenic.
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13. Vitamin E
● It is a fat soluble vitamin
● RDA 5-15 mg
● Foods rich in vitamin E - cereals, vegetable oils
Applied aspects
● Vitamin B12 deficiency manifests as posterolateral spinal cord syndrome with large fiber
neuropathy. The exact same manifestation can be seen in vitamin E deficiency and copper
deficiency as well.
● Vitamin E is to be supplemented in children with malabsorption and cholestasis.
● Physiological anaemia of prematurity has various causes and one of the causes is vitamin
E deficiency in preterm babies. Hence vitamin E supplements may be given in preterm
babies till 40 weeks postmenstrual age.
● Vitamin E is used in the treatment of NASH (non alcoholic steatohepatitis)
14. Chromosomal translocation

It is a chromosomal abnormality in which there is transfer of material from one chromosome to
another. Types :
● Balanced reciprocal translocation
○ Single breaks in two chromosomes, with exchange of material and without loss of
any genetic material
● Robertsonian translocation
○ A translocation between two acrocentric chromosomes, leading to formation of
one very large chromosome and one extremely small chromosome. The small
chromosome is subsequently lost and the resulting karyotype has only 45
chromosomes.
Applied aspects
● Several malignancies are caused by translocations. For example,
○ t(12;21) in ALL
○ Philadelphia chromosome t(9;22) in CML
○ t(8;21) in AML
○ t(8;14) in Burkitt lymphoma
● In Down syndrome, 95% cases are due to non-disjunction, 1% cases are due to
mosaicism and 4% cases are due to translocations involving chromosome 21.
Translocation (21;21) carriers have a 100% recurrence risk for a chromosomally
abnormal child.
22
15. Inborn error of metabolism

When to suspect ?
○ Clues related to parents
■ Family history of unexplained neonatal deaths
■ Consanguinity
○ Clues related to newborn baby
■ Sepsis like features – poor feeding, vomiting, lethargy
■ E. coli sepsis (galactosemia has increased risk of E. coli sepsis)
■ Rapidly progressive encephalopathy
■ Refractory / persistent hypoglycemia
○ Clues related to laboratory parameters
■ Hyperammonemia
■ Intractable metabolic acidosis
○ Clues related to older children
■ Organomegaly
■ Peculiar odour
■ Sudden deterioration during febrile illness
Classification of IEM
○ Urea cycle defects – eg. Ornithine transcarbamylase deficiency
○ Organic acidemias – eg. Propionic acidemia
○ Amino acid disorders – eg. PKU
○ Carbohydrate metabolism disorders – eg. Glycogen storage diseases
○ Fatty acid oxidation defects – eg. short chain acyl CoA dehydrogenase deficiency
○ Mitochondrial disorders – eg. Leigh syndrome
○ Lysosomal storage disorders – eg. Gaucher disease
○ Peroxisomal disorders – eg. Zellweger syndrome
Approach and Management - same as neurodegenerative disorders
16. Urea cycle defects
23
● Urea cycle defects

○ Carbamoyl phosphate synthetase I (CPS I) deficiency
○ Ornithine transcarbamylase (OTC) deficiency
○ Citrullinemia (accumulation of citrulline) – Argininosuccinate synthetase
deficiency
○ Argininosuccinic aciduria (due to accumulation of argininosuccinate) –
Argininosuccinase deficiency (Arginosuccinase is also called as argininosuccinate
lyase)
○ Argininemia (due to accumulation of arginine) – Arginase deficiency
○ Classical forms – poor feeding, vomiting, lethargy, seizures, encephalopathy,
coma
○ Partial deficiencies – poor feeding, vomiting, lethargy etc. triggered by stress /
illness
○ Intolerance to protein
○ Argininemia manifests as progressive spastic diplegia
● Investigations
○ Hyperammonemia with normal pH
○ Enzyme assay for enzymes like CPS-I, OTC etc.
○ TMS ± urine GC/MS can pick up elevated levels of citrulline, arginine etc.
○ Genetic testing
● Management
○ Acute phase of hyperammonemia
■ Same as management of acute encephalopathy in neurodegenerative
disorders
○ Maintenance phase
■ Protein restriction
■ Supplementation of essential amino acids
■ Sodium benzoate
17. Organic acidemia

Excretion of non-amino organic acids in urine
Clinical features
○ Acute encephalopathy, precipitated by stress / illness
○ Specific features
■ Abnormal odour – burnt sugar (MSUD), sweaty feet (isovaleric aciduria)
■ Skin and hair abnormalities – biotinidase deficiency
■ Acute stroke – methyl malonic acidemia, propionic acidemia, glutaric
aciduria
Investigations
○ Hyperammonemia with acidosis
○ Enzyme assay (eg. biotinidase)
○ TMS ± urine GC/MS
○ Genetic testing
Management
24
○ Acute crisis (encephalopathy)

■ Same as management of acute encephalopathy in neurodegenerative
disorders
○ Maintenance phase
■ Co-factor supplementation and adjunctive treatment
● Biotin supplementation in biotinidase deficiency
● B1 (Thiamine) supplementation in MSUD
● B12 (Cobalamin) supplementation in methyl malonic acidemia
(MMA)
● Metronidazole for MMA and propionic acidemia (PA)
○ Reduces production of propionate by gut bacteria
● L-carnitine supplementation in MMA, PA and isovaleric aciduria
● L-glycine supplementation in isovaleric aciduria
25
MICROBIOLOGY & IMMUNOLOGY
1. Stool examination
Procedure
● Stool specimen diluted with NS and two drops are placed on glass slides
● Place a cover slip on the first drop (unstained preparation)
● Add a drop of iodine to the other drop and place a cover slip (stained preparation)
Methods of concentrating the parasitic eggs so that they are easily found
● Floatation : Dissolve stool specimen in a solution of higher density than the eggs
(eg. saturated salt solution) so that the eggs float
● Sedimentation : Dissolve stool specimen in a solution of density less than the eggs
(eg. water) so that the eggs concentrate at the bottom
Also mention about
● Stool occult blood
● Faecal elastase and fat globules assessment in malabsorption
● Draw pictures with brown colour pencil
Ascaris lumbricoides egg (fertilised) Trichuris trichura egg
2. PCR
Definition
Amplification of a specific fragment of DNA in successive cycles
Steps
● Denaturation : dsDNA ssDNA at 94 deg C
● Annealing : Primers are added which anneal with complementary sequences
● Extension : Taq polymerase provides complementary strands at 72 deg C
Application
Detecting infections eg. TB, COVID-19
Detecting mutations
Forensic medicine (DNA fingerprinting)
Genetic engineering
DNA sequencing in Human Genome Project
26
3. Screening tests for blood transfusion

Tests Methodology
● anti HIV 1 & 2 ELISA
● HBsAg ELISA
● anti HCV ELISA
● Syphilis Rapid Plasma Reagin (modification of VDRL)
● Malaria RDT
4. Types of culture media

Based on consistency
● Solid media eg. LJ medium
● Liquid media eg. MGIT
● Semisolid media eg. Stuart’s medium
Based on aerobicity
● Aerobic media – most media are aerobic
● Anaerobic media eg. Robertson cooked meat medium
Based on complexity
● Simple media eg. Nutrient agar
● Enriched media – Substances such as blood, serum or egg are added to a basal
medium eg. blood agar, chocolate agar, egg media
● Enrichment media – Some substances are added in the medium to prevent
commensal organisms from overgrowing the pathogenic organisms eg.
Tetrathionate broth for Salmonella typhi
● Indicator media – Medium contains an indicator that changes colour with
bacterial growth eg. Potassium tellurite agar for diphtheria (black colonies)
● Differential media – Medium brings out differing characteristics of bacteria and
helps distinguishing them eg. MacConkey medium
○ lactose fermenters have pink colonies
○ non lactose fermenters have pale colonies
Transport media
● Special media for delicate organisms which may not survive the time taken for
transporting the specimen to the laboratory eg. Stuart’s medium for gonococci
5. Blood culture
Blood culture aids in the diagnosis of bloodstream infections. Isolating the bacteria on solid
media makes identification and susceptibility testing possible.
Antibiotic sensitivity testing

The commonly performed testing methods are :
1. Disc diffusion method of Kirby Bauer

● This method uses filter paper discs charged with antibiotics. These antibiotic discs are
applied with sterile forceps on the culture plate medium with bacteria growing in it. After
overnight incubation, the degree of sensitivity is determined by measuring the zones of
27
inhibition of growth of bacteria around the discs. The results are reported as ‘sensitive’,
‘moderately sensitive’ or ‘resistant’.
2. Dilution method
● In this method serial dilutions of the antibiotic in broth are taken in tubes and a
standardised suspension of the test bacterium is inoculated into the tubes. After overnight
incubation, the “minimum inhibitory concentration (MIC)” is read by noting the lowest
concentration of the antibiotic that inhibits growth. The “minimum bactericidal
concentration (MBC)” is the lowest concentration of the antibiotic that kills the
bacterium.
Automation in blood culture

Bactec is a recognised automated system worldwide. Previously it was necessary to subculture
each bottle manually after 24-48 hours. Nowadays bacterial growth is detected by the microbial
production of carbon dioxide or by the changes in the electrical impedance of the medium. These
detection systems provide continuous monitoring of blood culture bottles, allowing earlier
identification of pathogens.
Limitations of culture
The main limitation is the time required for incubation. Hence, for acutely ill patients,
therapeutic decisions must be made based on clinical features plus rapid microscopic
28
examination (eg. gram staining). This empirical therapy may be later modified after the culture
result is available.
Applied aspects
1. Blood culture is the main investigation whenever blood stream infection is suspected.
2. If blood culture grows staphylococcus aureus, always perform echocardiography to rule out
infective endocarditis.
3. Positive blood culture is part of the major criteria in modified Duke’s criteria for infective
endocarditis.
4. In pyogenic meningitis, if lumbar culture is delayed or contraindicated, perform blood culture
prior to the first dose of antibiotics.
5. In neonatal sepsis, culture positive sepsis needs antibiotics for 14 days. We can stop antibiotics
earlier in culture negative sepsis based on symptoms and CRP.
6. Coombs Test
Applications of DCT
● Testing for AIHA
● Testing for isoimmunisation in neonatal jaundice due to Rh / ABO incompatibility
Applications of ICT
● Cross match before transfusion
● Screening for Rh isoimmunisation in antenatal Rh negative women
29
7. ABO incompatibility
People are divided into four main groups based on the antigens found on their RBCs. They will
also have the corresponding opposing antibody in their serum.
Group Ag on RBC Ab in serum Reaction to anti-A sera Reaction to anti-B sera
A A anti-B Agglutination No agglutination
B B anti-A No agglutination Agglutination
AB A and B – Agglutination Agglutination
O – anti-A & anti-B No agglutination No agglutination
Applications
1. Cross match in blood bank
2. Hemolytic disease of newborn
8. ELISA
Purified HIV antigen is adsorbed onto the test container
Serum sample to be tested is added to the container
If HIV antibodies are present in the serum sample (PLHA), then the HIV antibodies form a
stable complex with the antigen
Washing of the container is performed to remove other unrelated human antibodies. This step
ensures that only HIV antibodies stay behind in the container, by virtue of being bound to the
adsorbed HIV antigen, which will not get washed away
Anti-human Ig conjugated with an enzyme is then added to the container
30
The anti-human Ig will bind to the HIV antibodies. (However, if the serum sample did not
contain HIV antibodies, then there would not have been a target for the anti-human Ig to bind to)
Washing of the container is again performed to remove unbound anti-human Ig (if any). This
process cannot remove the anti-human Ig which is bound to the HIV antibodies, which is in turn
bound to the HIV antigen adsorbed onto the container. (If the serum sample did not contain HIV
antibodies, then the unbound anti-human Ig gets washed away in this step)
A substrate is now added to the container, which is acted upon by the enzyme linked to the
anti-human Ig. (If the anti-human Ig was washed away in the previous step, then the enzyme
would not have been available in the container to act on the substrate) The substrate reacts with
the enzyme to give a coloured product, and the colour-change is an indication of test positivity.
Applications of ELISA
● Detecting antibodies eg. HIV, HCV, Dengue, Scrub, ANCA
● Detecting tumour markers eg. PSA, CEA
● Estimating hormone levels eg. LH, FSH
● Screening donated blood for HIV/HBsAg/HCV
● Detecting drug abuse
9. Mechanisms of antibiotic resistance in bacteria

Natural resistance
● Drug tolerant – altered penicillin binding protein in pneumococcus
● Drug destroying – beta lactamase produced by Staph, H. influenza
● Drug impermeable – gonococci deficient in porins (channels for penicillin entry)
Acquired resistance
● Mutations – Rifampicin resistance in mycobacterium
● Conjugation – Transfer of resistance through pili (Chloramphenicol resistant typhoid)
● Transduction – Transfer of resistance through phage (common in Staph aureus)
● Transformation – Transfer of resistance through DNA (Pneumococcus and Griffith study)
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10. Leptospirosis
Agent
Leptospira (spirochete)
Transmission
Direct or indirect contact with urine of infected animal
Clinical features
● Fever, conjunctival suffusion, severe mylagia, polyserositis
● Severe disease : Jaundice (Weil’s disease), renal failure, myocarditis, meningitis
Modified Faine’s criteria is used to diagnose leptospirosis
● Part A – Clinical data eg. bilateral conjunctival suffusion – 4 points
● Part B – Epidemiological factors eg. rainfall – 5 points
● Part C – Laboratory findings eg. MAT positive – 15 points
● Total score : > 25 – Definite leptospirosis
20 to 25 – Possible leptospirosis
Investigations
● Microscopic Agglutination Test (MAT) – 1:400 in endemic, 1:100 in non-endemic
● Dark Field Microscopy (DFM) – direct visualisation of leptospira
● Others – PCR, IgM ELISA
Management
● Doxycycline 5-10 mg/kg/day for 7 days
● Severe disease : Crystalline penicillin 50,000-1,00,000 U/kg/day or Ceftriaxone
● Supportive : Dialysis, management of hepatic failure, inotropes etc.
Prevention
● Not to wade through flood waters, not to play in puddles
11. Group B Streptococcus

30% women are vaginal/rectal carriers
Affects mothers (puerperal sepsis) and babies (sepsis, meningitis)
Affects immunocompromised elderly individuals (eg. diabetes) also – SSTI, UTI , LRI
32
Example – Streptococcus agalactiae
Differentiation Group A Streptococci Group B Streptococci

Bacitracin sensitivity Sensitive Resistant
PYR test Positive Negative
Hippurate hydrolysis test Negative Positive
CAMP test Negative Positive
Appearance of colonies Pinpoint (0.5 mm) Larger, mucoid (2 mm)
12. Atypical mycobacteria

They are opportunistic pathogens. They are of the following types :
● Photochromogens
Produce pigments only in light
eg. M. marinum causes swimming pool granuloma / fish tank granuloma
● Scotochromogens
Produce pigments even in dark
eg. M. scrofulaceum causes scrofula (cervical LAD)
● Non-photochromogens
Do not produce pigment
eg. M. avium intercellulare causes LAD, LRI & disseminated disease (PLHA)
● Rapid growers
Grow within one week
eg. M. fortuitum causes post trauma abscesses
13. Gas gangrene

Rapidly spreading myonecrosis occurring in severe crush injuries
Agents
Clostridium perfringens, C. novyi and C. septicum
Pathogenesis
● Contamination of crush wounds with clostridial spores present in soil
● Requires anaerobic environment for bacterial growth (necrotic tissue)
Clinical features
● Excruciating pain
● Foul smelling discharge
● Gas bubbles (crepitus) in muscle planes
● Oedema and induration
● MODS
Investigations
● Wound swab
● Gram staining : Gram positive bacilli
● Culture – Robertson cooked meat medium
Management
● Early surgical debridement (removal of spores and necrotic tissue)
● Antibiotics – penicillin and clindamycin
● Hyperbaric oxygen to kill the obligate anaerobic clostridia
Prevention
33
● Passive immunisation with antitoxin
14. Nosocomial infections

Infections acquired in the hospital by a patient
● who was admitted for some other reason
● in whom the infection was not present at admission
● symptoms occur 48 hours after admission
Organisms (ESKAPE)
● Enterococcus
● Staph aureus
● Klebsiella pneumonia
● Acinetobacter
● Pseudomonas
● Enterobacter
Transmission
● Direct contact
● Inhalational
Types
● UTI
● Pneumonia
● Surgical site infection
● Blood stream infection
Prevention
Hand hygiene
● Hand Wash with soap (duration of contact 40-60 sec)
● Hand Rub (alcohol + chlorhexidine based)
● 5 moments of hand hygiene
Specific measures
Barrier nursing for MRSA
15. Pathophysiology of NNEC

Risk factors
● Gut immaturity (most important)
● Hypoxia - Ischaemia (most important)
● Infection (most important)
● A/REDF
● Rapid increase in feeds
● Umbilical artery catheter
● PDA
● Baby on indomethacin or ibuprofen therapy
● Polycythemia
● Hypothermia
● Maternal hypertension
Pathogenesis
These risk factors cause intestinal inflammation. Subsequent bacterial invasion results in
cellular damage followed by gut necrosis.
34
16. Diagnosis of rickettsial infections

Rickettsial infections are diagnosed by :
1. Weil Felix reaction
2. Detection of IgM antibodies by ELISA and immunofluorescence
3. PCR based detection
Weil Felix reaction

● It is based on the presence of antigenic cross-reactivity between rickettsial species and
certain serotypes of proteus.
● In the serum of a patient with rickettsial infection, there will be IgM antibodies produced
against the rickettsial antigens. These antibodies will also cross-react against proteus
bacteria antigens in vitro resulting in agglutination.
● Based on the strain of the proteus bacteria getting agglutinated, it is possible to identify
the type of rickettsial infection in the patient.
● Whole cells of proteus-strain-OX2 agglutinates with the serum from a person infected
with spotted fever group rickettsiae (eg. Rickettsia conorii belongs to the spotted fever
group and it causes Indian tick typhus).
● Whole cells of proteus-strain-OX19 agglutinates with the serum from a person infected
with typhus group rickettisiae (Rickettsia prowazekii causes epidemic typhus and
Rickettsia typhi causes endemic typhus).
● Whole cells of proteus-strain-OXK agglutinates with the serum from a person infected
with scrub typhus (Orientia tsutsugamushi).
● It is a slide agglutination test and the significant titre is 1:80.
● Although it lacks specificity and sensitivity, it may be used in developing countries as the
initial diagnostic step in the diagnosis of rickettsial infection. But, detection of IgM
antibodies by ELISA and immunofluorescence remains the gold standard in diagnosing
rickettsial infection.
17. Opportunistic infections in HIV

Bacteria : TB, MAC, Brucellosis, Legionellosis, Campylobacter, Actinomycetes, Nocardia
Viruses : HSV, VZV, EBV, CMV
Fungi : Candida, Aspergillus, Cryptococcosis, Histoplasmosis
Parasites : Toxoplasma, P. carinii, Cryptococcus, Cryptospora, Isospora, Strongyloides
Tumours : Kaposi, Hodgkin, NHL
Applied aspects : All children with HIV infection are given septran prophylaxis to prevent P.
carinii pneumonia.
18. Infectious Mononucleosis

Agent
EBV
Transmission
Intimate sharing of oral secretions
Clinical features
● Fever, sore throat, HSM, LAD
● Ampicillin/amoxicillin rash
35
Investigations
● PS : Atypical lymphocytes with large, eccentrically placed nuclei
● Paul Bunnell Test (Heterophile agglutination test) : EBV specific antibodies
agglutinate cells from different species (eg. horse RBC)
● ELISA : IgM VCA (Viral Capsid Antigen)
● PCR
Management
● Supportive
● Avoid contact sports for 2-3 weeks (splenic rupture)
19. Zika virus

It is a flavivirus. It is a positive sense, single-stranded, enveloped RNA virus. It was first isolated
in 1947 from Zika forest in Uganda.
Transmission
Aedes mosquito
Non-vector transmission : Vertical, transfusion, transplant
Clinical features
Mild flu like illness
Investigations
ELISA & RT-PCR
Complications
CNS malformations and microcephaly in babies
GBS
Management
Symptomatic treatment
Prevention
Vector control
20. Ebola
It is a filovirus. It is a negative sense, single-stranded, enveloped RNA virus. It was first
discovered in 1976 near Ebola river, Africa
Reservoir
Fruit bats, primates
Transmission
Direct close contact with blood and body fluids of infected patients
(Health care workers and close contacts – family members are at risk)
Clinical features
● Prodromal symptoms similar to any other viral illness
● Progression to abdominal pain, haemorrhage, shock and death
Investigations
ELISA & RT-PCR
Management
● Supportive
● Remdesivir
36
21. Nipah virus

It is a paramyxovirus. It is a negative sense, single-stranded, enveloped RNA virus. It was
discovered in 1999 in Malaysia. The first case was from Nipah village, Malaysia.
Reservoir
Fruit bats
Transmission
● Direct close contact with blood and body fluids of infected patients
● Consumption of contaminated foods (eg. fruits contaminated by fruit bats)
● Droplet or aerosol exposure
Clinical features
● It produces a rapidly progressive encephalitis (Mention clinical features of viral
meningoencephalitis in detail).
● In fulminant cases, it progresses to MODS.
Investigations
● RT-PCR and ELISA
● Mention CSF findings of viral meningoencephalitis
Management
Supportive
22. Chikungunya
It is an alphavirus. It is a positive sense, single-stranded, enveloped RNA virus.
Vector
Aedes mosquito
Differentiation Dengue Chikungunya
Rash Day 3-7 Day 1-4
Myalgia Common Possible
Polyarthritis, tenosynovitis No Common
Leukopenia, thrombocytopenia Common No
Bleeds, shock Common No
Investigations
ELISA & RT-PCR
Management
Supportive
Prevention
Vector control
23. Bacteriophage
It is a type of virus that infects and replicates within bacteria.
Applications
● Lysogenic conversion
○ Bacteriophage DNA can code for a new protein in the bacteria by this method. eg.
toxin production by diphtheria bacilli is determined by prophage beta.
● Transduction
37
○ Bacteriophage can carry genes from one bacterium to another. eg. transfer of
plasmid-mediated drug resistance in staphylococcus.
● Cloning vectors
○ Bacteriophage can transfer genes of interest to the intended bacterial host in
genetic engineering.
Life cycle
24. Negri bodies

They are intra-cytoplasmic inclusion bodies which are used to diagnose rabies in post mortem
brain biopsy specimens.
Features
Round or oval shaped
Purplish pink in colour
Characteristic basophilic inner granules
38
25. Cryptococcus
● Opportunistic pathogen
● Infection usually acquired by inhalation
● Frequently found in soil contaminated with avian excreta
Clinical features
● Pulmonary cryptococcosis – causes pneumonitis
● Visceral cryptococcosis – resembles leukaemia
● Cutaneous cryptococcosis – vary from small ulcers to large granulomas
● CNS cryptococcosis – AES
Investigations
● Negative staining of capsules by India ink & nigrosin
● Gram stain : Gram positive round budding yeast cells
● Latex agglutination test
● Fungal culture (Sabourad Dextrose Agar)
Management
● CNS – Amphotericin B
● Others – Fluconazole
26. Pneumocystis jiroveci

Severe opportunistic infection occurring in immunocompromised patients
Clinical features
Fever
Hypoxemia out of proportion to clinical & radiological signs
Investigations
CXR : Bilateral fluffy infiltrates
CT chest : extensive ground glass attenuation
BAL : characteristic 6-8 mm cysts stained with methenamine silver
Management
Isolation
TMP20 – SMX100 mg/kg/day (IV preferred over oral)
Pentamidine 4 mg/kg/day IV (if TMP-SMX resistant)
Prevention
TMP150-SMX750 mg/m2/day for 3 consecutive days every week
27. Newer tests for malaria

1. Quantitative buffy coat (QBC)
2. Rapid diagnostic tests (RDT)
3. PCR
1. QBC
Principle
● Centrifugal force is applied to the blood sample within an acridine orange-coated QBC
capillary tube, resulting in density gradient layering of blood cells (red cells at the
bottom, white cells in between and platelets on top).
● The infected red cells are less dense than uninfected red cells, and are thus found between
the red cell and white cells layers.
● Acridine orange is a fluorescent stain and it stains the DNA of the malarial parasite.
39
Advantages
● Economical
● Highly sensitive test
● Test results in 15 minutes
Disadvantages
● Plasmodium species identification may not always be possible
● At very low levels of parasitaemia QBC may be negative
2. RDT
Principle
Detection of antibodies to plasmodium antigens in blood sample
Antigens
PfHRP, pLDH, Aldolase
Advantages
● Simple
● Test results in 15 minutes
Disadvantages
● Costly
● Less sensitive
● False positive in patients with RA factor positivity
Applications
● Screening in blood bank to identify infected donors
● Field work in remote locations (eg. Africa)
● Epidemiological surveys
3. PCR
Parasite nucleic acids are detected using PCR. Although this technique may be slightly
more sensitive than smear microscopy, it is of limited clinical utility as the results are
often not available quickly enough to be of value in a sick child.
28. Amoebiasis
It is caused by Entamoeba histolytica
Amoebic colitis
40
Crampy abdominal pain, dysentery

Extraintestinal amoebiasis
● Amoebic liver abscess – spread by portal system
● Amoebic lung abscess – spread from liver abscess
● Amoebic spleen abscess
● Amoebic brain abscess
● Granulomatous ulceration of skin adjoining a visceral lesion
● Urogenital amoebiasis – entry gained by rectovesical or rectovaginal fistula
● Amoebic peritonitis and pericarditis – after rupture of a liver abscess
Investigations
● Stool microscopy
● Serology – IHA, ELISA
● Imaging – USG for liver abscess
Management
● Metronidazole for both intestinal and extraintestinal amoebiasis
● Add luminal agent (diloxanide furoate) to eradicate colonisation
● Most liver abscesses can be managed without drainage. Large abscesses (>300 mL)
● may benefit from aspiration, however.
29. Life cycle of Taenia solium

Tapeworm infection
● Clinical features : abdominal discomfort, anorexia and change in stool pattern
● Diagnosed by : identification of eggs in the stool
● Management : albendazole 10 mg/kg single dose
Neurocysticercosis
● This occurs when the Taenia solium eggs are ingested by the child. Eggs release
oncospheres, which penetrate the intestinal wall and migrate to the brain and form
cysticerci.
● Clinical features : localised inflammation in the brain causing seizures, focal deficits and
sometimes features of raised ICP
● Diagnosed by
○ MRI brain
○ Serology - enzyme-linked immunoelectrotransfer blot (EITB)
● Management
○ Cysticidal therapy is not needed for inactive and calcified lesions
For active lesions, albendazole 15 mg/kg/day for 2-4 weeks. Also prednisolone 1-2
mg/kg/day is started 2-3 days prior to cysticidal therapy and continued for a total of 5
days during the albendazole therapy.
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30. Herd immunity

● It is a threshold phenomenon where a sufficient level of immunity in the population
prevents growth of an epidemic.
● As immunity accumulates in a population — naturally during the course of an epidemic
or through vaccination — the spread of an infectious disease is limited by the depletion
of susceptible hosts. If a sufficient proportion of the population is immune — above the
‘herd immunity threshold’ — then transmission generally cannot be sustained.
42
● When there is no immunity in the population (A), an infectious individual (red) can
readily spread disease to its contacts (bold lines), who are susceptible (green). These, in
turn, can then transmit to their susceptible contacts (thin lines). When some individuals
are immune (blue) but the population is below the herd immunity threshold (B), a large
outbreak may still occur. When the population is above the threshold (C), large epidemics
are prevented but small outbreaks may still occur among clusters of susceptible
individuals.
Applied aspects
● Herd immunity is critical for the long-term control of many infectious diseases. Since
vaccines are never 100% effective and uptake is imperfect, achieving herd immunity
offers a means of indirectly protecting those who remain at risk of infection, including
those who are unable to be vaccinated due to their age or health.
● Herd immunity has been achieved by vaccination for a number of infectious diseases,
leading to global eradication. eg. smallpox. Polio and several other diseases are near
eradication. However, until global eradication is achieved, countries that do not maintain
vaccination above the herd-immunity threshold may experience a resurgence.
● A classic example is measles in the UK. Prior to measles vaccine introduction, there were
500,000 cases of measles occurring in the UK annually. Mathematical models suggested
that 93% of the population should be vaccinated to attain herd immunity to prevent the
spread of measles. After the vaccine was introduced in 1971, the number of cases quickly
fell below 100,000 per year. In 1992, the 93% threshold was reached. For the next 10
years measles cases never rose above 500 annually, putting the UK on the brink of
eliminating measles. However, the claims of a link between the MMR vaccine and autism
in 1996 caused vaccine uptake to decline, reaching a nadir of 80% in 2004. There have
been multiple measles outbreaks since then, and although vaccine uptake subsequently
improved, the UK lost its ‘measles elimination status’ from the World Health
Organization.
31. AEFI
A medical incident that takes place after immunisation, which causes concern; this may be a true
adverse event or an event co-incidental to the immunisation
Classification based on clinical picture
● Minor AEFI
○ Local reaction, fever, GI symptoms, myalgia etc.
43
● Severe AEFI
○ Those AEFIs that are not minor, but do not result in hospitalisation,
disability or death
● Serious AEFI
○ Those AEFIs that result in disability, hospitalisation or death
Classification based on aetiology
● Vaccine related reactions
○ AEFI due to inherent properties of the vaccine (eg. suppurative
lymphadenitis in BCG) or quality defects of vaccine
● Programmatic error / immunisation error related reactions
○ AEFI due to inappropriate vaccine handling, inappropriate prescription or
inappropriate administration (eg. infection due to non-sterile injection).
These are preventable AEFIs
● Anxiety related reactions
○ AEFI arising from anxiety about immunisation eg. syncope
● Co-incidental event
○ AEFI that happens after immunisation, but is not related to it
Examples of AEFI
● BCG – disseminated BCG infection. suppurative lymphadenitis
● OPV – VAPP
● MMR – thrombocytopenia
● DTP – persistent screaming, seizures, hypotonic hyporesponsive episode,
encephalopathy
Reporting of AEFI
44
PHARMACOLOGY
1. Mechanism of drug action

● Direct physical property eg. activated charcoal in poisoning
● Direct chemical property eg. antacids
● Enzyme inhibition eg. ACEI, AChEI (neostigmine), Sildenafil (PDE-5 inhibitor)
● Ion channel modification eg. CCB, Nicorandil (potassium channel opener)
● Transporter modification eg. Furosemide acting on NKCC2
● Acting on receptor eg. ARB, 5HT3 antagonist (ondansetron), D2 blocker (haloperidol)
2. Teratogenicity
All drugs are assigned a category, based on the risk of teratogenicity.
Drug category Explanation Examples

A No risk to foetus in human studies Thyroxine
B No risk to foetus in animal studies Paracetamol
C Benefit outweighs teratogenic risk Steroids
D Evidence of foetal risk; but benefit outweighs teratogenic risk Aspirin, AED
X Evidence of foetal risk and teratogenic risk outweighs benefit Thalidomide
Examples of teratogenic drugs

● Thalidomide – phocomelia
● Phenytoin – Foetal hydantoin syndrome (cleft lip, cleft palate)
● Alcohol – Foetal alcohol syndrome (microcephaly, IUGR)
● Warfarin – Foetal warfarin syndrome (nasal hypoplasia, shortened limbs and digits)
● ACEI – Hypoplasia of foetal kidneys and lungs
● Methotrexate – Neural tube defects
3. Third generation cephalosporins

● Type of antibiotic
○ Beta lactam antibiotic
● Mechanism of action
○ Disrupt the synthesis of the peptidoglycan layer, which is responsible for the
bacterial
○ cell wall structural integrity; bactericidal
● Examples
○ Cefixime, Cefotaxime, Ceftriaxone, Cefoperazone, Ceftazidime
● Indications
○ First line broad spectrum empirical antibiotic for UTI, SSTI, LRI etc.
○ Drug of choice in meningitis, gonorrhoea, typhoid
○ Ceftazidime and Cefoperazone have antipseudomonal effect
○ Ceftazidime is used in meliodosis
● ADR
○ GI effects
○ Infusion site reactions
○ Hypersensitivity
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4. Fifth generation cephalosporins

Type of antibiotic
Beta lactam antibiotic
Active against
● GPC – Strep, MRSA
● GNC – Gonococcus
● GNB – Most, including pseudomonas
Mechanism of action
Disrupt the synthesis of the peptidoglycan layer, which is responsible for the bacterial
cell wall structural integrity; bactericidal
ADR
● GI effects (nausea, vomiting, diarrhoea, dysgeusia)
● Infusion site reactions
● Hypersensitivity
Examples
● Ceftaroline
● Ceftobiprole
5. Amikacin
● Aminoglycoside antibiotic
● Mechanism : inhibition of bacterial protein synthesis; bactericidal
● Dose : 15 mg/kg/day as OD
● ADR : nephrotoxicity, ototoxicity
● Indications
○ UTI
○ First line antibiotic in neonatal sepsis
○ Nosocomial infections (anti-pseudomonal)
○ While withholding conventional ATT due to drug induced liver injury
6. Anti parasitic agents

● Metronidazole
○ Effective for amoebiasis, giardiasis, trichomoniasis
● Anti malarial medications
○ Uncomplicated vivax malaria
Chloroquine 10 mg/kg zero dose followed by 5 mg/kg at 6 hours, 24 hours
and 48 hours. This is given along with primaquine 0.25 mg/kg/day for 14
days.
○ Uncomplicated falciparum malaria

Artemisinin based combination therapy is the standard of care. eg.
Artemether and lumefantrine combination for three days. This is given
along with primaquine 0.75 mg/kg single dose.
○ Severe malaria
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Artesunate 2.4 mg/kg IV zero dose, followed by the same dose at 12

hours, 24 hours and after that once daily for 7 days. Once the child gets
better, he may be shifted to oral artemisinin based combination therapy.
● Anti leishmaniasis medication
○ Amphotericin B (there is extensive resistance to sodium stibogluconate at present)
● Antihelminthics
○ Albendazole effective against majority of the worms, except :
■ Filaria – DEC, Ivermectin
■ Dracunculus – Metronidazole
7. Systemic antifungals
● Polyene antibiotic
○ Example : Amphotericin B
○ Mechanism : Increase fungal cell membrane permeability
○ ADR : distal RTA, AKI
● Echinocandin
○ Example : Caspofungin
○ Mechanism : Disrupt fungal cell by inhibiting glucan synthase
○ ADR : Similar to Amphotericin B; but less severe
● Triazole
○ Example : Fluconazole, Voricanozole
○ Mechanism : Impair ergosterol synthesis which then disrupts fungal membranes
○ ADR : Fluconazole – GI effects, Voriconazole – QTc prologation, visual
disturbances
8. 3% saline
Mechanism of action
Increases osmolality of blood, resulting in extravascular fluid entering intravascular
compartment, thereby reducing oedema
Indications
● Raised ICT (0.5-2 mL/kg/hour)
● Symptomatic severe hyponatremia
● Nebulisation
ADR
● Thrombophlebitis
● Osmotic demyelination syndrome (Monitor sodium frequently)
9. Levetiracetam
● Levetiracetam is a novel antiepileptic drug.
○ SV2A protein is a part of secretory vesicle membranes that mediates
calcium-dependent vesicular neurotransmitter release. The binding of
levetiracetam to SV2A modifies the release of GABA and glutamate.
● Adverse effects Most common side effects are neuropsychiatric, like sedation, irritability
and mood swings. Most of the time, the side effects are mild. Dose reduction is
associated with improvement in behavioural problems
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● Indications
○ In status epilepticus, if seizures are not controlled with benzodiazepines,
levetiracetam is an excellent option. A loading dose of 20-30 mg/kg is followed
by maintenance with 10 mg/kg/dose q8-12h.
○ It is useful in treating a wide variety of seizures like generalised seizures, partial
seizures, myoclonic seizures and Lennox Gastaut syndrome. The usual starting
dose is 20 mg/kg/day.
○ It is safe in pregnancy.
10. Newer anticonvulsants

Indications
These medications are used in the management of recurrent seizures.
Mechanism of action
● Lamotrigine – Blocks sodium channel and reduces glutamate activity
● Lacosamide – Blocks sodium channel and CRMP-2
● Topiramate – Blocks sodium channel, opens potassium channel, reduces glutamate &
GABA
● Zonisamide – Blocks T-type calcium channel
● Oxcarbazepine – Blocks sodium channel
● Levetiracetam – Binds to SV2A and modifies release of GABA & glutamate
Usual starting doses
● Lamotrigine – 0.5 mg/kg/day (keep multiplying by 2)
● Lacosamide – 1 mg/kg/day
● Topiramate – 2 mg/kg/day
● Zonisamide – 4 mg/kg/day
● Oxcarbazepine – 8 mg/kg/day
● Levetiracetam – 20 mg/kg/day
Adverse effects
● All these medications are relatively safe and well tolerated. The memorable rare
indication for each of these are :
● Lamotrigine – serious rashes requiring hospitalisation
● Lacosamide – arrhythmias
● Topiramate – proximal RTA
● Zonisamide – renal calculi
● Oxcarbazepine – SIADH; risk of SJS in HLA susceptible individuals
● Levetiracetam – psychosis, hallucinations, and suicidal thoughts
11. Sodium valproate ADR

● Transaminitis / fulminant hepatic failure
● Pancreatitis
● GI effects
● PCOS; irregular periods (avoid in young women)
● Teratogenic potential (NTD)
● Hypersensitivity (rash)
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12. Parenteral iron therapy

● Indications
○ Oral iron not tolerated
○ Oral iron not absorbed (malabsorption)
○ Oral iron not administered (non-compliance)
○ Pregnancy with moderate iron deficiency anaemia for rapid correction
○ Along with EPO to meet the increased demands of rapid erythropoiesis
● Dosage calculation
Iron requirement (in mg) = 2.3 x body weight x (target Hb minus patient’s Hb) + 10 mg/kg for
iron stores
● Formulations available
○ In addition to the usual iron sucrose and iron dextran, there are newer
formulations available like iron isomaltose and ferric carboxymaltose.
13. LMW Heparin
○ Both heparin and LMWH exert their anticoagulant activity by activating
antithrombin III, which inactivates thrombin, factor X and factor IX.
● Advantages over heparin
○ Better bioavailability with subcutaneous administration (70-90%)
○ Longer t½ (OD dosing)
○ Laboratory monitoring with aPTT not needed (as in heparin)
● Adverse effects
○ Osteoporosis
○ Hypersensitivity
○ Heparin induced thrombocytopenia
○ Increased risk of bleeding
● Indications
○ Established thrombosis (eg. LV clot, DVT, cortical venous thrombosis)
○ DVT and venous thromboembolism prophylaxis in high risk surgical patients,
immobilised children etc.
○ COVID-19 in children
■ Therapeutic role in COVID-19
● Established thrombosis
● MIS-C with dilated coronaries > 10 SD, or LVEF < 35%
■ Prophylactic role in COVID-19

● Family history or past history of thromboembolism
● Children with CVC with 2 risk factors*
● Children with 4 risk factors*
(*risk factors – obesity, malignancy, dehydration, trauma, recent surgery)
14. Statins
● Cholesterol lowering medication
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○ HMG CoA reductase inhibition

● Indication
○ Primary hyperlipidaemia
○ Secondary hyperlipidaemia eg. diabetes
○ CKD, if LDL > 130
● Adverse effects
○ Myalgia is the most common adverse effect
○ Increase in liver enzymes (monitor LFT after starting statins)
○ New onset diabetes mellitus is seen in 9% patients
15. Beta blockers

● Mechanism
○ Inhibit adrenergic responses mediated through beta receptors
● Types
○ Non selective – Propranolol
○ Cardioselective (β1 blocking) – Metoprolol, Atenolol
○ α + β blockers – Labetalol, Carvedilol
● Indications
○ Cardiology
■ CCF
■ HOCM
■ Arrhythmias
■ Cyanotic spell prevention
■ Hypertension – oral (atenolol) and intravenous (labetalol)
○ Neurology
■ Migraine prophylaxis
■ Essential tremor
○ Hepatology
■ Portal hypertension / prophylaxis of variceal bleed
○ Endocrinology
■ Thyroid storm
○ Ophthalmology
■ Glaucoma
● ADR
○ Bradycardia
○ Precipitates asthmatic exacerbation
16. Diuretics
Mechanism of action
● Loop diuretics block the Na-K-2Cl channel on the apical membrane of thick ascending
loop of Henle
● Thiazide diuretics block the Na-Cl symporter located on the DCT
● Mineralocorticoid receptor antagonists (MRA) block the mineralocorticoid receptor and
hence block the aldosterone mediated reabsorption of salt and water
● ENaC blocker blocks the epithelial sodium channel through which aldosterone reabsorbs
sodium
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● Mannitol increases the serum osmolality thereby causing osmotic diuresis

● Acetazolamide is a carbonic anhydrase inhibitor
Adverse effects
● Loop and thiazide diuretics
○ Hypokalemia
○ Hyponatremia
○ Metabolic alkalosis
○ Impaired glucose tolerance
○ Dyslipidemia
○ Hyperuricemia
● MRAs
○ Hyperkalemia
○ Gynecomastia
● Mannitol
○ Hyponatremia
○ Hypokalemia
● Acetazolamide
○ Proximal RTA
○ Normal anion gap metabolic acidosis
○ Hypokalemia
Indications
● Loop diuretics are used in pulmonary edema due to various causes like acute mitral
regurgitation, intravascular volume overload due to post streptococcal glomerulonephritis
or CKD.
● MRAs and loop diuretics are used in heart failure. Thiazide diuretics may be used as an
adjunct.
● MRAs and loop diuretics are used liver cirrhosis with portal hypertension and ascites
● Thiazide and loop diuretics are used in hypertension
● Although diuretics may be used in nephrotic syndrome to reduce the extravascular

edema, it is of questionable benefit. Since diuretics are albumin-bound, they depend on
albumin to reach the peritubular capillaries and exert their action on the renal tubules.
Hypoalbuminemia decreases the load of diuretic delivered to the renal tubules.
● Thiazide diuretic is the drug of choice in nephrogenic diabetes insipidus. ENaC blocker is
the drug of choice in lithium induced diabetes insipidus.
● ENaC blocker is the drug of choice in Liddle syndrome.
● Mannitol is used to relieve raised intracranial pressure.
● Acetazolamide is used in glaucoma and high altitude sickness.
● Loop diuretics are used in toxicology during forced alkaline diuresis eg. in salicylate
poisoning
17. Insulin antagonists

● Glucagon – used in severe hypoglycemic episodes in a diabetic child
● Diazoxide – inhibits insulin release from beta cells; start at 5 mg/kg/day
● Octreotide – inhibits insulin release from beta cells; start at 5 µg/kg/day
● Chlorothiazide – inhibits insulin release from beta cells
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(Diazoxide, octreotide and chlorothiazide are used in children with persistent hypoglycemia eg.
ABCC8 gene mutation causing persistent hyperinsulinemic hypoglycemia of infancy)
● Streptozocin – selective damage to beta cells; it is used in inoperable cases of CA

pancreas (chemical pancreatectomy)
18. Uses of Prostaglandins

● PGE1 Alprostadil – Ductal patency maintenance
● PGE1 Misoprostol – MTP, PPH
● PGE2 Dinoprostone – Cervical priming (induction of labour)
● PGF2α Carboprost – PPH
● PGF2α Latanoprost – Wide angle glaucoma
19. IVIg
● Isolated from pooled human plasma (~10,000 donors) and screened for HIV, HBV &
HCV
● Indications
○ Neurology – GBS, Myasthenia gravis, ADEM, Autoimmune encephalitis,
PANDAS
○ Haematology – ITP, AIHA, pure red cell aplasia
○ Cardiology – KD, Myocarditis
○ Nephrology – HUS
○ Immunology – XLA, CVID, WAS, HIGM
○ NICU – NNH due to Rh/ABO incompatibility
○ PICU – Profound sepsis (off label)
○ COVID-19 – MIS-C
● Dose
○ Replacement dose – 0.4-0.6 g/kg every 2-4 weeks
○ Others – 2 g/kg over 2-5 days
● ADR
○ Anaphylaxis
○ AKI
20. Monoclonal antibodies
Monoclonal antibodies are proteins produced by hybrid cells (hybridomas) resulting from the
fusion of a B cell capable of producing specific antibodies against a certain antigen, and a
myeloma cell capable of indefinite multiplication. The monoclonal antibodies hence produced
are all identical and are specifically targeted to a concrete antigen.
Applied aspects
1. Diagnostic application
MAbs have been produced against all the cell surface markers (CD), thus allowing the
identification and classification of a broad range of cells in flow cytometry. Hence it has wide
applications in diagnosis of haematological malignancies and immunodeficiency workup.
2. Therapeutic applications
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Neurology
● Rituximab in autoimmune encephalitis and NMO spectrum disorders
● Natalizumab (anti alpha 4 integrin), alemtuzumab (anti CD52) and ocrelizumab
(humanised anti CD20) for multiple sclerosis
Haematology
● Rituximab in non-Hodgkin lymphoma, AIHA and ITP
● Emicizumab in haemophilia - it is a humanised monoclonal antibody directed against
factor IXa and factor X. It binds to factor IXa with one arm and factor X with the other
thereby promoting factor IXa-catalysed factor X activation. Hence it mimics the cofactor
function of the deficient factor VIII in these patients
● Eculizumab (anti C5) in paroxysmal nocturnal haemoglobinuria
Cardiology
● PCSK9 inhibitors (alirocumab, evolocumab) in familial hypercholesterolemia
Nephrology
● Rituximab in membranous nephropathy
● Eculizumab in atypical HUS
Immunology
● JIA
○ Anti TNF therapy (adalimumab) for polyarticular JIA and uveitis associated with
JIA
○ IL-1 inhibitors (anakinra) for sJIA
○ IL-6 inhibitors (tocilizumab) for sJIA
● Enthesitis related arthritis
○ Anti TNF therapy
● SLE
○ Rituximab in refractory nephritis and refractory cytopenias associated with lupus
● JDM
○ Rituximab in refractory JDM
● ANCA associated vasculitis
○ Rituximab in GPA and MPA with RPGN or diffuse alveolar haemorrhage
○ Mepolizumab (anti IL5) in EGPA
● Kawasaki disease
○ Anti TNF therapy may be considered in children who fail to respond to the first
dose of IVIg (instead of second dose IVIg or IV methylprednisolone)
Pulmonology
● Omalizumab (anti IgE), dupilumab (anti IL4) and mepolizumab (anti IL5) in asthma
Ophthalmology
● Ranibizumab (humanised anti VEGF) in age related macular degeneration
Gastroenterology
● Anti TNF therapy in inflammatory bowel disease
● Cetuximab (anti EGFR) in Ménétrier disease
Endocrinology
● Denosumab (anti RANKL) and romosozumab (anti sclerostin) in osteoporosis
Oncology
● Multiple therapeutic targets in solid organ cancers eg. bevacizumab (anti VEGF),
trastuzumab (anti HER2/neu)
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Transplant immunology
● Rituximab in recipients who have pre-formed anti-HLA antibodies against the potential
donor (desensitisation protocol to remove the antibodies)
● Basiliximab (anti CD25) and alemtuzumab (anti CD52) in the induction phase of
immunosuppression post-transplant to prevent graft rejection
Infectious diseases
● Anti rabies monoclonal antibody (Rabishield) can be used instead of ERIG or HRIG. It is
more potent and requires a lower dose (3.33 IU/kg)
● COVID-19
On 03.12.2021, FDA approved bamlanivimab and etesivimab (administered
together) for the treatment of mild to moderate COVID-19 in all paediatric
patients, including newborns, who are at high risk for progression to severe
COVID-19 eg. a child on cancer chemotherapy with COVID-19 positivity
Tocilizumab may be considered in children with IVIg refractory MIS-C
Adverse effects of monoclonal antibodies

Anaphylactic reactions
Reactivation of TB and hepatitis with Rituximab
Risk of serious infections with anti TNF agents, anti IL1 agents and tocilizumab
LFT derangement with tocilizumab
Isolated reports of progressive multifocal leukoencephalopathy
Drug induced lupus
However, the increased efficacy of monoclonal antibodies exceeds the limitations imposed by
their adverse effects.
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NEPHROLOGY
1. Acid base balance

● The total production of H+ in our body is approximately 150 g/day. But the H+
concentration in the blood is only 40 nEq/mL. How is it reduced so much ? It is due to
the buffering systems. There are three buffering systems in our body. The chemical
buffering system which is the first to act, the respiratory buffering system which is the
next to act and the renal buffering system which is the last to act.
A. Chemical buffering system

There are extracellular and intracellular chemical buffers.
Extracellular chemical buffers
● The most efficient chemical buffer is the bicarbonate buffer system. The pKa of
bicarbonate is 6.1 and can hence exist both as HCO3- and H2CO3 in the body. So,
HCO3- combines with the excess H+ to form H2CO3, which then breaks up to form
water and carbon dioxide. The carbon dioxide is subsequently exhaled.
● Another chemical buffer is the phosphate buffer system. The pKa of phosphate is 6.8
which is closer to the physiological pH than bicarbonate. However, bicarbonate is
superior because the blood concentration of bicarbonate is much higher compared to
phosphate.
Intracellular chemical buffers
● Buffering is also performed by intracellular components like protein, haemoglobin and
phosphate (Phosphate is both intracellular and extracellular buffer).
B. Respiratory buffering system

● Whenever there is metabolic acidosis, the respiratory centre is stimulated to increase the
respiratory rate and hence eliminate more carbon dioxide.
C. Renal buffering system

Kidneys regulate acid base balance via bicarbonate reabsorption, new bicarbonate generation and
distal acidification.
C-1 Bicarbonate reabsorption

● The glomerulus filters about 4,320 mEq/day of bicarbonate, which is 100% reabsorbed at
the PCT.
● The bicarbonate which is filtered from the glomerulus, reaches the PCT lumen. Here it
combines with H+ and forms water and carbon dioxide, which freely diffuse into the PCT
cell. Once inside the cell the process occurs in reverse forming bicarbonate and H+. The
bicarbonate is reabsorbed into the capillary and H+ is excreted back into the lumen. This
process repeats with the excreted H+ and the next bicarbonate anion reaching the lumen
from the glomerulus.
● Applied aspect : A defect at this location leads to proximal RTA due to defective
bicarbonate reabsorption.
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C-2 New bicarbonate generation

● Normally 70-80 mEq/day (1 mEq/kg/day) of non-volatile acids are produced in the body
due to metabolic reactions and this has to be excreted by the kidney. To neutralise such
acids, the kidney actively generates an equal amount of bicarbonate. The excreted H+ are
buffered by ammonia and phosphate buffers. Ammonia buffer is more important than
phosphate buffer. Phosphate buffer is also called titratable acid excretion.
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C-3 Distal acidification

● The pH of the urine at the glomerulus is 7.4, but at excretion it is 4-5. The alpha
intercalated cell of the cortical collecting duct is the most important acidifying machinery
in the kidney. Aldosterone acts here to increase the H+ excretion.
● Applied aspects
○ Defective distal acidification leads to distal RTA.
○ Conditions with excess mineralocorticoid activity produce alkalosis eg. primary
hyperaldosteronism, Bartter syndrome etc.
○ Conditions with reduced mineralocorticoid activity produce acidosis eg. RTA type
4 due to hypoaldosteronism and pseudohypoaldosteronism.
2. Anion gap
● Total cations in the body = Total anions in the body
● So, Measured cations + unmeasured cations = Measured anions + unmeasured
anions
● On rearranging, we get
(Measured cations - measured anions) = (Unmeasured anions - unmeasured
cations)
● But, (Measured cations - measured anions) is the anion gap. Hence,
Anion gap = (Measured cations - measured anions) = (Unmeasured anions -
unmeasured cations)
Serum anion gap
● In the serum, measured cation is sodium and measured anions are chloride and
bicarbonate. So,
Serum anion gap = serum Na - (serum Cl + serum HCO3) = Unmeasured anions -
unmeasured cations
● The normal serum anion gap is 8-12 mEq/L.
Applied aspects
● Metabolic acidosis is characterised by a decrease in serum bicarbonate. To maintain
electroneutrality in the body, this loss of bicarbonate has to be compensated by an
increase in another anion.
HAGMA
● If the loss of bicarbonate is compensated by an increase in unmeasured anions, then the
anion gap increases. It is called high anion gap metabolic acidosis (HAGMA).
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● Examples of unmeasured anions which cause HAGMA : ketone acid (DKA), lactic acid
(lactic acidosis)
● Explanation
○ Serum anion gap = Unmeasured anions - unmeasured cations
○ So,whenever the unmeasured anions increase in the body, the serum anion gap
increases.
● Whenever HAGMA is diagnosed, the next step is to calculate the delta ratio.
● Delta ratio = (anion gap - 12)/(24 - bicarbonate)
● Normal delta ratio value is 1-2 and it implies that HAGMA is the only disorder which is
present.
○ If delta ratio is <1, it implies that there is HAGMA plus NAGMA.
○ If delta ratio is >2, it implies that there is HAGMA plus metabolic alkalosis.
NAGMA
● If the loss of bicarbonate is compensated by an increase in chloride, then the anion gap
remains unaltered. It is called normal anion gap metabolic acidosis (NAGMA).
● Explanation
○ Serum anion gap = serum Na - (serum Cl + serum HCO3)
○ When bicarbonate falls, chloride increases and so serum anion gap remains
unaffected (NAGMA). Hence NAGMA is also called hyperchloremic metabolic
acidosis.
● NAGMA has two main causes
○ RTA
○ Gastrointestinal loss of bicarbonate eg. diarrhoea, VIPoma, post
ureterosigmoidostomy
○ How to differentiate between the two ? The answer is urine anion gap.
Urine anion gap
● Anion gap = Measured cations - measured anions = Unmeasured anions - unmeasured
cations
● In the urine, measured cations are sodium and potassium, while the measured anion is
chloride. So,
● Urine anion gap = (urine Na + urine K) - urine Cl = Unmeasured anions - unmeasured
cations
● The normal urine anion gap is slightly negative. A positive urine anion gap is abnormal.
Highly negative urine anion gap is also abnormal.
● In RTA, there is defective secretion of hydrogen ions into the lumen of the distal tubule.
Normally the hydrogen ions combine with ammonia (NH3) to form ammonium ions
(NH4+). But in RTA, due to the decreased secretion of hydrogen ions into the lumen, the
urine concentration of NH4+ falls. NH4+ is an unmeasured cation in the urine.
○ Urine anion gap = Unmeasured anions - unmeasured cations
○ So, when unmeasured cations reduce, the urine anion gap becomes positive.
● Hence urine anion gap is positive in RTA. In gastrointestinal loss of bicarbonate, urinary
ammonium excretion is not impaired and so urine anion gap remains negative.
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3. Metabolic alkalosis
It is defined as high blood pH (>7.4) due to increased serum bicarbonate (>24)
Pathophysiology
There are two types of metabolic alkalosis - chloride responsive metabolic alkalosis and chloride
resistant metabolic alkalosis
● Chloride responsive metabolic alkalosis
○ This is due to chloride depletion via non-renal routes eg. gastrointestinal loss due
to vomiting, skin loss in cystic fibrosis etc. Since the chloride depletion is via
non-renal route, urine chloride level is <15 mEq/L.
○ Basically chloride depletion means that there will be coexisting fluid depletion
also. Volume depletion activates the RAAS axis. Aldosterone produces alkalosis
and hypokalemia.
○ This can be managed by saline infusion (which contains chloride). Replenishment
of the volume will inhibit RAAS and so pH and potassium return to normalcy.
● Chloride resistant metabolic alkalosis
○ This is due to chloride depletion via renal route. Since the chloride depletion is
via renal route, urine chloride level is >15 mEq/L.
○ It is further subdivided into two categories :
■ Chloride resistant metabolic alkalosis with high BP
● It is caused due to excessive mineralocorticoid activity and this
produces alkalosis and hypokalemia. eg. primary
hyperaldosteronism, Liddle syndrome, apparent mineralocorticoid
excess, glucocorticoid responsive aldosteronism etc. It will not be
corrected by saline infusion because volume replacement cannot
inhibit the excessive constitutive mineralocorticoid activity.
■ Chloride resistant metabolic alkalosis with low to normal BP
● It is seen in Bartter syndrome and Gitelman syndrome. Both these
conditions lead to salt wasting and polyuria. This causes secondary
activation of RAAS and then aldosterone produces alkalosis and
hypokalemia. It will not be corrected by saline infusion because
even after volume replacement, there is ongoing salt wasting and
polyuria due to an inherent defect in the renal tubules. The ongoing
salt wasting and polyuria once again lead to secondary activation
of RAAS, which again causes alkalosis and hypokalemia.
○ Chloride resistant metabolic alkalosis management is focused on treating the
primary condition like primary hyperaldosteronism and Bartter syndrome, with
which pH and potassium return to normalcy. Acetazolamide may also be
considered in patients with normal renal function.
Clinical features
Symptoms in metabolic alkalosis are produced due to a decrease in ionised calcium. Tingling,
paresthesias, tetany, seizures and arrhythmias may be seen. Symptoms of the coexisting
hypokalemia may also be seen, like cramps, muscle weakness and arrhythmias.
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4. Hypokalemia
It is defined as serum potassium level <3.5 mEq/L.
Physiology
● Out of the total body stores of potassium, 80% is present in the muscles.
● Movement of potassium from the blood into the cell is an active process. Intracellular
accumulation of potassium against its electrochemical gradient is made possible by
Na-K-ATPase.
● What causes the shift of potassium from the blood into the cell ?
○ Insulin
○ Beta-2 agonist
○ Alkalosis
○ Drugs : BCT (barium, chloroquine and theophylline)
○ Hypokalemic periodic paralysis (It is a calcium channelopathy however)
● Renal handling of potassium
○ 65% of potassium is reabsorbed passively at the PCT. This reabsorption occurs
irrespective of the potassium levels in the body and hence is not important for us
to study.
○ 25% is reabsorbed at the thick ascending loop of Henle via the Na-K-2Cl channel
(applied aspect : Bartter syndrome)
○ 10% is reabsorbed at the collecting duct. Aldosterone activates ENaC in the

principal cell of collecting duct and reabsorbs sodium and water. To counter this,
potassium moves out.
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Workup of hypokalemia
● The first step is to rule out coexisting hypomagnesemia.
● The next step is to check urine spot potassium creatinine ratio.
○ If it is more than 13 mEq/g, it suggests renal loss of potassium.
○ If it is less than 13 mEq/g, then it implies non-renal loss. Non-renal loss can mean
either gastrointestinal loss (eg. VIPoma causing WDHA syndrome) or shift of
potassium from the blood into the cell due to insulin, beta-2 agonist, alkalosis,
drugs and hypokalemic periodic paralysis.
● The next step in renal loss of potassium assessment is blood gas analysis.
○ If there is acidosis, it means RTA.
○ If there is alkalosis, then go to the next step.
● The next step is blood pressure assessment.
○ Renal loss of potassium with alkalosis and high blood pressure suggests endocrine
hypertension (primary hyperaldosteronism, Cushing syndrome, Liddle syndrome,
apparent mineralocorticoid excess and glucocorticoid responsive aldosteronism).
○ Renal loss of potassium with alkalosis and low-to-normal blood pressure suggests
Bartter syndrome or Gitelman syndrome.
Clinical features
● Muscle symptoms
○ Mild hypokalemia can present with cramps or a patchy weakness
○ Severe hypokalemia can present as a bilaterally symmetric ascending flaccid
quadriparesis sparing the sphincters and cranial nerves. Hypokalemia can also
precipitate rhabdomyolysis.
● Polyuria as hypokalemia is a cause of nephrogenic diabetes insipidus.
● Colonic pseudo obstruction
● ECG changes in hypokalemia
○ Sagging of ST segment
○ Flattening of T wave
○ Appearance of U waves
○ Prolongation of QT interval (QU interval)
Management
● Oral potassium chloride is the best and safest mode of correction.
● Severe hypokalemia may require an acute potassium correction with 0.3-0.5 mEq/kg
infusion over one hour followed by adding potassium supplementation in the
maintenance fluid and periodic serum potassium monitoring.
5. Renal tubular acidosis (RTA)
Proximal RTA (Type 2 RTA)

Pathophysiology
● In proximal RTA, there is defective reabsorption of bicarbonate at the PCT. Since the
distal acidification machinery is intact and the patient is able to excrete acid in the urine,
the urine pH is normal (pH <5.5).
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● Proximal RTA is usually associated with generalised dysfunction of PCT (Fanconi

syndrome). The substances being reabsorbed at PCT include glucose, amino acids,
phosphate and bicarbonate. The reabsorption of all these are affected and hence the
manifestations are glycosuria, aminoaciduria, phosphaturia and acidosis.
● Acidosis has two bad properties. It will cause resorption of calcium from the bones and
also deplete the intravascular volume. Decrease in intravascular volume will stimulate
RAAS and this leads to aldosterone mediated hypokalemia.
● In proximal RTA, the acidosis is mild as the distal acidification machinery is still intact.
Hence calcium resorption from the bones is less (and so hypercalciuria and
nephrocalcinosis are not seen in proximal RTA). Also, since the acidosis is mild, the
aldosterone induced hypokalemia is also mild.
● Phosphate is handled only in the PCT. If phosphate is not reabsorbed at PCT, then it is
completely lost in urine. Deficiency of phosphate leads to severe rickets (phosphate is
more important for the child’s bone growth than calcium).
Causes
● Inherited causes
○ Defective Na-HCO3 transporter at the basolateral membrane of PCT
○ Defective carbonic anhydrase
○ Wilson’s disease
○ Dent syndrome
○ Lowe syndrome
○ Cystinosis
○ Hereditary fructose intolerance
○ Galactosemia
○ Tyrosinemia
● Acquired causes
○ Myeloma
○ Drugs - cyclophosphamide, cisplatin, aminoglycosides, topiramate
Management
● Acidosis causes growth retardation. Hence Shohl or uriliser solution (alkali) is given. The
requirement of alkali is 5-15 mEq/kg/day.
● Phosphate supplementation 50-100 mg/kg/day for the rickets.
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Distal RTA (Type 1 RTA)

Pathophysiology
● In distal RTA, there is defective acidification at the collecting duct. Since the patient is
not able to excrete acid in the urine, the urine pH is alkaline (pH >5.5)
● Collecting duct is in the distal portion of the nephron and that is affected in distal RTA.
DCT is in the intermediate portion of the nephron and it is unaffected in distal RTA
● There is no associated generalised tubular dysfunction in distal RTA like Fanconi

syndrome in proximal RTA.
● In distal RTA, the acidosis is severe as the distal acidification machinery is defective.
Hence there is severe calcium resorption from the bones and this leads to hypercalciuria
and nephrocalcinosis. Another reason for nephrocalcinosis is hypocitraturia (the body
tries to reabsorb citrate to neutralise the severe acidosis). Also, since the acidosis is
severe, the aldosterone induced hypokalemia is also severe.
● There is no phosphaturia in distal RTA. But there is resorption of calcium from the bones
due to severe acidosis. Phosphate is more important for the child’s bone growth than
calcium. Hence there is only mild rickets in distal RTA.
Causes
● Inherited causes
○ H+ ATPase defect
○ H+/K+ ATPase defect
● Acquired causes
○ Sjögren's syndrome
○ Primary biliary cirrhosis
○ Amphotericin B
Management
● Acidosis causes growth retardation. Hence alkali solution is given. The requirement of
alkali in distal RTA is 1-2 mEq/kg/day, much lower than the requirement in proximal
RTA, even though the acidosis is more severe in distal RTA. It is because in proximal
RTA, the proximal tubular dysfunction causes loss of the supplemented bicarbonate as
well and hence a higher dose is needed.
● Phosphate supplementation is not required in distal RTA.
Type 4 RTA
● Discussed under hyperkalemia
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6. Hyperkalemia
It is defined as serum potassium level >5 mEq/L.
Physiology
● Movement of potassium from the blood into the cell is an active process. But the
movement of potassium from the cell into the blood is a passive process.
● What causes the shift of potassium from the cell to the blood ?
○ Destruction of cells eg. hemolysis, tumour lysis
○ Non-selective beta blocker eg. propranolol
○ Acidosis
○ Exercise
○ Drugs : SAM (succinylcholine, arginine, mannitol)
● Out of the total daily intake of potassium, 90% is excreted by the kidneys. So
hyperkalemia is due to low GFR, unless proved otherwise.
Workup of hyperkalemia
● The first step is to rule out low GFR.
● After ruling out low GFR, check urine potassium.
○ If urine potassium is >40 mEq/L, then it means that hyperkalemia is due to shift
of potassium from the cell to the blood due to hemolysis, tumour lysis,
non-selective beta blocker, acidosis, exercise and drugs.
○ If urine potassium is <40 mEq/L, then it means that hyperkalemia is due to RTA
type 4 which is a defect in the renal tubule at the level of the principal cell of
collecting duct. Recall that aldosterone activates ENaC in the principal cell and
reabsorbs sodium and water. To counter this, potassium moves out. The defect in
the principal cell impairs the tubular excretion of potassium and hence causes
hyperkalemia. RTA type 4 can be due to either hypoaldosteronism or
pseudohypoaldosteronism (inability to excrete potassium by the principal cell
despite aldosterone being normally available). This is differentiated by TTKG
(transtubular potassium gradient) and that is the next step.
● TTKG = (urine K/urine osmolality) x (plasma osmolality/plasma K)
○ Normal TTKG value is 6-12. In RTA type 4, as urine potassium (numerator) is
low due to impaired potassium excretion, TTKG is always <6.
○ Now the patient is administered fludrocortisone (mineralocorticoid). If the TTKG
increases to >10 post-fludrocortisone, then it means that RTA type 4 is due to
aldosterone deficiency because supplementing a mineralocorticoid increases the
urinary potassium excretion. Causes of hypoaldosteronism include Addison
disease and salt wasting forms of CAH.
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○ If the TTKG remains <6 post-fludrocortisone, then it means that RTA type 4 is
due to pseudohypoaldosteronism. Causes of pseudohypoaldosteronism :
■ Mineralocorticoid receptor defect (aldosterone cannot cause sodium
reabsorption and potassium excretion because its receptor is defective)
■ Chronic tubulointerstitial diseases like primary hyperoxaluria, ADPKD,
reflux nephropathy etc. - these conditions lead to tubulointerstitial fibrosis
and hence aldosterone cannot enter the cell to mediate its actions.
Clinical features
● Neuromuscular - tingling, paresthesias, muscle weakness
● ECG changes in hyperkalemia
Potassium level (mEq/L) ECG changes
○ 6-7 Tall peaked T waves
○ 7-8 Flattening of P waves, prolongation of PR interval,
widening of QRS interval
○ 8-9 QRS waves increase in amplitude
○ >9 No P waves (sine wave pattern), conduction blocks,
VT
Management
● Calcium gluconate stabilises the myocardium.
○ 10% calcium gluconate 0.5 mL/kg IV over 10 minutes under ECG monitoring
○ This does not reduce the potassium level however.
● Potassium lowering measures
○ Salbutamol nebulisation
○ 0.1 U/kg insulin in 1 gram/kg dextrose as an infusion over one hour
○ Potassium binding resins (K-bind) 1 gram/kg orally or PR
● Hyperkalemia refractory to medical therapy is an indication for dialysis.
7. Serum osmolality
● Osmolality indicates the concentration of all the particles dissolved in body fluid.
● It is calculated by the formula :
Serum osmolality = (2 x Na) + (glucose/18) + (BUN/2.8)
● Normally serum osmolality is 285-290 mOsm/kg of water.
● Water normally flows from the compartment of low osmolality to the compartment of
high osmolality. For example, if a cell is in a relatively hyperosmolar solution, fluid will
move out of the cell towards the highly concentrated compartment to reach homeostasis.
As a result, the cell will shrink.
Applied aspects
● Conditions with a high serum osmolality
○ Diabetes insipidus
○ Dehydration
● Conditions with a low serum osmolality

○ Nephrotic syndrome
○ Liver cirrhosis
○ SIADH
○ Psychogenic polydipsia
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8. Countercurrent system
Countercurrent multiplication
● The osmolality of the blood reaching the glomerulus for filtration is 285-290 mOsm/kg of
water (normal blood osmolality).
● The osmolality of the fluid reaching the PCT is 285-290 mOsm/kg of water.
● The osmolality of the fluid leaving the PCT is also 285-290 mOsm/kg of water as there is
iso-osmotic reabsorption occurring at PCT (both solutes and water are being reabsorbed
together at PCT).
● In the descending loop of Henle, only water is being reabsorbed. Hence the osmolality of
the tubular fluid increases and is the highest at the tip of the loop of Henle (1200
mOsm/kg of water).
● In the thick ascending loop of Henle (ThAL), only solutes are being reabsorbed (eg.
Na-K-2Cl transporter). Hence the osmolality reduces and reaches its lowest point (50-100
mOsm/kg of water) at the ThAL-DCT junction.
Countercurrent exchanger
● Although the osmolality of the tubular fluid in the ThAL-DCT junction is 50-100
mOsm/kg of water, the osmolality of the urine that we usually excrete is 800-900
mOsm/kg of water. How does this happen ?
● The concentration of urine has four major players. Only when all four players co-exist,
can we excrete a concentrated urine. If there is a defect in even one of the four players,
the concentrating mechanism of the kidney is lost and we will excrete a dilute urine with
osmolality <600 mOsm/kg of water.
● Player 1 : Osmolality of the renal medullary interstitium

○ If the osmolality of the medullary interstitium was low, then water would have
shifted from its area of higher concentration (interstitium) to lower concentration
(tubular lumen), thereby further diluting the urine.
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○ Applied aspect - if there is medullary interstitial fibrosis (due to chronic

tubulointerstitial diseases like oxaluria, ADPKD, reflux nephropathy etc.), the
patient loses the ability to concentrate the urine and passes dilute urine.
● Player 2 : Urea
○ The osmolality of the medullary interstitium is maintained at high levels with the
help of urea. Once the osmolality of the renal medullary interstitium is high, then
the stage is set for the entry of Player 3.
● Player 3 : ADH
○ ADH causes free water reabsorption thereby increasing the urine osmolality.
Further, ADH activates UTA1 (urea transporter A1) which reabsorbs urea (player
2).
○ Applied aspects - Deficiency of ADH causes central diabetes insipidus (DI).
Resistance to ADH causes nephrogenic diabetes insipidus (DI). DI patients pass
dilute urine.
● Player 4 : Vasa recta

○ Urea cannot stay forever in the medullary interstitium. Transporters in the loop of
Henle can transfer urea from the interstitium into the tubular lumen and then urea
will be lost in the urine. So, the descending limb of the vasa recta takes up urea
from the interstitium and the ascending limb of the vasa recta releases urea back
into the interstitium. Hence, urea is always maintained in the medullary
interstitium.
○ Applied aspects - RBC sickling and congestion in the vasa recta leads to ischemia
and associated impairment of urea reabsorption leading to passage of dilute urine.
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9. Hyponatremia
It is a disorder of water metabolism. It is defined as serum sodium level <135 mEq/L.
Mechanism of hyponatremia
A. Pseudohyponatremia
● Serum osmolality = 2(Na) + glucose/18 + BUN/2.8
● The most effective osmole is sodium. In other words, the strongest contributor to tonicity
is sodium. That is why the formula has 2(Na).
● So hyponatremia is associated with hypotonicity. When hyponatremia is associated with
hypertonicity or normal tonicity, it is called pseudohyponatremia.
● Example - in hyperglycemia, glucose increases the effective osmolality in the blood
outside the cell (hypertonic state). The concentration of glucose in the blood is higher
than its concentration inside the cell. Conversely, water concentration inside the cell is
higher than its concentration outside the cell. Water always moves from its higher
concentration to lower concentration. So water moves from inside the cell to the blood.
This translocation of water increases the water concentration inside the blood and hence
reduces serum sodium concentration. This is pseudohyponatremia due to translocational
hyponatremia. For every 100 mg/dL increase in blood glucose over 200, sodium level
falls by 1.6 mEq/L.
● Other causes of pseudohyponatremia are paraproteinemia (eg. multiple myeloma) and
hypertriglyceridemia which interfere with the laboratory methodology of assessing serum
sodium.
B. True hyponatremia
Pathogenesis of true hyponatremia
● Excess ADH
○ In the resting state there is no ADH. As soon as serum osmolality increases (eg.
due to dehydration), the thirst mechanism is activated and ADH is also released.
ADH causes free water absorption. Both these regulatory mechanisms reduce the
sodium levels and osmolality. The most important stimulus for ADH release is
increase in tonicity (osmotic stimulus).
○ Another stimulus (non-osmotic stimulus) for ADH release is decreased effective
intravascular volume, when ADH acts in unison with RAAS. Although there is
sodium reabsorption occurring due to aldosterone, water gets reabsorbed more
than sodium, which leads to hyponatremia.
● Psychogenic polydipsia
○ Because of a central defect in thirst regulation, the patient keeps on drinking water
(>20 litres/day) and it is beyond the kidney’s capacity to regulate.
Workup of hyponatremia
● First rule out pseudohyponatremia due to translocational hyponatremia, paraproteinemia
and hypertriglyceridemia.
● Next assess the volume status of the patient using clinical methods like signs of
dehydration, skin turgor, tachycardia, orthostatic hypotension and radiological methods
like the assessment of IVC on ultrasonography. Hence classify the patient as belonging to
either hypovolemic hyponatremia, hypervolemic hyponatremia and euvolemic
hyponatremia.
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● Hypovolemic hyponatremia
○ Reduced intravascular volume due to hypovolemia is the trigger for release of
excess ADH, which causes hyponatremia.
○ Causes of hypovolemic hyponatremia
■ Renal loss eg. tubular injury in ATN, cerebral salt wasting,
hypoaldosteronism
■ Gastrointestinal loss eg. diarrhoea, vomiting
■ Third space loss eg. burns, pancreatitis
○ To differentiate between renal and non-renal causes, check urine sodium.
■ If urine sodium is >20 mEq/L, it indicates renal loss.
■ If urine sodium is <10 mEq/L, it indicates non-renal aetiology like
gastrointestinal and third space losses.
■ Another clue is to assess the urine volume. If urine output is increased,
then it indicates renal loss. If urine output is low or normal, it indicates
non-renal loss.
● Hypervolemic hyponatremia
○ Causes of hypervolemia
■ Congestive cardiac failure
■ Liver cirrhosis with portal hypertension and ascites
○ Even though there is hypervolemia in these patients, the effective intravascular
volume is reduced due to significant extravascular edema and splanchnic
vasodilation. This is a stimuli for excess ADH release and this leads to
hyponatremia.
○ Identification of these patients is easy due to the presence of significant
extravascular edema. USG can help in confirming the suspicion by assessing the
IVC.
● Euvolemic hyponatremia
○ Once hypovolemia and hypervolemia are ruled out, then we are left with only
euvolemic hyponatremia.
○ Clinical clues and USG help in ruling out hypovolemia and hypervolemia.
○ The causes of euvolemic hyponatremia are hypothyroidism, hypocortisolism and
SIADH.
○ So after ruling out hypothyroidism and hypocortisolism with TFT and serum
cortisol levels, the diagnosis of exclusion is SIADH. Inappropriate release of
excess ADH in the absence of osmotic stimuli and non-osmotic stimuli leads to
SIADH.
Clinical features
● Mild hyponatremia : Sodium 130-134 mEq/L
○ Gastrointestinal symptoms only eg. nausea, vomiting, anorexia
● Moderate hyponatremia : Sodium 120-129 mEq/L
○ Gastrointestinal symptoms are predominant
○ Neurological symptoms are rare eg. lethargy, mild headache
● Severe hyponatremia : Sodium 100-119 mEq/L
○ Neurological symptoms are predominant eg. confusion, agitation, gait
abnormalities, ataxia
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● Very severe hyponatremia : Sodium <100 mEq/L

○ Features of raised intracranial pressure
○ Coma
○ Seizures
Management
● The most common cause of hyponatremia in children is hypovolemic hyponatremia. In
general, it is recommended that the correction rate of sodium does not exceed 8-10
mEq/L per day in order to prevent the risk of osmotic demyelination syndrome. In
children without seizures/coma/raised ICP, replacement of the lost fluid along with the
normal maintenance fluid may be all that is necessary.
Example : A 10 kg child with 3% dehydration and sodium 120 mEq/L without

seizures/coma/raised ICP
○ Fluid deficit = 10x10x3 = 300 mL
○ Maintenance fluid = 100 mL/kg/day = 1000 mL/day
○ Total fluid required = maintenance plus deficit = 1300 mL/day
○ How to calculate the degree of increase in sodium produced by infusing a fluid ?

○ Increase in sodium = (infusate sodium-serum sodium)/TBW + 1
○ TBW = 60% of body weight = 6 litre
○ One litre of 0.9% saline contains 154 mEq sodium. So infusate sodium is 154
mEq/L
○ Increase in sodium = 154-120/6+1 = 34/7 = 4.8

○ 1000 mL of 0.9% saline increases the sodium level by 4.8
○ Here we are using 1300 mL in one day.

○ So, 1300 mL increases the sodium level by 1300x4.8/1000 = 6.2
○ Hence the sodium level increases by 6.2 mEq/L.
● In children with seizures/coma/raised ICP, the aim is to increase serum sodium quickly by
2-3 mEq/L (which increases the serum osmolality by 4-6 mOsm/kg of water). This
increment may be sufficient to reverse cerebral edema and avoid impending brain
herniation.
○ This increment is achieved by infusing hypertonic saline at a dose of 2-3 mL/kg
over 30-60 minutes.
○ Subtract this bolus dose of hypertonic saline from the total fluid requirement
calculated for the day.
○ Also ensure that the subsequent rate of rise of serum sodium does not exceed
0.3-0.4 mEq/L per hour, by frequent serum sodium monitoring.
Example : A 10 kg child with sodium 100 mEq/L with seizures planned for 3 mL/kg (30 mL)
hypertonic saline
○ One litre of hypertonic saline contains 513 mEq sodium. So infusate sodium is
513 mEq/L
70
○ Increase in sodium = (infusate sodium-serum sodium)/TBW + 1

○ Increase in sodium = 513-100/6+1 = 413/7 = 59
○ 1000 mL of hypertonic saline increases the sodium level by 59
○ Here we are using only 30 mL of hypertonic saline
○ So, 30 mL increases the sodium level by 30x59/1000 = 1.8
○ Hence the sodium level increases by approximately 1.8 mEq/L.
● Patients with hypervolemic hyponatremia (eg. DCLD with ascites, CCF) will require salt
restriction and diuretics. SIADH needs fluid restriction.
10. Hypernatremia
It is a disorder of water metabolism. It is defined as serum sodium level >145 mEq/L.
Mechanism of hypernatremia
● Normal serum osmolality is 285-290 mOsm/kg of water.
● In the resting state there is no ADH. As soon as serum osmolality increases (eg. due to
dehydration), the thirst mechanism is activated and ADH is also released. ADH causes
free water absorption. Both these regulatory mechanisms reduce the sodium levels and
osmolality. A failure in these two regulatory mechanisms lead to hypernatremia.
○ Usually dehydration activates the thirst mechanism and the patient drinks water
and hence hypernatremia is prevented. Extreme dehydration along with the
patient not drinking water leads to hypernatremia. Examples of such a scenario :
■ Extreme preterm baby on nil per oral kept under radiant warmer and
phototherapy
■ Severe burns patient on nil per oral
■ A ventilated child with diarrhoea and severe dehydration on nil per oral
○ Diabetes insipidus (DI)
■ Central DI is due to defective ADH secretion. Causes of central DI -
● Injury to the pituitary stalk due to trauma, tumour (eg. growth
hormone secreting pituitary adenoma) or infiltration (eg.
Langerhans cell histiocytosis, sarcoidosis)
● Wolfram syndrome (DIDMOAD)
■ Nephrogenic DI is due to ADH resistance
● Causes of nephrogenic DI -
● Mutation of V2 receptor or aquaporin-2
● Hypercalcemia
● Hypokalemia
Clinical features
● Hypernatremia causes cellular dehydration by movement of fluid from inside the brain
cell to outside, resulting in brain shrinkage and tearing of bridging blood vessels, which
leads to intracranial haemorrhage.
● Hypercoagulability due to dehydration increases the risk of thrombosis.
● Osmotic demyelination syndrome which is seen in rapid correction of hyponatremia can
also occur in hypernatremia.
● Features of dehydration and doughy skin
Management of hypernatremia
● If there is shock at presentation, can resuscitate with 0.9% saline boluses as required.
71
● Calculate water deficit.

○ Water deficit = 0.6 x body weight x (patient’s sodium-140)/140
○ Example 10 kg child with sodium 160 mEq/L
Water deficit = 0.6 x 10 x (160-140)/140 = 6 x 20/140 = Around 0.85 litre (850
mL)
● The water deficit is to be replaced over 48 hours. So 425 mL is given on day 1 and 425
mL is given on day 2.
● 0.45% saline with 5% dextrose (D1/2NS) is usually the most preferred starting fluid.
Other options are 0.2% saline with 5% dextrose (D1/4 NS) and 5% dextrose, which may
be used only in certain special situations.
● The recommended rate of sodium reduction is not more than 8-10 mEq/L per day. Higher
rate of fall is associated with CNS complications.
○ How to check if we are exceeding this rate ?
■ Increase in sodium by a fluid = (infusate sodium-serum sodium)/TBW + 1
■ 1 litre of D1/2NS contains 77 mEq of sodium and so infusate sodium = 77
mEq/L
■ Total body water = 0.6 x body weight = 6 litre
■ Increase in sodium = (77-160)/(6+1) = -83/7 = -11.8 mEq
■ The value is negative and so sodium falls by around 12 mEq for every 1
litre of D1/2NS.
■ 1000 mL of D1/2NS reduces sodium by 12 mEq/L.
■ But we are using only 425 mL of D1/2NS per day.
■ This would reduce the sodium by only 425 x 12/1000 = 5.1 mEq/day.
■ Since the rate of sodium reduction is <8 mEq/day, the planned fluid
correction is safe.
● In addition to the water deficit, the child should also receive the usual maintenance fluid
volume (with potassium).
○ So the total fluid requirement in 24 hours for the child in the above example is :
■ Water deficit to be given on day 1 = 425 mL
■ Maintenance fluid requirement on day 1 = 100 mL/kg = 1000 mL
■ Total fluid requirement on day 1 = water deficit plus maintenance = 1425
mL
○ In Nelson textbook of paediatrics, the authors have mentioned a rule of thumb that
the typical starting rate of fluid administration in a hypernatremic child is 1.25-1.5
times the usual maintenance. In the example above, we see that the total fluid
requirement on day 1 is calculated to be 1425 mL, which is approximately 1.5
times the maintenance fluid for a 10 kg child (1000 mL). Now you can understand
the reasoning behind the authors’ rule of thumb.
● Always remember to replace the ongoing water loss and insensible water loss.
● After initiating therapy, check serum sodium every 2 hours.
○ If the rate of sodium fall is >0.5 mEq/L per hour, reduce the rate of intravenous
infusion.
○ If the rate of sodium fall is <0.5 mEq/L per hour, increase the rate of intravenous
infusion.
● 9. Extreme cases may require dialysis.
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11. Glomerular filtration rate

● The first step in urine formation is the filtration of large amounts of fluid through the
glomerular capillaries into the Bowman capsule. This process is called glomerular
filtration.
Components of the filtering membrane
○ The glomerular capillary endothelium, glomerular basement membrane and
podocyte slit diaphragm together form the filtration barrier in the glomerulus.
○ These three components maintain electronegativity due to the presence of
podocalyxin and heparan sulphate in them.
○ It is important for the filtration barrier to be negatively charged to repel albumin,
which is also negatively charged.
○ If the negative charge is lost in either component of the filtration barrier, then it
cannot repel albumin and this leads to albuminuria.
Determinants of glomerular filtration rate (GFR)

● GFR = Net filtration pressure x filtration coefficient
● Net filtration pressure = (net hydrostatic pressure) - (net oncotic pressure)
○ Net hydrostatic pressure favours filtration and net oncotic pressure is against
filtration
■ Net hydrostatic pressure = (capillary hydrostatic pressure) - (Bowman
space hydrostatic pressure) = 60-18 = 42 mm Hg
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■ Net oncotic pressure = (capillary oncotic pressure) - (Bowman space

oncotic pressure) = 32-0 = 32 mm Hg
○ Net filtration pressure = (net hydrostatic pressure) - (net oncotic pressure) = 42-32
= 10 mm Hg
● Filtration coefficient is 12.5 mL/min per mm Hg
● GFR = Net filtration pressure x filtration coefficient = 12.5 x 10 = 125 mL/min
Regulation of GFR (Tubuloglomerular feedback)

● Regulation to decrease GFR
○ In case of tubular injury (eg. ATN due to gentamicin), no tubular reabsorption will
occur and this can lead to death by polyuria and dehydration.
○ The protective mechanism in place to ensure that this does not happen is
tubuloglomerular feedback.
○ Macula densa will be sensing the solute load (eg. chloride concentration) in the
tubular fluid.
○ When there is tubular injury, there is no chloride reabsorption occurring and
hence the chloride concentration of the fluid in the tubular lumen is high. Macula
densa senses the increased chloride load and hence secretes adenosine, which
causes vasoconstriction of the afferent arteriole.
○ This causes reduction in GFR as a protective mechanism to prevent polyuria and
dehydration.
74
● Regulation to increase GFR

○ Decrease in effective circulating volume (eg. hypovolemia, cirrhosis with portal
hypertension and ascites etc.) reduces the renal perfusion.
○ This leads to a drop in GFR, which then results in a reduced chloride load
reaching macula densa.
○ This stimulates the juxtaglomerular cells (JG cells) to secrete renin. This leads to
activation of angiotensin II, which causes vasoconstriction of the efferent
arteriole. This increases the GFR.
○ To complete the story, aldosterone is the third character of the RAAS system
which along with ADH causes salt and water reabsorption and hence replenishes
the intravascular volume. Replacement of the intravascular fluid deficit inhibits
RAAS.
Applied aspects
● The best overall indicator of the renal function is GFR.
● GFR is the rate at which substances in plasma are filtered through the glomerulus; in
other words, the clearance of a substance from the blood.
● The most commonly used marker for the assessment of GFR is creatinine.
12. Renal Function Test

A. Assessing glomerular function
● The best overall indicator of the glomerular function is the glomerular filtration rate
(GFR). GFR is the rate at which substances in plasma are filtered through the glomerulus;
75
in other words, the clearance of a substance from the blood. Assessment of GFR using
inulin is considered the gold standard method for the estimation of GFR. Other
exogenous markers used are radioisotopes such as chromium-EDTA and
technetium-DTPA.
● The most commonly used endogenous marker for the assessment of glomerular function
is creatinine.
○ Using the Cockcroft-Gault equation, creatinine clearance can be calculated.
Creatinine clearance = (140 - age) x body weight / (72 x serum creatinine)
Creatinine clearance = GFR plus tubular secretion of creatinine
Hence creatinine clearance can be used to indirectly estimate GFR.

○ Serum creatinine is also utilised in GFR estimating equations such as the MDRD
study equation and the CKD-EPI study equation. For children, Schwartz equation
is used.
GFR = k x length / serum creatinine
(where k is a constant, usually taken as 0.4)
○ The advantage of these equations is that we directly obtain GFR, which is
superior to creatinine clearance.
○ The disadvantages of estimating GFR using creatinine are :
■ Creatinine is dependent on muscle mass.
■ Creatinine takes 24-48 hours after tubular injury to start increasing.
■ Cystatin C is a novel protein which is being studied for use in GFR
assessment like creatinine.
● Blood urea nitrogen (BUN)-creatinine ratio is useful to differentiate pre-renal acute
kidney injury from acute tubular necrosis. BUN-creatinine ratio is >20 in pre-renal AKI,
whereas it is <10 in ATN.
B. Assessing tubular function
The renal tubules play a vital role in the reabsorption of electrolytes, concentration of the urine
by conserving water, and maintaining acid-base balance.
● Estimation of serum and urine electrolytes helps in identification of tubular injury.
○ An example is fractional excretion of sodium (FeNa).
○ FeNa = (urine sodium/urine creatinine) x (plasma creatinine/plasma sodium)
■ The normal value of FeNa is 1-2.
■ FeNa is <1 in pre-renal AKI and >2 in ATN.
● Measurement of urine osmolality allows for assessment of concentrating ability of
urine tubules.
○ A urinary osmolality higher than 600 mOsmol/kg of water implies a normal
concentrating ability of tubules.
● A normal urine pH indicates that the distal renal tubule is intact. Examples :
○ In ATN due to tubular injury, urine pH is > 5.5 whereas urine pH is normal (4-5)
in pre-renal AKI.
○ The alpha intercalated cell in the collecting duct is the main acidification
machinery in the kidney. So, when the distal part of the nephron is affected due to
distal RTA, the acidosis is more severe when compared to proximal RTA. Further,
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H+ cannot be excreted in the urine in distal RTA and hence urine pH is >5.5. But
urine pH is normal in proximal RTA.
C. Urine analysis
Urine dipstick can be used to identify the following
● Glucose - positive in proximal RTA, diabetes mellitus etc.
● Ketones - positive in DKA
● Bilirubin - positive in conjugated hyperbilirubinemia
● Urobilinogen
○ Increased in extravascular haemolysis
○ Absent in complete obstruction of the biliary tree
● Leukocyte esterase and nitrite may indicate UTI
● Protein
● Haematuria
Urine Protein
● Urine dipstick detects only albumin. Other proteins (eg. light chains excretion in multiple
myeloma) are not detected by dipstick.
○ The results are expressed as - negative, trace, 1+, 2+, 3+ and 4+
○ 1+ albuminuria roughly corresponds to a urinary loss of 800 mg/day and 2+
roughly corresponds to 2000 mg/day (normal urine albumin excretion is <30
mg/day)
● The best test to look for proteinuria will be 24 hours urine protein.
○ A value of >500 mg/24 hours is significant proteinuria in adults.
○ In children, a value of >4 mg/m2/hour is considered abnormal and >40
mg/m2/hour indicates nephrotic range proteinuria.
● An alternative to the cumbersome 24 hour testing would be urine spot protein creatinine
ratio. In children, a value of <0.2 mg/mg is considered insignificant, >0.2 mg/mg is
significant proteinuria and >2 mg/mg indicates heavy proteinuria.
Workup of haematuria
● If 100 patients test positive for blood by urine dipstick :
○ 90% patients usually have urological cause eg. urolithiasis, Wilm’s tumour
○ 9% patients have a medical renal cause eg. glomerular hematuria
○ 1% patients have a haematological cause eg. intravascular haemolysis due to
paroxysmal cold haemoglobinuria, paroxysmal nocturnal haemoglobinuria etc.
● If the dipstick is positive for blood, the next step is urine centrifugation at 1600-2000 rpm
for 5 minutes.
○ After centrifugation, if the urine is still high coloured, then it indicates that the
cause of high coloured urine is haemoglobin (intravascular haemolysis) or
myoglobin (eg. rhabdomyolysis)
○ After centrifugation, if the supernatant becomes clear, then the cause for high
coloured urine is RBCs (RBCs settle down at the bottom). Now check under a
microscope to see if the “40-5-1 rule” is satisfied.
■ If the 40-5-1 rule is satisfied, then it is a glomerular haematuria. The rule
is satisfied if any one of these three are present
● > 40% dysmorphic RBCs
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● > 5% acanthocytes
● > 1 RBC cast
■ If all three are negative, then it is non-glomerular haematuria, which
usually indicates a urological cause.
Urine microscopy
● Urine RBCs
○ > 5 RBCs/hpf in a centrifuged specimen indicates microscopic haematuria. Urine
colour may be normal in microscopic haematuria.
● Urine WBCs
○ Isolated presence of WBCs does not confirm UTI. Presence of any bacteria/hpf in
fresh uncentrifuged urine is strongly suggestive of UTI, however.
● Casts in urine
○ Casts are formed in the DCT.
○ Matrix of the cast is formed by Tamm Horsfall protein.
○ RBC cast is seen in glomerular haematuria eg. IgA nephropathy.
○ WBC cast is seen in acute pyelonephritis, acute tubular necrosis(ATN), acute
interstitial nephritis (AIN) and post streptococcal glomerulonephritis.
○ Eosinophil cast is seen in ATN and AIN. But WBC casts and eosinophil casts are
not specific for ATN/AIN because they need not always be present in these cases.
○ Renal tubular epithelial cast is specific for tubulointerstitial injury (ATN/AIN).
○ Fatty cast is seen in nephrotic syndrome and Fabry’s disease.
○ Broad waxy cast is seen in CKD.
● Crystals in urine
Shape of the crystal Cause
○ Rhomboid Uric acid
○ Dumbbell Calcium oxalate monohydrate
○ Envelope Calcium oxalate dihydrate
○ Star Calcium phosphate
○ Coffin lid Triple phosphate (magnesium-ammonium-phosphate)
○ Hexagon Cystine
○ Cholesterol Nephrotic syndrome
○ Broom brush Amoxicillin
13. Benign orthostatic proteinuria

● ~70% of proteinuria in adolescents is attributed to benign orthostatic proteinuria
● Pathogenesis is not clear; may be mediated by hemodynamic mechanism in upright
posture
● Low grade proteinuria (< 1 gram per day)
● Diagnosed by sequential urine spot PCR examinations
○ Spot PCR < 0.2 in the first voided sample collected early in the morning
○ Higher than normal spot PCR on subsequent samples in the day
● Management
○ Benign condition; reassurance
○ Annual follow up of – urine PCR, blood pressure and anthropometry
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14. Minimal change disease pathogenesis

● The glomerular capillary endothelium, glomerular basement membrane and podocyte slit
diaphragm together form the filtration barrier in the glomerulus. These three components
maintain electronegativity due to the presence of podocalyxin and heparan sulphate in
them. It is important for the filtration barrier to be negatively charged to repel albumin,
which is also negatively charged. If the negative charge is lost in either component of
the filtration barrier, then it cannot repel albumin and this leads to albuminuria.
● In minimal change disease, there is increased expression of CD80 and
angiopoietin-like-4 peptide on the podocytes. This leads to a loss of negative charge in
the podocytes and hence albumin cannot be effectively repelled, leading to albuminuria.
● Electron microscopy shows effacement and fusion of the foot processes of podocytes.
There is no podocytopenia.
● Secondary causes of minimal change disease
○ Allergy - allergic rhinitis, atopic dermatitis, post vaccine, pollen allergy
○ Drugs - NSAID, interferon alpha, lithium
○ Malignancy - Hodgkin lymphoma, CLL, cutaneous T cell lymphoma
15. Renal biopsy in nephrotic syndrome

Indications
1. 90-95% of children with nephrotic syndrome have minimal change disease (MCD). So,
biopsy is not indicated at presentation for typical cases (children between 2-7 years
without hypertension, decreased GFR and haematuria). The following atypical cases will
need a biopsy, as these indicate that the cause of nephrotic syndrome is not MCD.
a. Extremes of age - infancy and adolescence
b. Presence of hypertension
c. Presence of haematuria
d. Increased serum creatinine
2. Persistence of albuminuria despite four weeks of steroids (SRNS) in children is an
indication for renal biopsy.
Pre-procedural assessment of the patients
1. Platelet, PT/INR
2. Bringing BP to normal level for age
3. If creatinine is very high, then dialysis may be indicated to reduce the risk of uremic
bleed
4. Size and location of kidneys confirmed by radiologist with USG
Complications
1. Gross haematuria in 10% cases, but it resolves over 24 hours.
2. Perinephric hematoma
Possible findings on the renal biopsy in a child with nephrotic syndrome
1. MCD
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a. Normal light microscopy (LM)

b. But there is effacement and fusion of the foot process of podocytes on electron
microscopy (EM). There is no podocytopenia.
2. FSGS
a. On LM, there is focal involvement (<50% of total glomeruli involved) and
segmental involvement (the involvement in each affected glomeruli is patchy or
partial i.e. <50%). Example : out of the 25 glomeruli available on the renal biopsy
sample, only 8 glomeruli (<50% of 25) are affected. Also the involvement in the 8
affected glomeruli are 5%, 10%, 15%, 20%, 25%, 30%, 35% and 40% (all are
<50% involvement). The involvement is in the form of accumulation of
eosinophilic hyaline material which occludes part of the glomeruli (sclerosis).
This causes occlusion of that part of the glomeruli.
b. On EM, there is effacement and fusion of the foot process of podocytes similar to
MCD. However, there is podocytopenia occurring in FSGS.
3. Membranous nephropathy
a. Capillary wall thickening is noted on LM
b. There are subepithelial deposits on EM, and the GBM is trying to protrude in
between these deposits, causing the famous “spike” pattern. There is effacement
and fusion of the foot process of podocytes similar to MCD. However, there is
podocytopenia occurring here, like FSGS.
4. Membranoproliferative glomerulonephritis (MPGN)
a. There is capillary wall thickening on LM, similar to membranous nephropathy.
But there is also cellular proliferation (hypercellularity of mesangial cells and
endocapillary cells) occurring here.
b. There are subendothelial deposits on EM, and these deposits cut the GBM into
two halves, causing the famous “tram track appearance”.
16. Erythropoietin
Erythropoietin (EPO) is a glycoprotein with 165 amino acids and 4 heavily sialylated
carbohydrate chains. EPO is produced by the peritubular interstitial fibroblasts in the renal cortex
and outer medulla.
Role of EPO in erythropoiesis

PPHSC (Pluripotent haematopoietic stem cells)
EPO and iron independent
BFU-E (Blood forming unit - erythroid)
EPO dependent, iron independent
CFU-E (Colony forming unit - erythroid)
EPO and iron dependent
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Erythroblast
Reticulocyte
RBC
Stimulation of EPO
Tissue hypoxia due to anaemia
Hypoxia inducible factor (HIF) alpha forms a dimer with HIF beta
HIF alpha-HIF beta dimer activates the EPO gene
Increased EPO production
Applied aspects
The main indication for EPO is in CKD patients with anaemia.
● In CKD, there is a disturbed oxygen-sensing mechanism. Hence the production of EPO in
CKD patients is inappropriately low for the degree of anaemia and tissue hypoxia in
them.
● In addition, the chronic inflammation in CKD activates hepcidin.
● Plus there are several uremic toxins in these patients which are inhibitors of
erythropoiesis.
● But the most important cause for anaemia in CKD patients is iron deficiency. Iron
deficiency can be due to anorexia, impaired iron absorption and uremic blood loss.
So always rule out iron deficiency before starting EPO in CKD patients with anaemia. Serum
ferritin >500 ng/mL plus transferrin saturation > 30% indicates that there is no iron
deficiency in a CKD patient with anaemia. This patient may be started on EPO therapy. If
serum ferritin <500 ng/mL or transferrin saturation <30%, then it is iron deficiency
anaemia and hence iron deficiency must be treated first before considering EPO.
Initiating EPO therapy : EPO is usually started at 50-100 units/kg/week and can go upto 300
units/kg/week.
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If the EPO requirement is >300 units/kg/week, then rule out the following :
● Iron deficiency
● Inadequate dialysis (uremic inhibitors of erythropoiesis are not being removed
efficiently)
● Chronic inflammation (eg. due to indwelling haemodialysis catheter infection etc.)
Contraindications of EPO
● Malignancy
● Stroke
17. Abnormal types of bladder

Nerve supply of bladder
● Parasympathetic efferent fibres – Pelvic nerve (S2 to S4)
○ Causes contraction of detrusor
○ Promotes voiding of urine
● Sympathetic efferent fibres – Hypogastric nerve (T11 to L2)
○ Causes relaxation of detrusor and contraction of internal urethral sphincter
○ Promotes urinary retention
● Somatic fibres – Pudendal nerve (S2 to S4)
○ Innervates external urethral sphincter (provides voluntary control over
micturition)
● Sensory nerves
○ Sensations from bladder (distension, pain) are carried mainly by parasympathetic
nerves (pelvic nerve) to sacral cord segments (S2 to S4).
○ Pain sensation from the bladder ascends in the spinal cord through the lateral
spinothalamic tract. Awareness of bladder distension travels through the posterior
column.
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Micturition reflex
Filling of urinary bladder
Stimulation of stretch receptor
Afferent impulse via pelvic nerve
Sacral segment of spinal cord
Efferent impulse via pelvic nerve
Contraction of detrusor and relaxation of internal sphincter
Voiding of urine
Applied aspects - Abnormal bladder types

● Autonomous bladder
○ It is also known as flaccid bladder or LMN type of bladder
○ It is seen in injury to spinal cord segments S2 S3 S4 eg. conus medullaris lesion
○ Awareness of bladder filling is lost and micturition reflex is absent
○ Bladder becomes flaccid and it is without any external reflex control. In other
words, bladder has become autonomous (acts independently)
○ Bladder fills to capacity and then overflows
● Automatic bladder
○ It is also known as spastic bladder or UMN type of bladder
○ It is seen in injury to spinal cord segments above S2 eg. T8 level intramedullary
cord compression
○ Awareness of bladder filling is intact and micturition reflex is present
○ However, voluntary inhibition of the micturition reflex (control by the higher
brain centres) will be lost
○ There is detrusor overactivity. So when the bladder reaches a certain volume,
suddenly the detrusor contracts (automatically) and this forces open the sphincters
and the patient voids unexpectedly.
18. Development of the urinary bladder and urethra

● The entire urogenital system develops from two structures - intermediate mesoderm and
cloaca
● Cloaca gives rise to primitive rectum and primitive urogenital sinus
● Primitive urogenital sinus forms two structures - vesicourethral canal (VUC) and
definitive urogenital sinus (DUS)
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Cloaca
Primitive urogenital sinus Primitive rectum
Vesicourethral canal (VUC) Definitive urogenital sinus (DUS)
Urinary Prostatic urethra Pelvic part of DUS Phallic part of DUS
bladder upto the opening Rest of the prostatic Spongy urethra
of ejaculatory duct urethra and also
membranous urethra
● In females, the urethra is formed from the VUC and pelvic part of DUS. The phallic part
of DUS gives rise to the vestibule.
● The lower portion of mesonephric ducts become incorporated into the posterior wall of
bladder to form trigone
Applied aspects – bladder exstrophy, urachal fistula (when a remnant of allantois persists)
19. Development of kidney
● Intermediate mesoderm gives rise to three structures - urogenital ridge, mesonephric duct
and paramesonephric duct.
● The lateral portion of the urogenital ridge is nephrogenic cord. The nephrogenic cord is
aligned close to the mesonephric duct.
● The nephrogenic cord forms the pronephros in the 4th week gestational age, which soon
regresses. Later in the 4th week, the nephrogenic cord forms the mesonephros, but this
also regresses by the 16th week.
● During the 5th week, two important structures are formed, namely :
○ Nephrogenic cord forms the metanephric blastema (which gives rise to the
excretory part of the nephron)
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○ Mesonephric duct forms the ureteric bud (which gives rise to the collecting
system of the nephron)
● In between the 6th and 8th week, there occurs an important process called “epithelial
mesenchymal interaction (EMI)”. It is an interaction occurring between the epithelium of
the ureteric bud and the mesenchyme of the metanephric blastema. EMI leads to the
formation of the first nephron by the end of 8th week. The first urine is formed by the 9th
week. Nephrogenesis is completed by 32-36 weeks.
Applied aspects
1. Genes involved in the process of EMI are PAX2, WT1, FGF etc. Defects in these genes
lead to renal agenesis.
2. Nephrogenesis ends by 36 weeks and there are no new nephrons being formed after birth.
This means that the final number of nephrons in each kidney is established at birth.
Studies have demonstrated that SGA babies (birth weight <10th percentile) have lesser
nephrons at birth and hence smaller kidneys. This is called “nephron underdosing” and
it is a risk factor for developing hypertension and CKD in later life.
20. Development of female reproductive system
The medial portion of the urogenital ridge is gonadal ridge.
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Intermediate mesoderm
Urogenital ridge
Gonadal ridge (medial portion of the urogenital ridge)
Primary sex cords formed
Primordial germ cells migrate from the yolk sac to the primary sex cord in the 5th week
Secondary sex cords formed
The primary sex cords eventually degenerate
The primordial germ cells undergo mitosis and then there occurs an arrest in meiotic prophase I.
This germ cell is now called primary germ cell (primary oocyte) and the primary oocytes are
situated inside primary follicles. A baby girl is born with 1-2 million primary follicles.
Paramesonephric ducts form the uterine tubes, uterus, cervix and the vagina.
20. Development of male reproductive system

● Both male and female gonads actually develop from a bipotential gonad. This means
that the initial few steps are identical in both genders i.e. till the migration of primordial
germ cells from yolk sac to primary sex cord.
● Presence of the SRY gene on the Y chromosome of a foetus upregulates the levels of
SOX9 and this in turn leads to :
○ Formation of Sertoli cells (which secrete mullerian inhibiting factor and also
provide the required support and nutrition to the germ cells to undergo
spermatogenesis). The germ cells and the Sertoli cells together form the
seminiferous cords.
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○ In a foetus without a Y chromosome (due to the absence of SOX9) the supporting

cells would have differentiated into follicle cells (which house the primary
oocytes).
○ The mesoderm in between the seminiferous cords give rise to the interstitial cells
of Leydig, which in turn secrete testosterone.
● The seminiferous cords acquire a lumen at puberty and then they are called seminiferous
tubules.
● The descent of testes occurs as a result of

○ Disproportionate growth of upper abdominal region away from pelvic region
○ Gubernaculum pulling the caudal pole of testes to the scrotum
● Mesonephric ducts form the epididymis, ductus deferens, seminal vesicles & ejaculatory
duct
22. Development of external genitalia

Proliferation of mesoderm around the cloacal membrane causes the overlying ectoderm to rise
up, so that three structures are visible externally – phallus (also called genital tubercle),
urogenital folds (also called urethral folds) and labioscrotal swellings.
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Structure Fate in boys Fate in girls

Phallus Glans penis Clitoris
Corpora cavernosa Corpora cavernosa
Corpus spongiosum Vestibular bulb
Urogenital fold Ventral aspect of penis (penile raphe) Labia minora
Labioscrotal swelling Scrotum Labia majora

Mons pubis
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CARDIOLOGY
1. Heart tube
The heart is at first seen in the form of a heart tube that has five dilatations
Name of the dilatation Fate
Truncus arteriosus Ascending aorta, pulmonary trunk
Bulbus cordis Smooth upper part of RV and LV
Primitive ventricle Trabeculated part of RV and LV
Primitive atrium Trabeculated part of RA and LA
Sinus venosus Smooth part of RA, coronary sinus
2. Formation of atrioventricular septum
The atrioventricular (AV) canal is initially circular in shape and later becomes transverse
Two thickenings (AV endocardial cushions) appear on the dorsal and ventral walls of AV canal
The AV endocardial cushions grow towards each other and fuse
The fused cushions form the AV septum, which is also known as “septum intermedium”
Round AV Canal becomes Dorsal & ventral Right Left
canal transverse AV cushions appear orifice orifice
Applied aspects : Endocardial cushion defect, tricuspid atresia
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3. Formation of the inter atrial septum
Septum primum grows down from the superior wall
Before the septum primum reaches and fuses with the AV endocardial cushions, blood flows
through the gap between them (this gap is ostium primum)
Before the septum primum fuses with the endocardial cushions and ostium primum is closed, the
upper part of the septum primum breaks down to form ostium secundum (so that blood can keep
flowing from RA to LA in the foetus)
A second septum (septum secundum) grows down from the superior wall. Septum secundum lies
to the right of septum primum. Septum secundum grows downward, but stops before reaching
the endocardial cushions. This ensures that most of the ostium secundum is covered by the
septum secundum, but a small gap is left behind. This gap is known as foramen ovale and this
remains patent throughout the foetal life for blood to flow from RA to LA
At birth, when pressure in the LA increases, septum primum and septum secundum press against
each other and close the foramen ovale. This process gets completed at around three months of
age
Applied aspects
Ostium primum ASD : Septum primum fails to fuse with the endocardial cushions
Ostium secundum ASD : Due to either excessive resorption of septum primum or
underdeveloped/reduced size of septum secundum
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4. Formation of the great arteries
● The distal half of bulbus cordis (known as conus), forms the outflow tract of both
ventricles
● Two septa are formed in the conus – proximal and distal bulbar septa
○ Proximal bulbar septum contributes to formation of interventricular septum
○ Distal bulbar septum separates the conus into aortic vestibule and infundibulum
● Truncus arteriosus undergoes division by spiral aortopulmonary septum into ascending
aorta and pulmonary trunk
● The spiral aortopulmonary septum is formed by union of truncal ridges and bulbar ridges,
which are in turn derived from neural crest cells
● Orientation and fusion of these ridges take place in such a manner, that at the proximal
part of the spiral septum, the pulmonary trunk lies anterior to the aorta, and in the
intermediate aspect of the spiral septum, the pulmonary trunk is on the left side and aorta
is on the right side, and at the distal part of the spiral septum, aorta lies anterior to the
pulmonary trunk
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The arch of aorta is formed from :

● Left horn of aortic sac
● Left fourth arch artery
● Left dorsal aorta
The pulmonary arteries are formed:

● from the left and right sixth arch arteries.
Applied aspects
○ Persistent truncus arteriosus
■ Failure of formation of spiral aortopulmonary septum
○ Transposition of great arteries
■ If the aortopulmonary septum is not aligned in a spiral fashion, then the
great arteries are also not spirally aligned, and they open into the opposite
ventricles
○ Fallot’s tetrad
■ It occurs when the aortopulmonary septum fails to align properly with the
interventricular septum
5. Formation of the interventricular septum
Interventricular septum (IVS) has three parts – muscular, bulbar and membranous IVS
○ Muscular IVS
■ Develops as an outgrowth of the muscular wall in the floor of the
primitive ventricle. This outgrowth grows up towards the AV endocardial
cushions, but does not join with it and hence creates the interventricular
foramen, leaving the septum incomplete.
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○ Bulbar IVS
■ The fusion of the right and left bulbar ridges in the conus forms the
proximal bulbar septum.
■ The proximal bulbar septum grows downward towards the muscular IVS,
but does not join with it.
○ Membranous IVS
■ The interventricular foramen and the gap between the upper edge of
muscular IVS and the lower edge of bulbar IVS are filled up by
proliferation of tissue from the AV endocardial cushions and right and left
bulbar ridges
Applied aspects
○ If these three components fail to fuse, it may result in ventricular septal defect. It
occurs commonly in the membranous part of the IVS
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6. Endocardial Cushion Defect (ECD)
● Embryology
○ During foetal life, the endocardial cushion tissue contributes to the closure of both
the lower part of the atrial septum (i.e. ostium primum) and the upper part of the
ventricular septum, in addition to the formation of the mitral and tricuspid valves.
○ The failure of normal development of this tissue may be either complete or
partial. In partial ECD, an ostium primum ASD is present, associated with a
mitral valve cleft. Ostium primum ASD, inlet VSD and clefts in the mitral and the
tricuspid valve leaflets are all present in complete ECD.
● Haemodynamics of partial ECD
○ It is similar to ostium secundum ASD, in which the RA and RV are dilated with
increased pulmonary blood flow. The cleft mitral valve is insignificant because
blood regurgitated into the LA is immediately shunted to the RA, thereby
decompressing the LA
● Haemodynamics of complete ECD
○ It is the sum of the changes seen in ASD and VSD. There is volume overload of
the LA and LV as in VSD and partially due to MR. In addition, it has volume
overload of the RA and RV as in ASD. The result is biatrial and biventricular
enlargement. The magnitude of the left to right shunt is determined by the level of
pulmonary vascular resistance.
Clinical features
● Partial ECD
○ The clinical features are similar to ostium secundum ASD.
○ These patients are asymptomatic during childhood.
○ Findings :
■ Wide fixed split S2
■ Systolic ejection murmur at the upper left sternal border
■ Systolic murmur of MR
■ Mid diastolic murmur of relative tricuspid stenosis
● Complete ECD
○ 70% of children with complete ECD have Down syndrome. 50% of the cardiac
defects found in Down syndrome patients are ECD.
○ Children with complete ECD develop heart failure 1-2 months after birth and
recurrent pneumonia is common.
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○ Findings :
■ Hyperactive precordium
■ Systolic murmurs of VSD and MR
■ Loud and narrowly split S2 because of pulmonary hypertension
● ECG
○ Superior QRS axis is characteristic of ECD.
○ Evidence of RV hypertrophy in partial ECD
○ Evidences of biventricular hypertrophy and biatrial hypertrophy in complete ECD
● Management
○ Partial ECD
■ Device closure cannot be done. Elective intracardiac repair can be
performed in asymptomatic children between 2-4 years of age. If
symptomatic, surgery can be performed earlier.
○ Complete ECD
■ PA banding in early infancy is no longer done. Most centres perform
intracardiac repair between 2-4 months of age.
7. Foetal circulation
Placenta
Oxygenated blood
Umbilical vein
Ductus venosus
IVC
Right atrium
Right ventricle Foramen ovale (major)
Pulmonary artery
PDA (major) Lung
Pulmonary vein
Left atrium
Left ventricle
Aorta
Umbilical artery with deoxygenated blood
Placenta
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Changes in foetal circulation after birth

● The primary change in circulation after birth is a shift of blood flow for gas exchange
from the placenta to the lungs.
● The removal of placenta results in the following :
○ An increase in overall systemic vascular resistance because the low-pressure
placenta circuit has been removed.
○ Cessation of blood flow in the umbilical vein results in closure of the ductus
venosus.
○ Placenta produces PGE2 to keep the ductus arteriosus patent and after birth the
placental supply of PGE2 is terminated.
● Lung expansion results in the following :
○ A reduction in pulmonary vascular resistance which leads to an increase in
pulmonary blood flow.
○ Functional closure of the foramen ovale as a result of increased pressure in the LA
in excess of the pressure in the RA. The RA pressure falls as a result of closure of
the ductus venosus.
○ Closure of patent ductus arteriosus as a result of increased arterial oxygen
saturation.
8. Cardiac cycle
Atrial systole
● At the end of the reduced filling phase (last step mentioned in this question), 70%
of the ventricles is already filled with blood. For emptying the remaining 30%
blood, the atria has to contract.
● If the ventricles are stiff due to impaired relaxation (ventricular diastolic
dysfunction eg. AS, HCM), then the atria contracts forcefully to fill the ventricles.
This causes S4.
Isovolumetric contraction
● To eject blood into aorta and PA, ventricles must open the semilunar valves
● Pressure inside a totally relaxed ventricle at the end of diastole is zero mm Hg.
But the pressure inside the aorta is 80 mm Hg.
● To open the semilunar valves, ventricles starts contracting and the pressure inside
the ventricle increases
● When the ventricular pressure exceeds the atrial pressure, AV valves close to
prevent regurgitation from the ventricles to the atria. (S1 heard)
● Now the ventricles contract against closed valves, and so the ventricular volume
will not change (isovolumetric contraction)
● Once the left ventricular pressure reaches above 80 mm Hg, the aortic valve opens
(similarly the pulmonary valve also opens)
Rapid ejection
● Once semilunar valves are opened, ventricles eject blood rapidly
Reduced ejection
● Ventricular pressure starts decreasing and ejection slowly falls
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Protodiastole
● Ventricular pressure becomes less than that of the aorta and PA. This causes
closure of semilunar valves to prevent regurgitation from the great arteries to the
ventricles (S2 heard).
Isovolumetric relaxation
● All 4 valves are closed. Pressure inside ventricles falls even more without change
in ventricular volume (isovolumetric relaxation)
● Once ventricular pressure falls below atrial pressure, AV valves open
Rapid filling
● Opening of AV valves leads to rapid filling of ventricles
● This rapid inflow of blood vibrates ventricular walls and causes S3
Reduced filling
● Rate of ventricular filling declines
9. Clinical significance of S2
● At the end of the ventricular systole, during the protodiastole phase, the ventricular
pressure becomes less than that of the aorta and PA. This causes closure of semilunar
valves to prevent regurgitation from the great arteries to the ventricles.
● Aortic pressure is higher than PA pressure and the distensibility of the aorta is also lesser
than that of the PA. Hence the aortic valve closes first (A2) followed by closure of the
pulmonary valve (P2). Further, A2 is normally louder than P2.
● The normal A2-P2 gap is 30 milliseconds. This is hard to appreciate. On asking the
patient to take a deep breath (inspiration), with increased venous return, the A2-P2 gap
can go upto 40-50 msec and may be appreciated. So, normally A2-P2 split cannot be
heard in expiration and is heard only in inspiration.
Applied aspects
● Loud P2 is heard in pulmonary hypertension. Soft P2 is heard in PS.
● In calcific AS, the A2 is soft. But in AS due to bicuspid aortic valve, there is no valve
degeneration like calcific AS. So the A2 can be louder here.
● In AR due to valve pathology (eg. RHD), the A2 is soft. But in AR due to aortic root
pathology (eg. syphilitic AR), the A2 is louder.
● Wide variable splitting of S2 : A2 occurs first, followed by P2. The split can be heard in
both inspiration and expiration. This can occur due to either early closure of A2 or
delayed closure of P2.
○ Early closure of A2 occurs because the LV blood escapes into the RV or the LA
instead of going into the aorta. The causes are VSD and severe MR.
○ Delayed closure of P2 occurs because it is difficult for the RV to pump out blood.
The causes are PS and pulmonary hypertension.
● Wide fixed split : here the ability of the right heart to accommodate the increased venous
return associated with inspiration is lost. So the variability of A2-P2 occurring with
respiration is lost. It is seen in RV failure and ASD.
● Paradoxical (or reverse) split S2 : here P2 occurs first, followed by A2. The split is heard
only during expiration and not during inspiration. This can occur due to either early
closure of P2 or delayed closure of A2.
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○ Early closure of P2 occurs because the RV blood escapes into the RA instead of
going into the PA. It is seen in severe TR.
○ Delayed closure of A2 occurs because it is difficult for the LV to pump out blood
due to obstruction occuring in conditions like severe AS and HCM. It may also be
seen when the LV contains excess blood as in severe AR, which takes longer
duration to pump out.
10. JVP
● Jugular venous pressure (JVP) assesses the right heart dynamics and the relationship of
the right heart to the venous system.
● Measurement of JVP
The patient is made to lie supine and a bed rest is applied at 45 degrees. The topmost
point of the IJV pulsations is normally at a height of 3 cm from the sternal angle and the
sternal angle is considered to be at a distance of 5 cm from the RA.
● Causes of JVP elevation
1. Increase in the effort needed to fill RV eg. RV failure, pulmonary hypertension,
conditions with diastolic dysfunction like RCM and CCP
2. Increase in RA pressure eg. TS
3. Circulatory overload eg. renal failure, cirrhosis with portal hypertension and
ascites
Jugular venous pulse (JVP) waveforms
a – right Atrial contraction
c – Carotid artery impact; tricuspid valve ascends
x – right atrial relaXation
v – Venous filling into right atrium
y – emptYing of right atrium
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Abnormalities in the JVP waveforms
1. Absent a waves in case of no effective atrial contraction eg. AF

2. Large a waves are seen due to an increase in RA pressure (eg. TS) and in conditions
which produce an increase in the effort needed to fill RV (eg. pulmonary hypertension).
3. Cannon a waves are seen when the RA contracts against a closed tricuspid valve, i.e. both
atria and ventricles are contracting simultaneously eg. complete heart block, AVNRT
4. Absent x descent in case of inability of RA to relax in atrial diastole due to regurgitant
blood entering from RV i.e. TR. Furthermore, TR also produces a tall v wave as RA is
filling from both sides i.e. SVC and RV. The combination of an absent x descent with a
tall v wave in TR merges the c and v waves, and this is known as ‘cv wave’.
5. Prominent x descent
This is seen due to three conditions producing severe diastolic dysfunction namely RCM
(restrictive cardiomyopathy), CCP (chronic constrictive pericarditis) and CT (cardiac
tamponade). Due to the severe diastolic dysfunction, filling of the cardiac chambers with
blood cannot occur in diastole as the chambers cannot expand freely. Hence filling can
occur only during ventricular systole, and systole is normal in these patients. So the x
descent is prominent due to the prominent cardiac filling occurring in the ventricular
systolic phase.
6. Absent y descent
In CT and RCM, there is no ventricular filling occurring in the diastole. Hence there is
absent y descent in both these conditions.
7. Prominent y descent
In CCP, the degree of diastolic dysfunction is probably not as severe as in RCM and CT.
Ventricular filling does occur during the early one-third of the ventricular diastole. After
the early one-third of the diastole, there is elevation and equalisation of pressures in all
four chambers due to the pericardial pathology. Hence the RA blood has to rapidly empty
within the early one-third of the ventricular diastole. This rapid emptying of blood from
the RA into the RV during the early one-third of the ventricular diastole produces the
prominent y descent in CCP.
8. Slow y descent is seen due to an obstruction impairing the atrial emptying eg. TS
11. Cardiac conduction system
Impulses originate from the SA node because the pacemaker potential of the SA node has the
highest slope and also because the intrinsic firing rate of the SA node is higher than the others
SA node depolarises the atria and it is seen on the ECG as the P wave
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AV node
Bundle of His
Right and left bundle branches
Purkinje fibres
Ventricular depolarisation occurs. It is seen as the QRS complex on the ECG. This is followed by
ventricular repolarisation, and this is seen as the T wave on the ECG.
Applied aspects
1. SA node dysfunction (eg. due to sick sinus syndrome) can initially manifest as sinus
bradycardia. Later when the SA node rate is too low, the AV node can take over
producing a junctional rhythm (AV node is the junction).
2. Supraventricular tachycardia has been discussed as the next question.
3. Sometimes an aberrant pathway can exist which provides an alternative circuit for the
electrical impulses to travel between the atria and ventricles. An example is Wolff
Parkinson White syndrome, in which the aberrant pathway is the bundle of Kent.
4. AV node dysfunction leads to heart blocks - first, second and third degree blocks.
5. Blocks can occur at the right and left bundle branches producing RBBB and LBBB.
6. In abnormal hearts (eg. post MI with scar) or due to dyselectrolytemia or due to
congenital conditions like long QT syndrome, ventricular tachycardias can occur.
12. Physiology of supraventricular tachycardia
Supraventricular tachycardia (SVT) is a general term that refers to any rapid heart rhythm
originating above the ventricular tissue.
Mechanisms
● The majority of SVTs are caused by re-entry. Examples include atrioventricular nodal
re-entry tachycardia (AVNRT) and atrioventricular re-entry tachycardia (AVRT).
● The other mechanism is enhanced automaticity. Examples include atrial tachycardia and
junctional tachycardia.
AVNRT
● In a normal person, there are two pathways in the AV node :
○ Fast pathway - conducts faster, but it has a longer refractory period
○ Slow pathway - conducts slower, but it has a shorter refractory period
● The impulse from the SA node reaches the AV node and travels down by both the fast
and slow pathways. But the conduction in the fast pathway is faster and hence the
fast-pathway-impulse reaches the ventricle first and activates the ventricle. A portion of
the fast-pathway-impulse goes back via the slow pathway and meets the
slow-pathway-impulse and both get neutralised.
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● In AVNRT, a perfectly timed ectopic PAC (premature atrial complex) impulse enters the
AV node. But the fast pathway is still in its refractory period after conducting the
previous normal impulse (from the SA node). So the PAC impulse enters the slow
pathway as it has a shorter refractory period. The slow-pathway-impulse reaches the
ventricle and activates it. By this time the fast pathway has completed its refractory
period and is ready to conduct. So, a portion of the slow-pathway-impulse goes back via
the fast pathway and activates the atria in a retrograde manner. This sets up the re-entry.
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● The retrograde activation of the atria through the fast pathway produces a P wave on the
ECG. But it is being produced at the same time as ventricular depolarisation. So, the P
waves are buried inside the QRS waves. That is why P waves are usually not seen in
AVNRT.
AVRT
● AVRT is the most common tachyarrhythmia seen in the paediatric age group.
● AVRT occurs in the setting of Wolff Parkinson White (WPW) syndrome. In WPW
syndrome, there exists a bypass tract (accessory atrioventricular conduction pathway)
between the atria and ventricles, known as the bundle of Kent.
● In AVRT, a perfectly timed ectopic PAC impulse enters the AV node. The AV node
conducts the impulse in an antegrade manner and it activates the ventricles. But the
impulse also travels back through the bundle of Kent and activates the atria (retrograde
activation of atria). This sets up the re-entry.
Closing remarks
● Both AVRT and AVNRT usually present with narrow QRS complex tachycardia and it
may occasionally be difficult to distinguish between the two on the ECG. But the
treatment for both the conditions are the same i.e. adenosine in haemodynamically stable
patients and synchronised DC cardioversion in unstable patients. Once the patient reverts
to sinus rhythm, then the ECG can reveal classical features of WPW syndrome like short
PR interval and delta waves. And the final diagnosis can be retrospectively made as
WPW syndrome with AVRT. All WPW syndrome patients will need Holter monitoring
and a cardiology consultation prior to discharge.
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13. Innocent murmurs
Innocent murmurs arise from cardiovascular structures in the absence of anatomic abnormalities.
More than 80% of children have innocent murmurs of one type or another sometime during
childhood.
A. Still’s murmur (classic vibratory murmur)

● Common age group : between 3-6 years of age
● Best heard at : mid left sternal border
● Nature : low frequency midsystolic murmur of grade 2 to 3 best heard with the bell of the
stethoscope in supine position. It is a vibratory sound with a musical character. There is
no thrill or ejection click
● Mechanism : it is generated by vibrations of normal intracardiac structures (eg.
pulmonary valve leaflets) during systole
● How to differentiate from VSD : VSD murmur is harsh, pansystolic and often
accompanied by a thrill
B. Pulmonary flow murmur of childhood

● Best heard at : upper left sternal border
● Nature : midsystolic murmur of grade 1 to 3 with a grating quality (not vibratory quality)
without radiation. There is no associated thrill or ejection click. S2 is normal
● Mechanism : it represents an exaggeration of normal ejection vibrations within the
pulmonary trunk
● How to differentiate from pulmonary valve stenosis : in pulmonary valve stenosis, there
may be an ejection click, systolic thrill and widely split S2
● How to differentiate from ASD : Wide fixed split S2 in ASD
C. Pulmonary flow murmur of newborn

● Common age group : newborn babies, especially preterm babies
● Best heard at : upper left sternal border
● Nature : midsystolic murmur of grade 1 to 2 which transmits well to the right and left
chest, both axillae and back. There is no ejection click
● Mechanism : blood flow through the small branches of the pulmonary arteries produces
turbulence
● How to differentiate from organic PA stenosis : Pulmonary flow murmur of newborn
disappears by 3-6 months of age whereas the murmur of organic PA stenosis persists
beyond infancy. Further, organic PA stenosis is frequently associated with other cardiac
defects like VSD or Fallot’s tetrad and it is also often seen as a component of rubella
syndrome, Williams syndrome or Alagille syndrome with characteristic non-cardiac
findings
D. Venous hum
● Best heard at : right, left or both infraclavicular and supraclavicular areas
● Nature : continuous murmur of grade 1 to 3 in which the diastolic component is louder
than the systolic component. The venous hum is heard only in the upright position and
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disappears in the supine position. It can be obliterated by rotating the head or by gently
occluding the neck veins with fingers
● Mechanism : flow of blood causes the jugular vein walls to vibrate thereby creating a
humming noise
● How to differentiate from PDA : The PDA murmur is loudest at the upper left sternal
border or left infraclavicular area. It may be associated with bounding peripheral pulses.
Further, the systolic component is louder than the diastolic component
E. Carotid bruit
● Common age group : any age
● Best heard at : right supraclavicular area and over the carotids
● Nature : early systolic murmur of grade 2 to 3 with an occasional faint thrill over the
carotid. There is no ejection click
● Mechanism : bruit is produced by turbulence in the carotid arteries
● How to differentiate from AS : The AS murmur is louder at the upper right sternal border
and is often associated with a systolic thrill. Further, an ejection click is often present
14. Mechanism of cyanotic spell

● Because the VSD of Fallot’s tetrad is large enough to equalise systolic pressures in both
ventricles, the RV and LV may be viewed as a single chamber that ejects blood into the
systemic and pulmonary circuits.
● The ratio of pulmonary flow and systemic flow (Qp/Qs) is related to the pulmonary
vascular resistance (PVR) and systemic vascular resistance (SVR).
● If the PVR increases, it will increase the degree of the right-to-left shunt, producing
hypoxia. Similarly if the SVR decreases, it will again increase the degree of the
right-to-left shunt, producing hypoxia. Hypoxia leads to pulmonary vasoconstriction and
systemic vasodilation. Hence PVR increases and SVR decreases, which will again
increase the degree of the right-to-left shunt, producing even more hypoxia (hypoxia
begets hypoxia).
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● However there is no evidence that RVOT spasm occurs as the primary event in cyanotic
spells. It is more likely that SVR reduction occurs as the primary event and sets the ball
rolling. Crying, defecation and increased physical activity can reduce SVR and initiate a
cyanotic spell. In addition to decreased SVR, other causes such as excessive tachycardia
or hypovolemia can also increase the right-to-left shunt resulting in hypoxia.
● Hypoxia leads to acidosis and this stimulates the respiratory centre which produces
hyperpnea. The hyperpnea, in turn makes the negative thoracic pump more efficient and
this results in an increase in the systemic venous return to the RV. This leads to more
right-to-left shunting, which further worsens the hypoxia and hence establishes a vicious
cycle.
Management is directed at breaking this cycle by using the following

● Knee chest position to increase the SVR.
● Administration of oxygen may improve the oxygen saturation.
● Morphine to suppress the respiratory centre and abolish hyperpnea.
● Sodium bicarbonate to correct acidosis.
● Vasoconstrictors increase the SVR eg. phenylephrine
● Ketamine increases the SVR and also sedates the child.
● The role of propranolol in the acute setting is to reduce the heart rate and also to increase
SVR by antagonising the vasodilating effects of beta-2 receptors. Propranolol is also used
in the prophylaxis of cyanotic spells as it may stabilise the vascular reactivity of the
systemic arteries, thereby preventing a sudden decrease in SVR.
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15. Aschoff nodule
Swollen eosinophilic collagen surrounded by lymphocytes, giant cells and Anitschkow cells
(cells with caterpillar like chromatin) in myocardium in rheumatic fever
16. Fat embolism
● Causes
○ Fracture of long bones
○ Sickle cell anaemia
○ Pulmonary insufficiency
○ Neurological symptoms (CVA)
○ Petechial rash
● Investigations
○ Anaemia
○ Thrombocytopenia
○ Fat globules in urine
● Management
○ Supportive therapy
● Prevention
○ Early fixation of long bone fractures
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HEPATOLOGY
1. Bilirubin metabolism
Heme
Heme oxygenase
Biliverdin
Biliverdin reductase
Unconjugated bilirubin is formed and it is lipophilic and water insoluble. So it is bound to

albumin and then reaches the hepatocyte for conjugation
UDP glucuronyl transferase I (conjugation)
Conjugated bilirubin
Secretion of conjugated bilirubin into bile by active transport mechanism
Protein involved in this transport – Multidrug Resistance like Protein 2 (MRP2)
Conjugated bilirubin enters intestines and is then deconjugated (into urobilinogen and
stercobilinogen) by intestinal flora
80% of the deconjugated bilirubin 20% undergo enterohepatic circulation
is excreted in the faeces
A small fraction (urobilinogen) escapes
from the liver into the systemic circulation
and is then excreted in the urine
Applied aspects
1. In Crigler Najjar syndrome type I, there is severe unconjugated hyperbilirubinemia due to
complete absence of UDP glucuronyl transferase I activity.
2. In Crigler Najjar syndrome type II, there is moderate unconjugated hyperbilirubinemia
due to UDP glucuronyl transferase I activity being <10% of normal.
3. In Gilbert syndrome, there is mild unconjugated hyperbilirubinemia due to UDP
glucuronyl transferase I activity being around 30% of normal.
4. Conjugated hyperbilirubinemia is seen in Dubin Johnson syndrome due to MRP2
mutation.
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5. Urinary urobilinogen is increased in extravascular hemolysis due to excess heme

breakdown.
6. Urinary urobilinogen is absent in complete obstruction of the biliary tree.
2. Liver function test
● Tests of excretory function (serum bilirubin)

○ In hyperbilirubinemia, if the direct bilirubin (DB) is <15% of total bilirubin (TB),
then it indicates indirect hyperbilirubinemia eg. Gilbert syndrome, extravascular
hemolysis
○ In hyperbilirubinemia, if DB is 15-50% of TB, then it indicates hepatic
hyperbilirubinemia eg. viral hepatitis
○ In hyperbilirubinemia, if DB is >50% of TB, then it indicates direct
hyperbilirubinemia eg. cholangiocarcinoma
● Markers of hepatocellular injury (ALT, AST)
○ Since the enzymes are located inside the hepatocytes, they are considered markers
of hepatocellular injury.
○ ALT is present only in the liver, but AST can be additionally found in skeletal
muscle, cardiac muscle etc. Hence, ALT is more specific for liver diseases.
● Tests of synthetic function (albumin and INR)
○ The liver produces 15 gram of albumin per day. So it is a marker of chronicity in
liver disease.
○ However, it is also a negative acute phase reactant and the production of albumin
will be reduced by the liver during acute inflammation. So it cannot be used as a
marker of chronicity in the setting of acute hepatitis.
○ Clotting factor VII has the shortest half life (6 hours) among the vitamin K
dependent factors and it is present in the extrinsic pathway of coagulation
cascade. Hence INR becomes abnormal earlier than aPTT in liver failure.
● Tests of metabolic function (ammonia)
○ The major source of ammonia is the gut and it is converted to urea by liver
● ALP, GGT and 5’-nucleotidase are markers of cholestasis. Serum bile acids can be used
to quantitatively assess the hepatic reserve. It is also increased in cholestasis.
3. Portosystemic anastomoses
The hepatic portal system has a fairly robust collateral circulation. When blood flow through the
liver is severely reduced in portal hypertension, portal blood will be diverted along the following
three routes of collateral circulation to enter the IVC in order to return to the heart.
Site Portal system vein IVC system vein Applied aspect
Oesophagus Left gastric vein Oesophageal vein Oesophageal varices
Umbilicus Paraumbilical vein Sup. & inf. epigastric veins Caput medusae
Rectum Superior rectal vein Middle & inf. rectal veins Anorectal varices
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Applied aspects
● Portal hypertension is defined as :
○ Portal venous pressure > 12 mm Hg
○ Sinusoidal pressure > 6 mm Hg
○ Hepatic Venous - Portal pressure Gradient (HVPG) > 10 mm Hg
■ When HVPG is more than 12 mm Hg, there is high risk of complications
occurring due to portal hypertension.
■ When HVPG is more than 20 mm Hg, there is a high risk of variceal
rupture.
4. Basis of Wilson disease
Copper metabolism
● Copper is absorbed from the proximal small intestine.
● Copper is sequestered inside the duodenal epithelial cell by binding to metallothionein.
● Subsequently copper reaches the liver and it binds to apoceruloplasmin with the help of
ATP7B protein to form holoceruloplasmin, which then enters the systemic circulation.
● The excess copper in the liver which does not bind to apoceruloplasmin is subsequently
excreted in the bile with the help of ATP7B.
In Wilson disease, ATP7B is defective and hence copper can neither be incorporated into
apoceruloplasmin to form holoceruloplasmin, nor can it be excreted in the bile. So,
● Copper gets deposited in the hepatocellular lysosomes
● This eventually leads to free radical mediated hepatocyte inflammation and damage.
● Finally it spills over to plasma with toxicity of the extrahepatic organs including basal
ganglia, cornea, erythrocytes and kidney.
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Applied aspects
● Serum ceruloplasmin level is low in Wilson disease as the half life of apoceruloplasmin is
less than that of holoceruloplasmin.
● Copper chelators like penicillamine and trientene inhibit accumulation of copper in
hepatocellular lysosomes and also increase urinary copper excretion.
● Further, zinc increases metallothionein synthesis in the intestine. Metallothionein traps
copper inside the intestinal epithelial cell so that it finally gets excreted in faeces without
reaching the liver.
5. Chronic hepatitis
● Causes
○ Chronic HBV / HCV
○ Metabolic causes like Wilson’s disease
○ Autoimmune hepatitis
○ Budd Chiari syndrome
○ Alcohol
○ NASH
○ Chronic hepatitis is usually asymptomatic or has only vague symptoms. Fatigue is
the most common symptom. Jaundice is not usually seen. Hence it is difficult to
diagnose the disease in the “chronic hepatitis” stage and patients usually end up
progressing to cirrhosis and then portal hypertension and that is when they present
to us.
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● How to identify if a patient with chronic hepatitis has cirrhosis or not ?

○ Transient elastography (fibroscan) and liver biopsy can differentiate between the
two.
Management principles
1. Chronic hepatitis B
Not all chronic hepatitis B patients are treated. The indications to treat are :
a. Chronic hepatitis with evidence of cirrhosis on fibroscan or biopsy are treated
regardless of liver enzyme levels, HBV DNA levels and HBeAg status.
b. Absence of cirrhosis but there is evidence of active viral replication (HBeAg
positive or HBV DNA elevated) along with evidence of hepatocellular injury
(liver enzymes elevated).
The treatment options available are interferon alpha, tenofovir and entecavir. Any one
of these is usually given for an extended period. The child also needs to be screened for
HCC periodically.
2. Chronic Hepatitis C
All chronic hepatitis C patients are treated with a combination of NS5A inhibitors
(eg. velpatasvir) and NS5B inhibitors (eg. sofosbuvir) for a total duration of 12
weeks. Sustained viral response of 99.5-99.7% has been attained with these newer
antiviral medications.
3. Autoimmune hepatitis
Autoimmune hepatitis can be diagnosed with the help of polyclonal
hypergammaglobulinemia (eg. serum globulin level 10 g/dL), autoantibodies
(eg. anti-SMA and anti-SLA in type I and anti-LKM-1 and anti LC-1 in type II
autoimmune hepatitis) and also unique features on liver biopsy like interface
hepatitis. Remission is induced with steroids, and it is followed by a combination
of low dose steroid and a steroid sparing medication (eg. azathioprine) during the
maintenance phase.
4. Mention the investigations and treatment of Wilson’s disease also.
6. Ascites
Pathophysiology
● Mechanical and functional components during the origin of portal hypertension
○ The fibrous septations in cirrhosis compress the sinusoids causing a resistance to
flow (mechanical component).
○ Nitric oxide (NO) levels are increased everywhere else (eg. splanchnic
circulation), but inside the hepatic sinusoids, there is a decrease in NO level. This
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causes sinusoidal vasoconstriction and hence, there is a resistance to flow

(functional component).
● Ultimately, this leads to sinusoidal defenestration. In other words, the sinusoids lose
their permeability.
● Why does a patient with cirrhosis and portal hypertension develop ascites ?
● As mentioned earlier, NO levels are increased in splanchnic circulation, which causes
pooling of blood in the splanchnic circulation. Hence, effective intravascular volume
decreases, which stimulates the RAAS axis, causing salt and water retention. This excess
fluid leaks out as ascites.
● Serum ascitic fluid albumin gradient (SAAG)
○ SAAG = Serum albumin minus ascitic fluid albumin
○ SAAG is assessed along with ascitic fluid total protein levels.
○ SAAG and ascitic fluid protein (eg. low SAAG low protein) help in classifying
ascites and finding out the probable aetiology.
● Low SAAG
○ Low SAAG ascites means SAAG is <1.1
○ For SAAG to be low, either serum albumin should be low, or ascitic fluid albumin
should be high.
○ Low SAAG low protein ascites is seen in nephrotic syndrome, as there is heavy
albuminuria leading to hypoalbuminemia (hypoproteinemia).
○ Low SAAG high protein ascites is seen in peritoneal pathology like peritoneal
carcinomatosis or peritonitis, where both albumin and protein leak through the
inflamed peritoneal capillaries.
● High SAAG
○ High SAAG ascites means SAAG is >1.1
○ For SAAG to be high, ascitic fluid albumin should be low.
○ High SAAG low protein is seen in cirrhosis with portal hypertension. Due to the
hepatic sinusoids losing their permeability (sinusoidal defenestration), both
proteins and albumin cannot leak through the sinusoids.
○ High SAAG high protein is seen in Budd Chiari syndrome. The occlusion
occurs at the hepatic vein (and not the hepatic sinusoids like in cirrhosis). Small
proteins leak into the ascitic fluid across the hepatic vein due to the sluggish
blood flow. However, albumin is a large protein and hence cannot leak into the
ascitic fluid through the hepatic veins.
Management of ascites
● Mild ascites
○ Salt restriction
● Moderate ascites
○ Salt restriction and diuretics
○ The diuretic of choice is spironolactone (as it targets the overactive RAAS axis).
○ If the ascites is not controlled with spironolactone, then loop diuretics may be
added.
● Severe ascites
○ Large volume paracentesis with replacement of albumin
○ TIPSS may be considered in refractory ascites.
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7. Liver biopsy in fulminant hepatic failure

● Differential diagnosis of fulminant hepatic failure (FHF)
○ Viral hepatitis
○ Drug and toxin induced liver injury
○ Ischaemic hepatitis
○ Alcoholic hepatitis
○ Metabolic conditions like Wilson’s disease
○ Autoimmune hepatitis
● Pre-procedural assessment of the patients

○ It is preferable to have platelet count >50,000 and INR <1.5.
○ However, if INR is >1.5 despite best efforts, then a transvenous approach of liver
biopsy may be considered. It is performed by an interventional radiologist through
the jugular vein.
○ The same approach may be used if the patient has massive ascites which can
hamper percutaneous biopsy.
Complications
● Pain at the biopsy site
● Haemorrhage
Biopsy findings in FHF
The patterns of necrosis can give clues to the underlying cause
● Centrilobular necrosis (necrosis in zone 3 hepatocytes which are near the
hepatic vein) may be seen in ischaemic hepatitis and alcoholic hepatitis.
● Periportal necrosis (necrosis in zone 1 hepatocytes which are near the
portal vein) may be seen in autoimmune hepatitis and Wilson’s disease.
● Massive necrosis involving >75% of hepatocytes may be seen in viral
hepatitis and drug induced hepatitis.
8. Reye syndrome
● It is an acute encephalopathy with fulminant liver failure. The pathogenesis is :

Viral pathogen (influenza, varicella) Salicylate intake
Rarely bacteria (Chlamydia, mycoplasma)
Mitochondrial injury
Hepatic dysfunction Inhibition of fatty acid metabolism

Hyperammonemia Hypoglycemia
Cerebral oedema
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Investigations
○ CSF total count < 8
○ CSF analysis not suggestive of infective aetiology
○ LFT and ammonia elevated
○ Liver biopsy – Jones Type 2 fulminant hepatic failure
Management
○ Supportive management of hypoglycaemia, liver failure and raised ICT
9. Grading of splenic size
Hackett’s grading
Grade 0 - Spleen not palpable even on deep inspiration
Grade 1 - Palpable only on deep inspiration and it is palpable below the costal margin
Grade 2 - Palpable till halfway between the costal margin and umbilicus
Grade 3 - Palpable till the umbilicus
Grade 4 - Palpable below the umbilicus
Grade 5 - Palpable till the pubic symphysis
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GASTROENTEROLOGY
1. Rotation of gut
● Midgut forms a U-shaped loop that herniates through the primitive umbilical ring into the
extraembryonic coelom, beginning at week 6 of intrauterine life (IUL).
● The midgut loop has two limbs
○ Cranial limb – consists of jejunum and upper part of ileum
○ Caudal limb – lower part of ileum, caecum, appendix, ascending colon and
proximal ⅔ of transverse colon
● The herniated midgut loop rotates 270 degrees anti-clockwise around the superior
mesenteric artery (SMA) before it returns into the abdominal cavity at around week 10-11
IUL.
Applied aspects
● Non rotation
○ The small intestine lies on the right side of the abdomen and the entire large
intestine lies on the left.
○ Generally children with this condition are asymptomatic. However, if volvulus
occurs in such a child, SMA may get obstructed, resulting in bowel gangrene.
● Mixed rotation / incomplete rotation
○ The caecum lies just inferior to the pylorus of the stomach, and is fixed to the
posterior abdominal wall by peritoneal bands (Ladd bands) that pass over the
duodenum. These bands and volvulus usually cause duodenal obstruction.
● Reverse rotation
○ The midgut loop rotates in a clockwise direction instead of anti-clockwise
direction. As a result, the duodenum lies anterior to the SMA, instead of being
posterior to it. Also, the transverse colon lies posterior to the SMA, instead of
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being anterior to it. The transverse colon may get obstructed by pressure from
SMA.
● Omphalocele (ventral body wall defect)
○ Failure of physiologically herniated bowel loops to return to the body cavity
23. Meckel’s diverticulum
Persistent vitellointestinal duct
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● Rule of two
○ 2% population
○ 2 inches long
○ 2 feet from ileocaecal valve
● Contains ectopic gastric or pancreatic mucosa
● Peptic ulceration is noted at the junction of ileal and ectopic gastric mucosa because
bicarbonate rich secretion of duodenum and pancreas is not available in ileum to
neutralise the acid from ectopic gastric mucosa
● Most common clinical manifestation is intermittent painless hematochezia in babies < 2
years old
● Always rule out Meckel diverticulum in a child with significant painless bleeding PR
● Investigations : Meckel scan (99mTc) or diagnostic laparoscopy
● Management : Surgical excision
3. Development of pancreas
Foregut endoderm outgrowths
Ventral pancreatic bud Dorsal pancreatic bud
Due to 90 degree clockwise rotation of duodenum,
the ventral pancreatic bud rotates dorsally and fuses
with the dorsal bud to form definitive pancreas
Ventral bud gives rise to uncinate process and a Dorsal bud gives rise to the
portion of head of pancreas remaining portion of head,
body and tail
Ventral pancreatic duct Distal ⅔ of dorsal Proximal ⅓ of dorsal
pancreatic duct pancreatic duct
Anastomose to form main pancreatic duct Accessory pancreatic duct
(Wirsung) (Santorini)
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Applied aspects
● Pancreatic divisum (not fused)
● Annular pancreas : the two parts of pancreas surround the duodenum and constrict
it
4. Carbohydrate digestion and absorption
Mouth Salivary amylase
Starch Maltose
Stomach
No enzyme for carbohydrate digestion
Pancreas
Pancreatic amylase
Starch Maltose
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Intestine
Brush border enzymes (also known as disaccharidases) act on disaccharides and convert
them into monosaccharides
Maltase
Maltose Glucose + Glucose
Lactase
Lactose Glucose + Galactose
Sucrase
Sucrose Glucose + Fructose
Absorption
● Carbohydrate absorption predominantly occurs in the duodenum and jejunum
● Glucose and galactose get absorbed via SGLT1
● Fructose gets absorbed via GLUT5
Applied aspects
● D-xylose test : D-xylose is a pentose that is completely absorbed in the proximal small
intestine independent of pancreatic assistance. 25 gram of D-xylose is given orally and
urine is then collected for the next 5 hours. An excretion of <5 gram D-xylose in the urine
is suggestive of malabsorption affecting the proximal small intestine.
● Lactose intolerance - It can be primary or secondary. In primary lactose intolerance, there

is a defect in the enzyme lactase. An infant with lactose intolerance presents with
diarrhoea and failure to thrive on mother’s milk. Perianal excoriation may be present due
to the acidic stool. Adult patients usually have only mild lactase deficiency and may
present with IBS-like symptoms. Secondary lactose intolerance is associated with other
diseases like celiac sprue, tropical sprue, Crohn's disease, gastrointestinal infections etc.
which affect the intestinal brush border.
Pathophysiology - Lactose reaches the colon as it is unabsorbed in the small intestine.
Some of it may be broken down by the flora into lactic acid, which reduces the pH of the
colonic lumen and the stools. The rest of it is passed in the stools, yielding a positive test
for stool reducing substances.
5. Protein digestion and absorption
Mouth
No proteolytic enzyme
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Stomach
Pepsin
Protein proteoses and peptones
Pancreas
Enterokinase converts trypsinogen to trypsin. Trypsin then activates the remaining enzymes.
Trypsin, chymotrypsin and elastase
Proteoses & peptones poly, tri and di-peptides
Carboxypeptidase A & B
Poly, tri and di-peptides Amino acids
Intestine
Aminopeptidase
Poly, tri and di-peptides Amino acids
Tripeptidase
Tripeptides Amino acids
Dipeptidase
Dipeptides Amino acids
Absorption
Absorption of amino acids occurs primarily in the proximal small intestine (duodenum and
jejunum) via various transporters (facilitated diffusion).
Applied aspects
1. Protein malabsorption usually occurs along with carbohydrate and fat malabsorption (eg.
celiac sprue). Protein malabsorption is detected by reduced levels of chymotrypsin and
elastase in stool.
2. Diseases affecting only protein malabsorption
a. Enterokinase deficiency
b. Transporter defect
i. Neutral amino acid transporter defect - Hartnup disease
ii. Dibasic amino acid transporter defect - Cystinuria
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6. Fat digestion and absorption
There are eight steps in fat digestion and absorption. Defect in any of these steps will lead to fat
malabsorption resulting in steatorrhea.
Step 1
● Bile acids (also known as bile salts) are formed in the liver.
● Defect in step 1 : In liver cirrhosis, bile acids are not formed.
Step 2
● Bile acids travel down in the biliary tree
● Defect in step 2 : In biliary cirrhosis (eg. PBC), bile acids cannot reach the intestine
Step 3
● Bile acids reach the intestine and are ready to attack
● Defect in step 3 : In SIBO (small intestinal bacterial overgrowth), the bile acids are
rapidly deconjugated and inactivated by the bacteria present in the small intestine
Step 4
● Bile acids act together with pancreatic lipase to convert the fats into micelles
● Defect in step 4 : Exocrine pancreatic insufficiency
Step 5
● Micelles are transported across the intestinal mucosa into the intestinal epithelial cell
● Defect in step 5 : In celiac sprue, tropical sprue and Whipple disease, there is a loss of
integrity of the intestinal epithelial mucosa
Step 6
● Micelles are converted into triglycerides. Then triglyceride (lipid) combines with Apo
B48 (apoprotein) to form chylomicron (apolipoprotein)
● Defect in step 6 : Defect in the enzyme (MTTP) needed for chylomicron formation
results in abetalipoproteinemia
Step 7
● Delivery of chylomicron from the intestinal cell into the lymphatics
● Defect in step 7 : Abnormal lymphatics (lymphangiectasia)
Step 8
● 95% of the bile acids reaching the ileum get reabsorbed and travel back to the liver to
repeat this cycle again. Enterohepatic circulation maintains the bile acid pool
● Defect in step 8 : Ileal diseases like Crohn's disease and TB result in impaired bile acid
reabsorption and depletion of the bile acid pool
7. Tropical sprue
● It is a type of intestinal malabsorption found in residents of tropical countries like India,

Sri Lanka, West Indies etc.
● Initially there is acute intestinal infection with toxigenic coliforms like E. coli, klebsiella,
enterobacteria etc. This leads to production of toxins and fermentation products, which
are toxic to the intestinal epithelial cell mucosa. This damage involves the entire small
intestine (pan intestinal) with distal small intestine (ileum) being more involved than
proximal.
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● Investigations
○ Absorption of all the three main nutrients are affected as proximal small
intestine and distal small intestine are both involved (pan intestinal involvement).
So, d-xylose test is positive, faecal elastase is low and faecal fat globules are
present.
○ Vitamin B12 and folate levels are low.
○ Intestinal biopsy shows partial villous atrophy (celiac disease has complete
villous atrophy).
● Management
○ A combination of antibiotics and micronutrients (folic acid and vitamin B12) is
given for an extended duration.
8. Hirschsprung disease
● Failure of cranio-caudal migration of ganglion cell precursors along GIT during 5-12 wk
GA
● Loss of intrinsic innervations of the distal colon
● The aganglionic segment is in a state of constant contraction and the internal anal
sphincter does not relax. The bowel proximal to the aganglionic segment becomes dilated
due to the functional obstruction
○ Any newborn not passed meconium within 48 HOL – suspect HD
○ During the PR exam, the anal canal and rectum appear to be empty. But, as the
finger is withdrawn, there is a sudden explosive gush of offensive stools.
○ Intractable constipation in older children
● Investigations
○ Barium enema
○ Anorectal manometry
○ Rectal biopsy showing absence of ganglion cells (IHC is used to stain AChE)
● Management
○ Resection of aganglionic segment and re-anastomoses
9. Stool occult blood

Principle
● It is based on the conversion of the colourless dye guaiac to a bluish compound by the
peroxidase present in haemoglobin.
Applications
● Stool occult blood positive in a neonate with NNEC implies that she belongs to modified
Bell stage IA. Bleeding PR shifts her to stage IB.
● Babies with allergic enteropathy (eg. cow milk protein allergy) can have either occult or
gross blood in stools.
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● It can be used to differentiate between IBD and irritable bowel syndrome. Patients with
Crohn’s disease can have occult blood in stools. Ulcerative colitis generally presents with
bloody stools. Irritable bowel syndrome has no blood in stools.
● Gastrointestinal involvement in Henoch Schönlein purpura can be identified by testing
for occult blood in stools. Severe GI involvement may be an indication for steroids.
● It is used during workup of iron deficiency anaemia, to rule out gastrointestinal blood
loss.
● It can be used to screen for colorectal malignancies.
10. Probiotics
● It is a preparation containing viable microorganisms that alter the gut flora by
colonisation and hence exert a beneficial effect.
Examples
● Lactobacilli
● Bifidobacteria
Indications
● It has been demonstrated that probiotics reduce the duration of hospital stay in children
admitted with infectious diarrhoea.
● Probiotics induce colonisation by normal gut flora which suppress clostridium difficile
and hence are useful in pseudomembranous enterocolitis.
● Alteration in gut flora plays a role in IBD pathogenesis. Probiotics can have a supportive
role in inducing and maintaining remission in IBD. Turboprobiotics are strains of
lactobacillus which have been genetically engineered to secrete IL-10 (an
anti-inflammatory cytokine) in vivo. They are found to be useful in Crohn’s disease.
● Probiotics are used in the prophylaxis of NNEC in babies with birth weight <1.25 kg and
babies with birth weight between 1.25-1.5 kg with A/REDF.
Prebiotics
● The drawback of probiotics is that it is difficult to deliver viable bacteria to the distal gut
as the bacteria may be destroyed in the stomach or duodenum.
● Prebiotics are fibres and complex proteins that are not digested or absorbed in the gut.
They deliver nutrients to the endogenous flora and hence stimulate their growth.
● Examples - lactulose, chicory
● Mother’s milk is a natural prebiotic.
Synbiotics
● Viable microorganisms (probiotics) are combined along with prebiotics to ensure the
survival of the probiotic microorganisms. eg. bifidobacterium with chicory
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HAEMATO-ONCOLOGY
1. Flow cytometry
Provides rapid analysis of multiple characteristics of single cells, made to flow in a single line
Indications
Oncology – Leukaemia and lymphoma markers
Haematology – EMA in HS, diagnosis of PNH
Immunology – HLA typing, immunodeficiency workup
Obstetrics – quantification of FMH
Blood Bank – Assessment of WBC contamination of blood products
2. RBC indices
MCV
Average volume of one RBC (80-100 fL)
MCH
Average mass of haemoglobin per RBC (30 ± 3 pg)
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MCHC
Average concentration of Hb in a given volume of packed red cells (34 ± 2 g/dL)
RDW
Coefficient of variation of RBC volume (12-16)
Applied aspects
● MCV <80 : microcytosis

● MCV >100 : macrocytosis
● Mentzer index was used in the post to differentiate between iron deficiency anaemia and
beta thalassemia trait.
○ Mentzer index = MCV/RBC count
○ In iron deficiency anaemia, both MCV and RBC count decrease and so Mentzer
index remains >13
○ In beta thalassemia trait, MCV decreases but RBC count remains constant. So the
Mentzer index is <13.
● MCH is low in iron deficiency anaemia (hypochromic anaemia)
● MCHC is low in iron deficiency anaemia
● If RDW increases, it suggests anisopoikilocytosis. Anisopoikilocytosis can be seen in
both iron deficiency anaemia and megaloblastic anaemia.
3. Reticulocyte count
● Reticulocyte is the precursor of RBC. Reticulocyte is identified using supravital stains

like brilliant cresyl blue
● Usually reticulocyte is expressed as a percentage of RBCs
● Normal reticulocyte count is 0.5-1.5%
● Normal absolute number of reticulocyte count is 25000-75000/microlitre
● Reticulocyte takes 1-2 days for maturation. We need to correct the reticulocyte count
based on haemoglobin level and maturation time. The corrected reticulocyte count hence
obtained is called reticulocyte production index (RPI)
RPI = reticulocyte count x (observed Hb/desired Hb) x 0.5
Applied aspects
● If RPI is > 2.5, it is hyperproliferative anaemia and if RPI is <2.5, it is hypoproliferative
anaemia
4. ESR
● The ESR test measures the rate at which the erythrocytes, in a sample of whole blood, fall
to the bottom of the Westergren tube. This process of "falling" is called sedimentation.
● Blood containing an anticoagulant in a tube remains as suspension (without erythrocytes
settling at the bottom) for a relatively long time due to negative electrical charges on
erythrocyte surfaces, which make them repel each other.
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● Erythrocytes typically fall at a faster rate in people with inflammatory conditions such as
infections, cancer, or autoimmune conditions. These conditions lead to an increase in the
number of proteins in the blood. Many plasma proteins have positive charges and can
effectively neutralise the negative surface charges of the erythrocytes, which causes red
blood cells to aggregate and settle at a faster rate, thereby forming a longer column on the
tube, which translates to a higher millimetre reading.
● In anaemia, with the haematocrit reduced, the velocity of the upward flow of plasma is
altered, so that the erythrocytes fall faster.
● Methods of measuring ESR : Westergren method, Wintrobe method, automated ESR
analyser
5. Importance of peripheral smear
It can be divided into five headings

A. To cross check the findings in case of flagging (excessively high values) in automated
blood count analyser
● This can be explained by taking beta thalassemia as an example.
○ The nucleated RBCs may be misinterpreted by the automated analyser to be
WBCs which leads to an erroneously high WBC count.
○ Similarly, the fragmented RBCs may be misinterpreted by the automated analyser
to be platelets which leads to an erroneously high platelet count.
These findings can easily be cross checked using a peripheral smear study.
B. Identifying RBC abnormalities
The following RBC abnormalities are detected on the peripheral smear :
● Anisocytosis : a wide variation in cell size eg. iron deficiency anaemia
● Microcytosis : smaller RBCs eg. iron deficiency anaemia
● Macrocytosis : larger RBCs eg. vitamin B12 deficiency anaemia
● Abnormal RBC shapes can give clues to identify the underlying disease.
○ Sickle cell - sickle cell anaemia
○ Target cell - beta thalassemia
○ Schistocytes - microangiopathic haemolytic anaemia
○ Acanthocytes - abetalipoproteinemia
○ Tear drop cells - primary myelofibrosis
○ Bite cells - G6PD deficiency
○ Pencil cells - iron deficiency anaemia
○ Stomatocytes - hereditary stomatocytosis
○ Elliptocytes - hereditary elliptocytosis
○ Spherocytes - hereditary spherocytosis
● Identifying inclusion bodies inside the RBCs
○ Howell Jolly bodies - splenic hypofunction
○ Basophilic stippling - lead poisoning
○ Ringed sideroblasts - sideroblastic anaemia
○ Heinz bodies - G6PD deficiency
● Hypochromia : the area of central pallor in the RBCs is increased eg. iron deficiency
anaemia
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● Rouleaux formation : linking of RBCs into chains resembling stacks of coins eg.
paraproteinemia in multiple myeloma
C. Identifying WBC abnormalities
● WBCs in infection
○ Apart from helping to detect the usual leukocytosis, leukopenia, neutrophilia,
lymphocytosis etc. some important findings are :
○ Toxic granules - Toxic granulations are seen in the neutrophils cytoplasm due to
compensatory increase in microbicidal granules.
○ Left shift - Normally, the band neutrophil population on a smear is less than 8%
and metamyelocytes less than 0.5%. An increase in the proportion of myeloid
precursors is termed left shift.
○ Leukemoid reaction - A leukemoid reaction is a haematological disorder, defined
by a leukocyte count greater than 50,000 cells/cu. mm, caused by reactive causes
outside the bone marrow. It is characterised by a significant increase in mature
neutrophils in the peripheral blood and also a differential count showing marked
left shift. The most important cause is severe infection.
● Granules within the WBCs
○ Chediak Higashi syndrome patients have typical giant granules in the leukocyte
cytoplasm.
● Lymphoblasts, myeloblasts, plasmablasts etc. help in identification of haematological
malignancy cases. But confirmation with flow cytometry is performed in all cases as it
will yield additional information which helps in prognostication and planning treatment.
● Neutrophil nuclear segmentation
○ The nuclei of neutrophils have a segmented appearance. The majority of
neutrophils have three nuclear segments (lobes).
○ Hypersegmented neutrophils (>5 lobes) - megaloblastic anaemia
○ Pseudo Pelger Huet cells (<2 lobes) - dysplastic WBCs in myelodysplastic
syndrome
D. Platelet abnormalities
● Apart from helping to detect the usual thrombocytopenia and thrombocytosis, the
important platelet abnormalities identified on the peripheral smear are :
○ Giant platelets - Bernard Soulier syndrome
○ Microthrombocytopenia - There is reduction in the number and size of the
platelets in Wiskott Aldrich syndrome
E. Parasites
● The following parasitic infections are detected on peripheral smear :
● 1. Malaria
● 2. Babesiosis
● 3. Filariasis
● 4. Leishmaniasis
● 5. Trypanosomiasis
6. Erythropoiesis at various ages
● 3 weeks to 3 months GA – Yolk sac

● 3 months to 5 months GA – Liver, spleen
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● 5 months to 9 months GA – Red bone marrow in long and flat bones

● After birth till 20 years – Red bone marrow in long and flat bones
● After 20 years of age – Only in flat bones like ilium
7. Iron absorption
● Absorption of iron mainly occurs in the duodenum.

● Cellular entry and exit of iron can occur only as Fe2+. Storage inside the cell occurs as
Fe3+.
● Animal sources of iron (heme iron) exist as Fe2+ and so enters the duodenal intestinal
epithelial cell directly through HCP-1 (heme carrier protein). Plant sources of iron (non
heme iron) exist as Fe 3+. So it is converted first to Fe2+ by the duodenal cytochrome B
reductase and then it enters the cell via DMT-1 (divalent metal transporter).
● Ascorbic acid favours intestinal iron absorption whereas absorption is inhibited by
phytates (cereals), tannins (tea) & oxalates (leafy vegetables).
● After cellular entry, some of the Fe2+ gets converted to Fe3+ and is stored as ferritin. The
rest binds to ferroportin and is transported out of the cell. Hephaestin converts the Fe2+
to Fe3+ and the Fe3+ then binds to transferrin
● Hepcidin is produced by the liver and it regulates iron absorption by inhibiting
ferroportin. Hepcidin is stimulated by HFE and hemojuvelin genes. Matriptase-2
inactivates hepcidin.
Applied aspects
● Mutations in HFE and hemojuvelin genes mean that hepcidin is not stimulated and hence
cannot regulate ferroportin. This leads to excessive iron absorption and it is deposited in
various sites like liver, skin, pancreas, heart, joints and pituitary. This condition is called
hemochromatosis.
● If matriptase-2 is defective, hepcidin is overactive and hence iron cannot get out of the
duodenal epithelial cell to bind to transferrin. This condition is called IRIDA (iron
refractory iron deficiency anaemia).
129
8. Thrombogenesis
A. Virchow’s triad is required for the formation of intravascular thrombus.
A-1. Endothelial injury

● Normally endothelium is resistant to thrombus formation. But when there is
endothelial injury, the subendothelial collagen gets exposed, which favours
thrombus formation. Further, vWF is released from the endothelial Weibel Palade
granules due to endothelial injury. vWF binds to the subendothelial collagen on
one side, and to platelets (Gp Ib/IX) on the other side. This is called ‘platelet
adhesion’.
A-2. Abnormal blood flow
● Turbulent blood flow causes endothelial injury and predisposes to thrombus

formation.
● Stasis or sluggish blood flow also predisposes to thrombosis.
● Applied aspects :
○ Stasis of blood in the lower limbs during immobilisation due to
injury/hospitalisation/long distance air travel can predispose to deep vein
thrombosis and thromboembolism.
○ Stasis of blood in the LA in MS and in the LV in DCM leads to LA
appendage clot and LV clot respectively.
130
○ Hyperviscosity conditions like polycythemia and sluggish blood flow due

to deformed blood cells in sickle cell anaemia also predispose to
thrombosis.
○ The turbulent jet in valvular and congenital heart diseases predispose to
formation of a platelet-fibrin clot, which is called non bacterial thrombotic
endocarditis (NBTE) and when bacteria adhere and proliferate on top of
the NBTE, it leads to infective endocarditis. The starting point was
turbulent blood flow.
A-3. Hypercoagulability
It can either be inherited or acquired

● Inherited :
○ Factor V Leiden mutation
○ Deficiency of protein C, protein S and antithrombin III
○ Homocystinuria
● Acquired :
○ Antiphospholipid syndrome
○ Dehydration
○ Polycythemia
○ Nephrotic syndrome
○ Inflammatory bowel disease
○ Pregnancy
○ OCP
B. Formation of primary hemostatic plug

It involves two processes :
○ 1. Platelet adhesion - already described above
○ 2. Platelet aggregation - Gp IIb/IIIa on platelets bridges adjacent platelets
C. Formation of secondary hemostatic plug

Coagulation cascade forms the secondary hemostatic plug. The clotting factors are :
● I – Fibrinogen VII – Stable factor XII – Hageman factor
● II – Prothrombin VIII – Anti haemophilic factor XIII – Fibrin
● III – Thromboplastin IX – Christmas factor stabilising
● IV – Calcium X – Stuart Prower factor factor
● V – Labile factor XI – Plasma thromboplastin antecedent
Applied aspects
● Defective thrombogenesis may be due to :
1. Thrombocytopenia
2. Platelet function defects
■ Bernard Soulier syndrome (Gp Ib/IX defect)
■ Glanzmann thrombasthenia (Gp IIb/IIIa defect)
■ von Willebrand disease (vWF defect)
131
3. Disorders of coagulation
■ Haemophilias
■ Vitamin K deficiency
■ Disseminated intravascular coagulopathy
9. Platelets
● Platelets are disc-shaped anucleate cell fragments which are shed from megakaryocytes.
● There are two types of granules in the platelets :
○ Alpha granules - contain clotting factors and PDGF
■ Defect in alpha granules causes grey platelet syndrome
○ Dense granules - contain ADP and serotonin
■ Defect in dense granules causes Hermansky Pudlak syndrome
● Mention about vWF, gp IIb/IIIa and gp Ib/IX
Applied aspects
● Thrombocytosis is seen in inflammatory conditions (eg. KD) and also in essential
thrombocytosis
● Thrombocytopenia can be seen in viral infections, microangiopathic hemolytic anaemia,
hypersplenism, ITP and can also occur as part of pancytopenia.
● Platelet functional disorders are screened for by PFA-100 analyser. Examples of such
disorders include von Willebrand disease, Bernard Soulier syndrome and Glanzmann
thrombasthenia.
10. von Willebrand disease
● Most common inherited bleeding disorder
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● Inheritance
○ All are AD inherited, except type 3 (AR)
● Role of vWF
○ Adhesion of platelets to subendothelium
○ Binding protein of factor VIII (hence increases t½ of factor VIII)
● Pathology
○ Type 1 – partial deficiency of vWF; most common type
○ Type 2 – qualitative defect of vWF
○ Type 3 – severe deficiency of vWF; most severe type
● Investigations
○ PT – normal
○ aPTT – increased
○ TT – normal
○ Ristocetin induced platelet aggregation – defective
● Management
○ Desmopressin induces the release of vWF from endothelium
○ vWF concentrates are now available
11. Disseminated intravascular coagulopathy (DIVC)

● Thrombohemorrhagic disorder characterised by excessive activation of coagulation and
thrombus formation in the microvasculature
● Causes
○ Sepsis
○ Trauma
○ Shock
○ Obstetric complications – abruption, IUD
○ CA stomach, pancreas
○ Kasabach Merritt syndrome
● Pathogenesis
○ Widespread injury to endothelial cells
○ Release of tissue factor and other procoagulants
○ Consumption of platelets and clotting factors in ensuing thrombosis
● Investigations
○ FDP (fibrin degradation products)
○ d-dimer
○ Thrombocytopenia
○ Elevated PT, aPTT and TT
○ Schistocytes on PS
● Management
○ Treat underlying condition
○ Blood product transfusion
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12. BMA picture in AML

● > 20% blasts in bone marrow
● Myeloblasts have delicate nuclear chromatin, 2-4 nucleoli and moderate amount of
cytoplasm
● Auer rods : needle-like, azurophilic, fusiform cytoplasmic inclusions in myeloblasts
● Faggots : Bundles of Auer rods in criss cross pattern
● Phi Body : Round or oval inclusions in myeloblasts
13. Graft versus host disease
Graft versus host disease (GVHD) occurs when immunocompetent T cells in the graft attack the
immunodeficient recipient due to minor HLA mismatches.
Settings in which GVHD occurs

● Following allogeneic HSCT (most common setting)
● Following transplantation of solid organs that are rich in lymphoid cells (eg. liver)
● Following transfusion of un-irradiated blood
Classification of GVHD
● Acute classic GVHD - Presents within 100 days of transplant
● Classic chronic GVHD - Presents after 100 days of transplant
Manifestations
A. Acute GVHD
● Skin
○ A maculopapular rash initially appears over the face, palms and soles, which later
involves the trunk. Subsequently there is bullae formation and desquamation.
● Liver
○ hyperbilirubinemia
● GIT
○ diarrhoea
● Eyes
○ Hemorrhagic conjunctivitis and pseudomembrane formation
B. Chronic GVHD manifestations
● Cytopenias
● Liver
○ cholestasis
● GIT
○ esophageal stricture and malabsorption
● Eyes
○ keratoconjunctivitis sicca
Management
● All patients receiving HSCT should receive prophylaxis against GVHD. The protocols
differ from one institution to another, but usually it is a combination of steroids,
cyclosporine and methotrexate which may be continued for several months
post-transplant.
● Once the patient develops GVHD, then steroids are the most commonly used medication
along with various combinations of steroid sparing agents like tacrolimus, MMF etc.
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14. Hodgkin lymphoma
● It is a B-lineage lymphoma with a characteristic malignant cell called Reed Sternberg

(RS) cell.
● It is a cell with bilobed nuclei, eosinophilic nucleoli and a clear space separating the
nucleoli from the nuclear membrane.
● Causes
○ Genetic – Mutations of the PDL1 gene on chromosome 9
○ Infection – EBV
○ Immunity – NF-kb is upregulated
● Pathological types (and how to remember them)
○ Mixed Cellularity - the Most Common classical RS cells are seen (MC for MC)
○ lymphocyte Predominant - Popcorn RS cells are seen (P for P)
○ lymphocyte DEPLETION - No RS cells (DEPLETION of RS cells)
○ Lymphocyte RICH - (Being rich is better than being depleted. So) there are few
RS cells
○ NODULAR sclerosis - LACUNAR RS cells are seen (nodular rhymes with
lacunar)
○ Painless LAD (80% cases have cervical LAD) – most common symptom
○ HSM or mediastinal mass
○ B symptoms
■ weight loss > 10%
■ unexplained persistent/recurrent fever
■ drenching night sweats
● Ann Arbor staging
○ Stage I – single region (LN or extralymphatic site) involved
○ Stage II – two or more regions involved on the same side of the diaphragm
○ Stage III – involvement on both sides of the diaphragm
○ Stage IV – Diffuse or disseminated involvement
○ A – absence of B symptoms; B – at least one B symptom within the last 6 months
● Investigations
○ LN biopsy
135
○ CT neck, chest and abdomen

○ PET-CT
● Management
○ ABVD regimen of chemotherapy is initiated along with radiotherapy. If there is
residual disease after treatment completion, then switch over to COPP regimen.
○ ABVD : Adriamycin (Doxorubicin), Bleomycin, Vinblastine, Dacarbazine
○ COPP : Cyclophosphamide, Oncovin (Vincristine), Procarbazine, Prednisolone
15. Myeloproliferative disorders
It is a terminal myeloid cell (mature cell) expansion. Terminal myeloid cells are RBCs, platelets,
granulocytes and monocytes. The common feature in all these disorders is the mutated,
constitutively activated tyrosine kinases.
● CML
○ Mutation – BCR-ABL fusion
○ Clinical features – HSM, LAD
○ Phases
■ Dormant – < 10% blasts
■ Accelerated – 10-20% blasts
■ Blast crisis – > 20% blasts
● Polycythemia vera
○ Mutation – JAK2
○ Clinical features
■ Hb > 16.5 (male) and > 16 (female)
■ Thrombosis
■ Erythromelalgia
■ Gout
● Essential thrombocytosis
○ Mutation – JAK2 and MPL
■ Sustained thrombocytosis > 4.5 lakh
■ Abnormal size, shape and granularity of platelets
■ Microvascular occlusions – TIA, digital gangrene
● Primary Myelofibrosis
○ Mutation – JAK2 and MPL
○ Clinical features – Obliterative marrow fibrosis resulting in leukoerythroblastosis
and dacrocytes
● Systemic Mastocytosis
○ Mutation – c-KIT
■ Increased mast cells in skin
■ Mast cell infiltration of marrow, spleen, liver and lymph nodes
16. Neuroblastoma
● Malignant tumour of autonomic nervous system derived from neural crest
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● Causes
○ N-myc mutations
○ Hyperdiploidy
● Sites
○ Adrenal (30%) > paravertebral (28%) > post. mediastinum (15%) > pelvis (5%) >
neck (5%)
○ Abdominal lump
○ Fever
○ Raccoon eyes
○ Bone pain
○ Two paraneoplastic syndromes
■ Watery diarrhoea (VIP secretion)
■ Opsoclonus – myoclonus syndrome (immunologic phenomenon)
● Investigations
○ Imaging – USG/MRI/CT
○ Nuclear scintigraphy – MIBG scan
○ Urine catecholamines
○ Biopsy with Neuron Specific Enolase (NSE) positivity on IHC is gold standard
○ Homer Wright pseudorosettes, primitive neuroblasts & punctate calcification on
HPE
● Staging
○ I – Localised tumour with complete excision undertaken; lymph nodes negative
○ II – Localised tumour; incompletely excised – lymph nodes negative
○ II B – Localised tumour; incompletely excised – ipsilateral LN +ve, contralateral
–ve
○ III – Tumour infiltrating across midline (or) contralateral LN involvement
○ IV – Distant metastases
○ IV S
■ S for Special
■ S for Small children (applicable only in infants)
■ S for Small primary tumour (localised disease as in stage I or II)
■ S for Spread limited to Skin, liver and/or marrow
■ S for Spontaneous regression likely
● Management
○ Localised tumour – Surgery alone
○ Advanced disease – Chemotherapy along with surgery, radiotherapy and BMT
○ IV S tumour – Observation for spontaneous regression
17. Wilms tumour
● Aetiology
○ Gene mutations associated with Wilms tumour
■ Loss of function mutations of tumour suppressor genes like WT1, WT2,
FWT1, FWT2, p53, BRCA2
○ Syndromes associated with Wilms tumour
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■ WAGR : Wilms tumour, Aniridia, Genitourinary anomalies, mental

Retardation
■ Denys Drash syndrome : congenital nephropathy
■ Beckwith Wiedemann syndrome : macrosomia, macroglossia,
hemihypertrophy, organomegaly, renal abnormalities
Fever, abdominal mass (noted while giving the baby a bath etc.), gross haematuria
● Investigations
USG / CT abdomen
● Staging
I – tumour limited to kidney; completely excisable
II – tumour extends beyond kidney (perirenal soft tissues); completely excisable
III – non-hematogenous spread confined to abdomen; not completely excisable
IV – hematogenous distant metastases
V – bilateral renal involvement at diagnosis
● Management
Stages I and II – Total surgical excision with chemotherapy
Stages III and IV – Surgical resection with chemotherapy and radiotherapy
Stage V – initial chemotherapy followed by surgical resection
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NEUROLOGY
1. Brachial plexus
Roots
C5, C6, C7, C8 and T1
Trunks
C5 and C6 give rise to upper trunk
C7 gives rise to middle trunk
C8 and T1 give rise to lower trunk
Divisions
Each trunk gives rise to anterior and posterior divisions
Cords
Anterior divisions of upper and middle trunks join to form the lateral cord
Anterior division of lower trunk forms the medial cord
Posterior divisions of all three trunks join to form the posterior cord
Branches
Root branches
Dorsal scapular nerve
Long thoracic nerve of Bell
Upper trunk branches
Suprascapular nerve
Nerve to subclavius
Lateral cord branches (LML)
Lateral pectoral nerve
Musculocutaneous nerve
Lateral root of median nerve
Medial cord branches (M4U)
Medial pectoral nerve
Medial root of median nerve
Medial cutaneous nerve of forearm
Medial cutaneous nerve of arm
Ulnar nerve
Posterior cord branches (STARS)
upper Subscapular nerve
Thoracodorsal nerve
Axillary nerve
Radial nerve
lower Subscapular nerve
Applied aspects
Erb’s palsy Klumpke’s paralysis

Mode of injury Undue separation of head & neck Hyperabduction of arm
Location of injury Upper trunk injury Lower trunk injury
Muscles affected Deltoid Intrinsic muscles of hand

Supraspinatus
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Erb’s palsy Klumpke’s paralysis

Infraspinatus
Biceps
Brachialis
Brachioradialis
Supinator
ECRL
Deformity Policeman tip posture Claw hand
Sensory loss Outer aspect of arm Medial border of forearm

and arm
ANS lesion – Horner syndrome
2. Sciatic nerve
● It is the thickest nerve in the body

● It has two parts – tibial part and common peroneal part – which are enclosed in a
common sheath of connective tissue
● Formation
○ Tibial part : ventral division of anterior primary rami of L4, L5, S1, S2 and S3
○ Common peroneal part : dorsal division of anterior primary rami of L4, L5, S1
and S2
Course
Sacral plexus
Sciatic nerve
Enters gluteal region through greater sciatic notch and passes below piriformis
Runs under cover of gluteus maximus
Enters back of thigh
Crossed by long head of biceps femoris
Divides into tibial nerve and common peroneal nerve
Branches
● Articular branches to hip and knee

● Muscles of the back of thigh
○ Tibial component supplies
■ Semitendinosus
■ Semimembranosus
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■ Adductor magnus (hamstring part)

■ Long head of biceps femoris
○ Common peroneal component supplies
■ Short head of biceps femoris
Applied aspects
● Sciatic nerve is injured by misplaced IM injections, hip dislocation & pelvic fractures
● Sciatic nerve damage causes
○ Impaired extension at hip
○ Impaired flexion at knee
○ Loss of dorsiflexion of ankle (foot drop) and plantar flexion of ankle
○ Loss of inversion and eversion of foot
○ High stepping gait
● Intervertebral disc prolapse impinging on L5/S1 spinal nerve root produces sciatica (back
pain radiating to leg)
3. Facial nerve
Fibres of facial nerve
● SVA – Taste from anterior two thirds of tongue and palate
● SVE – Muscles of facial expression
● GVE – Lacrimal pathway to lacrimal, nasal and palatine (LNP) glands
- Submandibular pathway to submandibular & sublingual salivary (SSS)
glands
● GVA – Sensation from soft palate and adjacent pharyngeal wall
● GSA – Sensation from posterior surface of external ear (posterior auricular
branch)
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Course of facial nerve
Facial nucleus (pons)
Facial nerve loops around abducens nucleus (raising the facial colliculus)
Exits brainstem at pontomedullary junction
Enters internal auditory meatus
Lesion D
Geniculate ganglion
Greater petrosal nerve Pterygopalatine ganglion LNP glands
Facial nerve in the facial canal
Lesion C
Nerve to stapedius
Lesion B
Chorda tympani Submandibular ganglion SSS glands
Chorda tympani also carries taste sensation from
anterior two-thirds of tongue and palate to nucleus
tractus solitarius
Exits skull through stylomastoid foramen
Lesion A
Enters parotid gland
Sends branches to muscles of facial expression
Clinical correlation – Bell’s palsy
Causes
Idiopathic; may be associated with HSV infection
Management
Oral prednisolone within 48 hours of onset may reduce inflammation and duration of
weakness. Taper gradually over two weeks.
Acyclovir
Artificial tears / eye lubrication / adhesive strapping of eyelids
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Physiotherapy
Prognosis
Usually recovers in 4-8 weeks
NCS or EMG may be used to prognosticate
Aberrant reinnervation causes crocodile tears syndrome and synkinesia (jaw winking)
Site of Lesion Location of Lesion Clinical features
Lesion A Stylomastoid foramen Paralysis of muscles of facial expression
Lesion B Proximal to chorda tympani Loss of taste in anterior two third of tongue
Decreased salivation
Plus features of lesion A
Lesion C Proximal to nv. to stapedius Hyperacusis (loss of stapedial reflex)
Plus features of lesions A and B
Lesion D Proximal to geniculate gang. Loss of lacrimation
May present later with crocodile tears syndrome
Plus features of lesions A, B and C
4. Abducens nerve
● It is the sixth cranial nerve which supplies the lateral rectus muscle of the eyeball.
● Nucleus
The abducens nucleus is situated in the lower pons beneath the facial colliculus.
● Course
○ The nerve runs downwards to reach the lower border of the pons and then it runs
upward through the cisterna pontis to reach the cavernous sinus.
○ The nerve pierces the posterior wall of the cavernous sinus, and bends sharply
forwards over the petrous temporal bone superior border, and then lies lateral to
the internal carotid artery in the cavernous sinus.
○ The nerve enters the orbit through the middle part of the superior orbital fissure
and ends by supplying the lateral rectus muscle.
Applied aspects
● Abducens nerve paralysis is one of the most common false localising signs in patients
with raised intracranial pressure. Its susceptibility to such damage is due to its long
course in the cisterna pontis and its sharp bend over the petrous temporal bone superior
border. Abducens nerve paralysis causes failure of abduction of the affected eye and
results in diplopia.
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● Millard Gubler syndrome is a ventral pontine syndrome characterised by ipsilateral

abducens and facial nerve LMN weakness and contralateral hemiparesis and is caused by
a brainstem stroke due to basilar artery occlusion.
● Cavernous sinus thrombosis caused by sepsis in the dangerous area of the face involves
the oculomotor, trochlear and abducens nerves, resulting in weakness of the extraocular
muscles.
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5. Cavernous sinus
● Dural venous sinus that lies on either side of the body of sphenoid bone in middle cranial
fossa
● Extent
○ From superior orbital fissure to apex of petrous temporal bone
○ Average length – 2 cm, width – 1 cm
● Contents
○ Cavernous segment of ICA
○ Perivascular T1 sympathetic plexus associated with cavernous segment of ICA
○ III nerve
○ IV nerve
○ V1 (ophthalmic nerve)
○ V2 (maxillary nerve)
○ VI nerve
● Role
○ Receives blood from brain, meninges and orbit
Applied aspects
● Infection involving dangerous area of face may lead to cavernous sinus septic thrombosis
● Clinical features of cavernous sinus pathology
○ Ptosis (weakness of levator palpebrae superioris)
○ Proptosis (venous congestion causes protrusion)
○ Chemosis (congestion leads to swelling of conjunctiva)
○ Periorbital oedema
○ Diplopia (dysmotility of extraocular muscles)
○ Sluggish pupillary response (involvement of III nerve)
○ Decreased corneal reflexes (involvement of V1 nerve)
○ Sensory disturbances in V1 and V2 territory
6. Corticospinal tract
Origin
● The corticospinal tract (CST) has 30-30-40 origin :

○ 30% from primary motor cortex (area 4)
○ 30% from premotor and supplementary cortex (areas 6 and 8)
○ 40% from sensory cortex / post central gyrus (areas 3, 1 and 2)
● CST arises from the pyramidal neurons in layer 5 of the above regions and hence CST is
also called pyramidal tract.
Subcortex
● Corona radiata
● Internal capsule
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Corona radiata Internal capsule

CST fibres are loosely packed CST fibres are densely packed
Dense hemiplegia is not seen Dense hemiplegia is seen in internal

in corona radiata lesions capsule lesions
CST fibres are not near cortico- In internal capsule, both are in close
-bulbar fibres in corona radiata proximity
Corona radiata lesions do not have Internal capsule lesions are usually
coexisting facial weakness associated with facial weakness
Brainstem
In the lowermost part of the medulla, CST fibres decussate to the opposite side.
Spinal cord
In the spinal cord, CST fibres descend in the lateral funiculus of the spinal cord and
finally terminate on the anterior horn cell.
7. Internal capsule
● It is a structure composed of a collection of axons (white matter) in the inferomedial part

of cerebral hemisphere
● It separates the caudate nucleus and thalamus from the lentiform nucleus
146
Part Constituent fibres

○ Anterior limb Frontopontine fibres
○ Genu Corticobulbar fibres
○ Posterior limb CST fibres are located in the ant. ⅔ of the post. limb
○ Retrolentiform Optic radiation
○ Sublentiform Auditory radiation
Blood supply
● Superior part of anterior and posterior limbs and genu
○ Lenticulostriate branches of MCA
● Inferior part of anterior limb
○ Anterior cerebral artery (including recurrent branch of Heubner)
● Inferior part of genu
○ Internal carotid artery
● Inferior part of posterior limb
○ Anterior choroidal artery (branch of internal carotid artery)
Applied aspects
● Internal capsule is prone to CVA because the perforating arteries that supply the region
are predisposed to occlusion or rupture due to their small diameter.
● Lesion of the anterior two-third of the posterior limb of the internal capsule produces
contralateral motor weakness.
● Further, the motor fibres are densely packed in the internal capsule and hence there is
dense hemiplegia in internal capsule lesions.
● Also, in the internal capsule the corticospinal tract fibres are in close proximity to the
corticobulbar fibres. Hence internal capsule lesions are usually associated with facial
weakness as well.
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8. Circle of Willis
Location
At the base of the brain, in the interpeduncular fossa
Formation
Formed by nine arteries
Anteriorly – Anterior communicating artery
Anterolaterally – Paired anterior cerebral arteries
Laterally – Proximal segments of both ICAs
Posterolaterally – Paired posterior communicating arteries
Posteriorly – Proximal segments of both posterior cerebral arteries
Role
● It serves as a channel of collateral circulation, in the event of an arterial occlusion
Branches
● Central branches
○ Anteromedial branches
■ Largest branch is the recurrent artery of Heubner
○ Anterolateral branches
■ Largest branch is Charcot’s artery of cerebral haemorrhage
○ Posterolateral branches
○ Posteromedial branches
● Cortical branches / External branches
○ Run on the surface of cerebrum and anastomose freely
148
9. Visual pathway
149
10. Pain pathway
Pain from skin
Receptor : free nerve ending
1st order neuron : posterior nerve root ganglia
2nd order neuron : neurons of marginal nucleus and substantia gelatinosa of Rolando
(cross over to the opposite side occurs in the spinal cord itself)
Fibres ascend in the form of lateral spinothalamic tract
3rd order neuron : neurons in thalamic nucleus, tectum, reticular formation
and periaqueductal grey matter
Centre for pain sensation : post central gyrus of parietal cortex
Pain from face

Trigeminal nerve
Visceral pain
● Oesophagus, trachea and pharynx – glossopharyngeal and vagus nerves
● Thoracic and abdominal viscera – thoracolumbar sympathetic nerves
● Pelvic region – sacral parasympathetic nerves
Applied aspects
Contralateral loss of pain and temperature if the spinothalamic tract fibres are affected
11. Pain reflex (Withdrawal reflex)
● It occurs in response to painful stimulation of skin and subcutaneous tissue

● It is a polysynaptic reflex
● Response
○ Ipsilateral (affected) limb
■ Flexor muscle contraction and extensor muscle inhibition
■ This withdraws the limb away from the stimulus
○ Contralateral limb
■ Extension occurs to support the body
12. Stretch reflex (Monosynaptic reflex)
● When a skeletal muscle with an intact nerve supply is stretched within physiological
limits, it contracts.
● Example – tapping patellar tendon stretches the quadriceps femoris, which leads to its
contraction and extension of the knee joint
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Muscle spindle (receptor to detect stretch)
Spindle afferents
Alpha motor neuron
Muscle contraction
Gamma motor neuron sends efferents to muscle spindle from spinal cord
○ Role - Increase the sensitivity of stretch reflex
○ Example - Jendrassik manoeuvre
13. CSF circulation with diagram
CSF is secreted by choroid plexus within the ventricles by ultrafiltration & active secretion
Lateral ventricles
Interventricular foramen of Munro
3rd ventricle
Aqueduct of Sylvius
4th ventricle
Foramen of Luschka and Magendie
Cerebral and spinal subarachnoid spaces
Absorbed via arachnoid villi into venous channels and sinuses
Production : 20 mL CSF/hour
Turnover : 3-4 times a day
Applied aspects
1. Aqueductal stenosis presents with hydrocephalus involving the third and lateral
ventricles. But the 4th ventricle is normal sized.
2. In tubercular meningitis, basal exudates can involve the basal cisterns. This can cause
hydrocephalus either via impaired absorption of CSF at the level of arachnoid
granulations, or there may be obstruction to the flow at the level of basal cisterns.
3. Ventriculoperitoneal shunt or endoscopic third ventriculostomy are operative
interventions available to address hydrocephalus.
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14. Types of cerebral oedema
● Vasogenic oedema
○ Due to disruption of BBB
○ eg. VEGF induced increased vascular permeability causing peri-tumoral oedema
● Cytotoxic oedema
○ Due to cell injury
○ eg. head injury, stroke
● Interstitial oedema
○ Due to outflow of CSF
○ eg. hydrocephalus
● Osmotic oedema
○ Due to osmolarity derangement
○ eg. DKA, hyponatremia
15. Neuromuscular junction (NMJ)
Stimulus
Sodium ion enters through voltage gated sodium channel
Depolarisation
152
When the impulse reaches the end of the axon, it increases the permeability of calcium ions
Calcium ion enters through voltage gated calcium channel
Exocytosis of synaptic vesicles containing Acetyl Choline
Release of ACh into the synaptic cleft
ACh degraded by Acetyl Cholinesterase (AChE)
Few molecules of ACh escape degradation by AChE and get attached to ACh receptor
Influx of sodium ion
Depolarising potential (end plate potential)
Applied aspects
● Myasthenia gravis
○ Blocking type antibodies are formed against postsynaptic ACh receptors at the
NMJ of skeletal muscles
● Botulism
○ Botulinum toxin produces paralysis by blocking the presynaptic release of ACh at
the NMJ
● Organophosphate poisoning
○ The mechanism of action of this poison is inhibition of AChE, leading to
accumulation of ACh throughout the nervous system, resulting in overstimulation
of muscarinic and nicotinic receptors
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16. CSF in meningitis
Component Normal Bacterial Viral TB/fungal
CSF pressure 5-15 mm Hg High Normal/slightly high High
WBC (cells/cu. mm) <5 10-2000 0-1000 50-750
(in thousands) (in hundreds) (in hundreds)
Polymorphs % 2 >80 <50 <50
Protein (mg/dL) <40 40-500 20-200 40-1500
Glucose (mg/dL) >60 <40 >40 <40
CSF/blood glucose >0.6 <0.3 0.3-0.6 <0.4
17. Pathology of bacterial meningitis
● Neutrophils fill the subarachnoid space and are found around the leptomeningeal blood
vessels
● Later, they infiltrate the vessel walls and extend into the brain substance (cerebritis)
● Phlebitis leads to venous thrombosis and hemorrhagic infarction of the underlying brain
18. Albuminocytologic dissociation

● It is a CSF finding in Guillain-Barré syndrome (GBS).
● GBS is a polyradiculoneuropathy. Since the radicles (spinal nerve roots) are being
involved, proteins leak into the CSF, leading to increased CSF protein levels. But the CSF
WBC count will be normal. This is known as albuminocytologic dissociation.
● This phenomenon is not seen if the lumbar puncture is performed in the first seven days
of the illness. It is usually seen only after seven days.
19. Embryological basis of neural tube defect
Notochord develops in the axial line of the embryo
Notochord induces the overlying ectoderm to form the neural plate
154
By the end of the third week, the lateral margins of the neural plate thicken and become elevated
to form the neural folds
The neural folds then grow over the midline and begin to fuse to form the neural tube, which
later separates from the surface ectoderm
Neural tube has a cavity (neural canal) which is in continuity with the amniotic cavity in the
beginning. The cavity gives rise to the central canal of the spinal cord and ventricles of the brain
Closure of the neural tube begins in the cervical region and continues cranially and caudally.
When the neural tube starts closing in the cervical region, the neural canal is still open at the
cranial end (anterior neuropore) and caudal end (posterior neuropore). Gradually the neuropores
shut close, disconnecting the neural canal from the amniotic cavity
Applied aspects
● Craniorachischisis occurs due to total failure of neural tube closure.
● Non-closure of anterior neuropore leads to anencephaly.
● Non-closure of posterior neuropore leads to spina bifida.
○ Spina bifida occulta - failure of vertebrae to close around the spinal cord
○ Meningocele - meninges extend out of the defective spinal canal
○ Meningomyelocele - meninges and spinal cord extend out of the defective spinal
canal
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Management
● MRI spinal cord with brain screening
● Surgical closure of the defect
Prevention
● Prescribe periconceptional folic acid for all prospective mothers - 0.4 mg/day two months
before and three months after conception. For mothers with neural tube defect in their
previous child, the dose of folic acid is 4 mg/day.
● Anomaly USG, elevated levels of maternal AFP and elevated levels of amniotic fluid
AFP and acetyl cholinesterase for antenatal diagnosis.
20. Vein of Galen malformation
Anatomy
Paired internal cerebral veins drain the deep parts of the cerebral hemisphere and finally unite to
form the great cerebral vein of Galen. Just before their union, each internal cerebral vein receives
the corresponding basal vein of Rosenthal. The great cerebral vein of Galen then empties into the
straight sinus.
156
Embryology
● Between the 6th and 11th week of intrauterine life, the developing choroid plexus has
arterial blood supplied by the ICA and its terminal branches and the venous drainage is
by the median prosencephalic vein.
157
● By the 11th week, the paired internal cerebral veins take over the venous drainage of the
choroid plexus. This results in the regression of the median prosencephalic vein, except
for its most caudal part, which joins the internal cerebral veins to form the vein of Galen.
● Vein of Galen malformations result due to the failure of the regression of the median
prosencephalic vein. This means that the original connections between the arteries (that
were supplying the developing choroid plexus) and the median prosencephalic vein
persist and result in enlargement of the latter. Hence, arterial blood is shunted from
choroidal arteries (high pressure) to the median prosencephalic vein (low pressure).
● The median prosencephalic vein lacks a fibrous wall, is largely unsupported and lies free
in the subarachnoid space within the fluid of the quadrigeminal cistern and hence it
balloons out to a large size.
● The high flow across the arteriovenous fistula may result in the retention of foetal
patterns of venous drainage, which could in turn prevent development of other sinuses
such as the straight sinus.
Clinical features
● During intrauterine life, the low resistance of the placental circulation competes with the
cerebral arteriovenous shunt, thereby blood flow through the shunt is not as great as it is
after birth. Exclusion of the low resistance placental circulation results in an abrupt
increase in the flow across the fistula, leading to high-output cardiac failure.
● The high flow within the arteriovenous shunt and restriction of venous drainage results in
high cerebral venous pressure, which prevents resorption of CSF and thus results in
hydrocephalus, cerebral edema, and hypoxia.
Management
● Antenatal USG can pick up this anomaly and such mothers are referred to higher centres
for delivery.
● Cranial MRI is the preferred preoperative imaging modality.
● Aggressive management of cardiac failure can usually postpone the intervention until the
child is aged about 5-6 months, at which point intervention is easier and safer.
158
● Prior to endovascular intervention, the prognosis was dismal, with 100% mortality
without treatment and 90% mortality following conventional intracranial surgery. At
present, the AV fistulas are occluded by an interventional neuroradiologist using embolic
agents such as coils, balloons or cyanoacrylate glue.
● Emergency embolization of the malformation may be necessary to reduce the shunt in
neonates with refractory cardiac failure.
159
PULMONOLOGY
1. Bronchopulmonary segments
● A bronchopulmonary segment (BPS) is the anatomical, functional and surgical unit of the
lung.
● It is the largest subdivision of a lobe of the lung.
● It is named according to the segmental bronchus supplying it.
● It is wedge-shaped and is surgically resectable.
● It contains a segmental bronchus, a branch of the bronchial artery and a branch of the
pulmonary artery, which run together through the central part of the segment and is
surrounded by connective tissue.
● The bronchopulmonary segments are :
Right lung Left lung
● Upper lobe ● Upper lobe

○ I Apical ○ I Apical
○ II Posterior ○ II Posterior
○ III Anterior ○ III Anterior
○ IV Superior lingular
● Middle lobe ○ V Inferior lingular
○ IV Lateral
○ V Medial
● Lower lobe ● Lower lobe

○ VI Superior ○ VI Superior
○ VII Medial basal ○ VII Medial basal
○ VIII Anterior basal ○ VIII Anterior basal
○ IX Lateral basal ○ IX Lateral basal
○ X Posterior basal ○ X Posterior basal
Applied aspects
● The tributaries of the pulmonary veins are intersegmental and lie at the margins of the
bronchopulmonary segments. They create surgical planes, which a surgeon can follow for
segmental resection with minimal tissue damage.
● In case of foreign body aspiration occurring in erect posture, the aspirated material most
commonly enters the posterior basal (X) BPS of the right lower lobe. In case of aspiration
occurring in supine posture, the aspirate usually enters the apical (VI) BPS of the right
lower lobe or the posterior (II) BPS of the right upper lobe.
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2. Respiratory muscles
Muscles of inspiration
● During quiet inspiration, diaphragm is the major muscle. During deep inspiration, the
accessory muscles like the external intercostal muscles, scalene and sternocleidomastoid
are utilised.
Muscles of expiration
● Expiration is a passive process caused by the elastic recoil of the lungs. Active expiration
occurs during speech, singing, exercise and in pathological conditions. During active
expiration, rectus abdominis, external and internal oblique muscles, transversus
abdominis and internal intercostal muscles are utilised.
Applied aspects
● Abnormal lungs due to pneumonia etc. result in increased airway resistance and
decreased chest and lung compliances. This requires a greater pressure to inflate the lung
to the same volume. This results in the recruitment of the accessory muscles of
respiration. Retractions of the intercostal, subcostal, sternal and supraclavicular muscles
indicate that the underlying lung is diseased. In severe respiratory distress, when the
oxygen supply-demand balance of the respiratory muscles is disturbed, respiratory failure
may ensue because of muscle fatigue.
● Respiratory muscle weakness may be seen in muscle pathology (eg. DMD), NMJ
disorders (eg. myasthenia gravis) and also neuropathy (GBS). This manifests as shallow
breathing and may require mechanical ventilatory support.
● Phrenic nerve (C3 C4 C5) injury leads to elevation and paradoxical movement of the
hemidiaphragm during forceful inspiration.
● Ondine’s curse (congenital central hypoventilation syndrome) is characterised by the
loss of involuntary control of breathing during sleep.
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3. Pathological stages of pneumonia
Stage Duration Gross finding

Congestion 1-2 days Heavy & boggy lung
Red hepatisation 2-4 days Red, airless, consistency like liver
Grey hepatisation 5-8 days Gray, airless, consistency like liver
Resolution 8-9 days Resolution
HPE findings
Congestion
● Vascular engorgement
● Intra-alveolar fluid accumulation
● Bacterial growth in the fluid
● Neutrophilic infiltrate
Red hepatisation
RBCs, fibrin and neutrophils present in the alveolar exudates
Grey hepatisation
RBCs disintegrate, leaving behind a fibrinosuppurative alveolar exudates
Resolution
Alveolar exudates undergo enzymatic degradation into debris
This debris can be either expectorated, or ingested by macrophages, or
organised into fibroblasts
4. Pleural fluid analysis

Light’s criteria
To label an effusion as an exudate, any one of the following should be positive :

● Pleural fluid protein / serum protein ratio >0.5
● Pleural fluid LDH / serum LDH ratio >0.6
● Pleural fluid LDH >2/3rds of upper limit of normal of serum LDH
All three criteria should be negative to label an effusion as transudative.
Causes of transudative effusion

● Congestive heart failure
● Hypoalbuminemia
● Nephrotic syndrome
● Liver cirrhosis
Causes of exudative effusion

● TB
● Synpneumonic effusion
● Malignancy
● Connective tissue disease
Most synpneumonic effusions resolve completely with appropriate antibiotics. If the child is not
improving even after 3-4 days of appropriate antibiotics, empyema is suspected.
162
Empyema is defined as the presence of frank pus or microorganisms in the pleural fluid. If
frank pus or microorganisms are absent in the pleural fluid, then empyema may be diagnosed if
the following features are met :
● Pleural fluid pH <7.2
● Pleural fluid LDH >1000 IU/L
● Pleural fluid glucose <40 mg/dL
Intercostal drainage tube should be inserted in all children diagnosed with empyema.
5. Tuberculous lymphadenitis HPE

● Granuloma
○ It is an aggregation of activated macrophages surrounded by mononuclear cells
○ Macrophages get activated to form epithelioid cells
○ Some epithelioid cells fuse together to form Langhans type giant cells
● Caseous necrosis
○ The granuloma gradually undergoes caseous necrosis
○ It has a cheesy appearance due to the presence of mycolic acid
6. GeneXpert
● It is a semi-quantitative, fully automated real-time polymerase chain reaction (PCR)

based nucleic acid amplification technology.
● It detects Mycobacterium tuberculosis, but cannot detect non tuberculous mycobacteria.
● It detects both live and dead bacteria.
● It also detects rpoB gene mutation i.e. can also detect rifampicin resistance.
● It can provide results within 2 hours.
● Any sample from the body can be tested, except blood, urine and stool. Only 2 mL
sample is needed.
● It is a fully closed diagnostic system; therefore, there is no risk of contamination and
biohazard. It also does not require high expertise because of a very simple software-based
reporting system.
● On completion of a test run, the following results are possible :
○ MTB not detected
○ MTB detected Rif resistance indeterminate
○ MTB detected Rif resistance not detected
○ MTB detected Rif resistance detected
○ Error
● Further, based on the cycle threshold (CT) value, the MTB detection results are also
displayed in a semi-quantitative manner, as :
○ MTB detected high
○ MTB detected medium
○ MTB detected low
○ MTB detected very low
● Sensitivity in various specimens :
○ Lymph node - 85%
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○ Gastric fluid - 84%

○ CSF - 80%
○ Pleural fluid - 44%
7. Management of drug resistant tuberculosis
Mono drug resistant tuberculosis

● Resistance to isoniazid alone
● Management
○ Replace isoniazid with levofloxacin.
○ Rifampicin, pyrazinamide and ethambutol also to be given similar to drug
sensitive TB.
○ Total duration of treatment is 6 months.
Multi drug resistant (MDR) TB

● Resistance to rifampicin and isoniazid
● Management
○ There are 3 groups of medications :
■ Group A - Bedaquiline, levofloxacin, linezolid
■ Group B - Cycloserine, clofazimine
■ Group C - Delaminid, meropenem, amikacin, pyrazinamide, ethambutol,
ethionamide
○ From group A, all 3 medications are given. Bedaquiline is given for 6 months.
Levofloxacin and linezolid are given for 18-24 months.
○ From group B, any one out of the two options is chosen and given for 18-24
months.
Extensively drug resistant (XDR) TB

● Resistance to rifampicin, isoniazid, levofloxacin and at least one more group A
medication (either bedaquiline or linezolid or both)
● Management
○ Group C medications are included in the treatment regimen along with whichever
group A and group B medications are sensitive.
8. Newer medications for tuberculosis

Bedaquiline
● It is a quinoline derivative.
○ Mycobacterial ATP synthase inhibitor
● ADR
○ QT prolongation
● Indication
● It is an oral group A drug used in MDR-TB. Duration of treatment with bedaquiline is for
six months. Other medications are continued for 18-24 months.
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Delamanid
● It is a nitroimidazole derivative.
○ Mycolic acid synthesis inhibitor
● ADR
○ QT prolongation
● Indication
○ It is an oral group C drug used in XDR-TB. Duration of treatment with delamanid
is for six months. Other medications are continued for 18-24 months.
9. Pulmonary function test

It has three components - FVC, DLCO and flow volume curves
FVC and FEV1
● Forced vital capacity (FVC) is the maximum amount of air that can be expired after a
forceful maximal inspiration.
● FVC = tidal volume (500 mL) + inspiratory reserve volume (3000 mL) + expiratory
reserve volume (1000 mL) = 4500 mL
● Forced expiratory volume-1 (FEV1) is the maximum amount of air that can be expired in
the first second after a forceful maximal inspiration. Normal individuals can expire
around 80% of the FVC volume in the first second. So, normal FEV1/FVC is 80%.
○ In obstructive diseases, inspiration is unaffected. But during expiration there
occurs a dynamic compression of the airways and the patient takes a long time
to expire the FVC volume out. FVC is normal (as the entire FVC volume is
eventually expired slowly), but the FEV1 is reduced as the patient cannot expire
rapidly due to the dynamic airway compression. Hence, FEV1/FVC ratio is
reduced in obstructive diseases (<80%) as the numerator decreases.
○ In restrictive diseases, inspiration is affected due to fibrosis. Hence FVC is low
(FVC = TV + IRV + ERV; since IRV is low due to fibrosis, FVC is also low).
There is no dynamic airway compression occurring here and so FEV1 is normal.
Hence, FEV1/FVC ratio is increased in restrictive diseases (>80%) as the
denominator decreases.
Diffusing capacity of the lungs for carbon monoxide (DLCO)

● DLCO assesses the capacity of the lungs to diffuse CO across the respiratory
membrane.
● DLCO is low in case of reduced diffusion occurring across the respiratory membrane. It
can be either due to fibrosis of the respiratory membrane (interstitial lung disease) or due
to reduced pulmonary blood flow (pulmonary hypertension or venous
thromboembolism).
● DLCO is increased in case of increased pulmonary blood flow due to diffuse alveolar
haemorrhage (DAH). DAH may be seen in conditions like Goodpasture syndrome,
granulomatosis with polyangiitis and SLE.
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Flow volume curves

a. Normal flow volume curve
i. A flow volume curve depicts flow on the y axis and volume on the x axis.
ii. A normal flow volume curve starts from the residual volume, has a saddle
shaped inspiratory curve and the expiratory curve depicts a peak (which
denotes the peak expiratory flow rate)
b. In obstructive diseases, the inspiratory portion is not affected. There is a ‘scooped
out pattern’ demonstrated in the abnormal expiratory phase.
c. In restrictive diseases, the TLC, FVC and RV are all reduced, but expiration is
normal. Hence it looks like a miniature of the normal curve.
Normal Obstructive disease Restrictive disease
10. Bronchodilators
Beta-2 agonists, anticholinergics methylxanthines are the three main medications in this
category.
Beta-2 agonists
● Types of beta-2 agonists and examples
○ Short acting beta-2 agonists (SABA) - salbutamol, terbutaline
○ Long acting beta-2 agonists (LABA) - formoterol, salmeterol
○ When the beta-2 receptor is activated, the smooth muscle of the airway relaxes
and so the patient experiences better airflow.
● Adverse effects
○ Tremor, tachycardia, palpitations, and muscle cramps.
● Indications
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○ SABA is used as reliever as and when needed in the long term management of
asthma
○ SABA is also used in asthmatic exacerbation
■ Salbutamol is used in acute severe asthma, life threatening asthma and
near fatal asthma - 2.5 mg of salbutamol nebuliser solution is diluted in
3-4 mL normal saline and nebulised through oxygen over 20 minutes and
can be repeated thrice.
■ Terbutaline infusion may be considered in near fatal asthma.
○ LABA is used along with ICS in step 3 (moderate persistent asthma) and step 4
(severe persistent asthma) of long term management of asthma.
Anticholinergics
● Examples
○ Ipratropium, tiotropium
○ Anticholinergics target parasympathetic nervous system receptors (M3) in the
airways and inhibit their function. Since the parasympathetic nervous system is
responsible for increased bronchial secretions and bronchoconstriction, reversing
those should provide bronchodilation and fewer secretions.
● Adverse effects
○ Dry mouth, urinary retention, tachycardia and constipation.
● Indication
○ Ipratropium is used in life threatening asthma and near fatal asthma - 250-500
mcg ipratropium is nebulised through oxygen over 20 minutes and can be
repeated thrice.
Methylxanthines
● Examples
○ Aminophylline, caffeine
○ Methylxanthines act by blockade of adenosine receptors and by inhibition of
phosphodiesterase. This leads to bronchial smooth muscle relaxation.
○ Methylxanthines also increase calcium uptake in diaphragmatic muscles. Hence
they increase the contractility of diaphragm and also reverse the fatigue of
diaphragm.
● Adverse effects
○ Methylxanthines have a narrow therapeutic index with greatest efficacy at serum
drug concentrations of 5 to 15 mcg/mL and when the level exceeds 20 mcg/mL,
adverse effects like tachycardia, palpitations, hypotension, arrhythmias, tremors
and seizures are seen. Hence methylxanthines are to be used with caution.
● Indications
○ Asthmatic exacerbation - aminophylline infusion may be considered in near fatal
asthma.
○ Caffeine is used in NICU for babies with recurrent apnoea.
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11. Inhaled corticosteroids
Mechanism of action
● Inhaled corticosteroids (ICS) have potent glucocorticoid activity and work directly at the
cellular level by reversing capillary permeability and lysosomal stabilisation to reduce
inflammation.
● This mode of administration decreases the dose required for the desired effect as it
bypasses the first-pass metabolism in drugs taken orally. The reduced systemic
bioavailability also minimises side effects.
Mode of administration
● ICS is usually administered through metered-dose inhalers (MDI). Additionally a spacer
may be used, which acts as a reservoir for the aerosol, resulting in greater drug delivery
to the airways and less wastage to the atmosphere.
● Selecting the appropriate inhalation device
○ <4 years : MDI with spacer and face mask
○ 4-12 years : MDI with spacer
○ >12 years : MDI may be used directly
Adverse effects
● Adverse effects include dysphonia, reflex cough and oral candidiasis. It is advisable to
have the patient rinse their mouth out after ICS use to prevent oral candidiasis.
Indication
● It is used in the long term management of asthma.
● Step 1 (intermittent asthma)
○ Symptoms less than twice a month
○ Low dose ICS is taken along with SABA, whenever SABA is taken PRN
● Step 2 (mild persistent asthma)
○ Symptoms more than twice a month
○ Daily low dose ICS
● Step 3 (moderate persistent asthma)
○ Symptoms on most days, or waking with asthma once a week or more
○ Daily low dose ICS plus LABA
● Step 4 (severe persistent asthma)
○ Symptoms on most days, or waking with asthma once a week or more, and
low lung function
○ Daily medium dose ICS plus LABA
● Examples and dose of ICS
○ Budesonide
■ Low dose ICS : 100-200 mcg/day
■ Medium dose ICS : 200-400 mcg/day
○ Fluticasone
■ Low dose ICS : 50-100 mcg/day
■ Medium dose ICS : 100-200 mcg/day
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ENDOCRINOLOGY
1. Calcium and phosphorus metabolism
Calcium
● Calcium intestinal absorption
○ Calcium absorption occurs predominantly in the upper small intestine.
○ 95% of calcium is absorbed actively and 5% is absorbed passively.
○ The active absorption is transcellular (through the cell) and is controlled by
vitamin D.
○ The passive absorption is paracellular (in between two cells) and it is not
dependent on vitamin D.
○ Calbindin is a vitamin D dependent protein and is responsible for calcium entry
into the cell, along with the TRPV6 channel.
○ When the body needs calcium, vitamin D increases calcium absorption via
calbindin. When the body does not need calcium, vitamin D does not activate
calbindin.
○ Further, PTH is the most important stimulator of 1-alpha hydroxylase which
forms active vitamin D. So, PTH and vitamin D together increase the intestinal
absorption of calcium.
● Calcium renal reabsorption

○ 65% of calcium reabsorption occurs at PCT, 25% occurs at the thick ascending
loop of Henle (ThAL) and 10% occurs at DCT.
○ PCT
■ 80% of the calcium reabsorption at PCT occurs by passive paracellular
transport. This is a PTH-independent process.
■ 20% of the calcium reabsorption at PCT occurs by active transcellular
transport. This is a PTH-dependent process.
○ ThAL
■ Both calcium and magnesium are reabsorbed here by passive paracellular
transport mediated by claudin 16/19. PTH stimulates claudin 16/19 and
hence enhances calcium reabsorption.
■ CaSR (calcium sensing receptor) is activated by hypercalcemia and
inhibits claudin 16/19 and thereby inhibits calcium reabsorption.
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○ DCT
■ Here the calcium reabsorption occurs by an active transcellular process
mediated by PTH and vitamin D (TRPV5 and calbindin)
So, PTH and vitamin D together increase the renal reabsorption of calcium.
Phosphorus
● Phosphorus intestinal absorption
○ Phosphorus absorption occurs predominantly in the upper small intestine. 80% is
absorbed actively and 20% is absorbed passively.
○ The active absorption is transcellular and is controlled by vitamin D (TRPV6 and
calbindin). The passive absorption is paracellular and it is not dependent on
vitamin D.
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● Phosphorus renal reabsorption

○ 100% of phosphorus reabsorption occurs at PCT. The reabsorption is mediated by
the sodium-phosphate cotransporter.
○ PTH is a potent phosphaturic substance. It inhibits the sodium-phosphate
cotransporter, thereby leading to phosphate excretion.
Applied aspects
● Rickets
● Phosphorus has the ability to convert a normal endothelial cell into an osteoblast. These
osteoblasts trap calcium and lead to irreversible tunica media calcification inside the
blood vessels. This is the reason why medial calcification occurs in CKD patients with
hyperphosphatemia. Hence CKD patients are advised dietary phosphate restriction and
phosphate binders.
● Proximal RTA can be differentiated from distal RTA based on fractional excretion of
phosphorus. It will be normal in distal RTA and increased in proximal RTA, as 100% of
phosphorus reabsorption occurs at PCT. Further, proximal RTA will have more severe
rickets than distal RTA, due to heavy loss of phosphorus in urine.
● Primary hyperparathyroidism (eg. due to parathyroid adenoma) manifests with high
calcium and low phosphorus levels.
● Hypoparathyroidism (eg. due to DiGeorge syndrome) manifests with hypocalcemia.
● Bartter syndrome type 5 is seen due to gain of function mutation of CaSR and
manifests with hypocalcemia and hypercalciuria. Familial hypercalcemic hypocalciuria
(FHH) is seen due to loss of function mutation of CaSR and manifests with
hypercalcemia and hypocalciuria.
2. Development of thyroid
Endoderm in the floor of foregut
Thyroid diverticulum
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Both lobes of thyroid and isthmus formed
Descends caudally into the neck passing ventral to hyoid and laryngeal cartilages
During descent thyroid remains connected to the tongue by thyroglossal duct
Thyroglossal duct is later obliterated and the site of the duct is marked by foramen cecum
Parafollicular C-cells of thyroid are derived from the neural crest cells via the ultimobranchial
body in the fourth pharyngeal pouch, and then these C-cells migrate into thyroid (secrete
calcitonin)
Applied aspects : Lingual thyroid, thyroid dysgenesis
3. Thyroid hormone synthesis
Plasma iodide
Transport across the basolateral membrane uses NIS (sodium iodide symporter).
NIS is blocked by thiocyanates and perchlorates.
Transport across the apical membrane uses pendrin, which is also present in the
inner ear. Pendred syndrome due to a defect in pendrin manifests with goitre and
SNHL.
Iodide reaches inside thyroid
Iodide is converted to iodine by the enzyme TPO (thyroid peroxidase). TPO is blocked by
methimazole, carbimazole and propylthiouracil. Hashimoto’s thyroiditis is characterised by
anti-TPO antibodies.
Iodine gets attached to the tyrosine residues present on thyroglobulin to form

monoiodotyrosine (MIT) and diiodotyrosine (DIT). MIT and DIT undergo coupling with each
other to form T3 and T4.
Release of the thyroid hormones into circulation
MCT8 is a membrane protein which is responsible for the efflux and uptake of thyroid
hormones. In the thyroid gland, it transports thyroid hormones across the basolateral
membrane (efflux) into the circulation. In the brain, MCT8 is responsible for the entry of
thyroid hormones (uptake) into the brain cells. Defective MCT8 in the brain impairs
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thyroid hormone entry into the brain cells and hence produces a condition which presents
similar to congenital hypothyroidism with hypotonia and severe developmental delay.
But the distinguishing feature is that fT3 level is elevated in this condition (fT3 cannot
enter the cell) whereas in congenital hypothyroidism, fT3 is low. The name of this
condition is Allan Herndon Dudley syndrome.
Iodide at high doses transiently inhibits the synthesis and secretion of thyroid hormones
(Wolff Chaikoff effect) and this principle is used in thyrotoxic crisis.
Peripheral conversion of T4 to T3
Peripheral conversion requires deiodinase. Propranolol blocks deiodinase and is useful

in thyrotoxic crisis.
Hormone action at the end organ
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4. Thyroid function test
● Fourth generation chemiluminescence immunoassays are used for measuring TSH and
thyroid hormones.
● TFT reference range in adults
○ TSH 0.5 - 5 milliIU/L
○ fT4 12 - 20 pmol/L
○ fT3 2 - 5 pmol/L
● It is recommended to use age-appropriate reference ranges while interpreting TFT in
children.
Applied aspects
1. Approach to hypothyroidism
● Scenario I : High TSH and low fT4 (Primary hypothyroidism)
USG +/- technetium thyroid scintigraphy
Ectopic or hypoplastic thyroid Enlarged thyroid
Thyroid autoantibodies
Positive Negative
Autoimmune thyroiditis Dyshormonogenesis
(eg. Pendred syndrome)
Confirm with
perchlorate discharge test
● Scenario 2 : High TSH and normal fT4

○ It is subclinical hypothyroidism. Check for thyroid autoantibodies.
● Scenario 3 : Low or normal TSH and low fT4
○ It is secondary hypothyroidism. Can proceed with MRI pituitary and TRH
stimulation test if needed.
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2. Approach to hyperthyroidism
A. Scenario 1 : Low TSH and high fT4 (primary hyperthyroidism)
Thyroid autoantibodies
Present in Absent in
Graves’ disease toxic adenoma or toxic MNG
B. Scenario 2 : Low TSH and normal fT4
It is subclinical hyperthyroidism. Check for thyroid autoantibodies
C. Scenario 3 : High TSH and high fT4
It is secondary hyperthyroidism. Can proceed with MRI pituitary.
3. Screening for congenital hypothyroidism
Either cord blood or 72 hour postnatal sample can be used to check TSH levels
<20 >40 20-40
Normal Screen positive Recall and repeat screening
40-80 >80
Confirmatory TSH, fT4 Initiate thyroxine supplementation soon

and thyroxine after taking samples for confirmation
supplementation (need not wait for confirmatory test results to start treatment)
after confirmation
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5. Development of adrenal gland
● Adrenal gland
○ Cortex – develops from intermediate mesoderm
○ Medulla – develops from neural crest cells
● Development of adrenal cortex
Intermediate mesoderm
Foetal cortex Definitive cortex (subsequently formed)
formed initially Differentiates into
(then disappears) Zona glomerulosa Zona fasciculata Zona reticularis
● Peculiarities of zona reticularis

○ Zona glomerulosa and zona fasciculata are present at birth. But zona reticularis
becomes recognisable at the end of 3rd year of life only.
○ Cells of foetal cortex are incorporated into zona reticularis
● Development of adrenal medulla
○ Neural crest cells migrate to the region of developing cortical cells and are
surrounded by them
6. Adrenal gland physiology
A. Adrenal cortex
1. Mineralocorticoids
● Aldosterone acts at the principal cell of the cortical collecting duct and enhances the
reabsorption of sodium and water as well as the excretion of potassium and acid.
○ The RAAS axis is activated by renal hypoperfusion due to intravascular volume
depletion and this leads to increased aldosterone activity causing return of BP to
normalcy and also metabolic alkalosis along with hypokalemia. This is known as
secondary hyperaldosteronism (secondary to RAAS activation). Secondary
hyperaldosteronism due to hypovolemia is the cause of hypokalemia and
metabolic alkalosis in Bartter syndrome and Gitelman syndrome.
○ Primary hyperaldosteronism is caused due to excess aldosterone production by the
adrenal cortex occurring independently of the RAAS axis eg. adrenocortical
adenoma. Primary hyperaldosteronism leads to hypertension, metabolic alkalosis
and hypokalemia.
○ Hypoaldosteronism causes type 4 RTA with metabolic acidosis and hyperkalemia
eg. salt wasting CAH.
2. Glucocorticoids
a. Effect on glucose metabolism - Cortisol stimulates gluconeogenesis. Hence,
hypercortisolism (eg. Cushing syndrome) produces impaired glucose tolerance.
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b. Effect on protein metabolism - Cortisol reduces protein synthesis and increases

protein breakdown. The amino acids hence formed by protein breakdown are
converted into glucose by gluconeogenesis. Increased protein breakdown
manifests as severe muscle wasting whereas reduced protein synthesis manifests
as weak connective tissue (striae) in hypercortisolism. A combination of these
factors also lead to shortness in stature.
c. Effect on fat metabolism - Cortisol stimulates ketogenesis and lipolysis. It also
causes redistribution of body fat which manifests as obesity and buffalo hump in
hypercortisolism.
d. Cortisol has some mineralocorticoid activity as well. So hypercortisolism also
produces hypertension, metabolic alkalosis and hypokalemia similar to
hyperaldosteronism.
e. Cortisol also has some sex steroid activity. This manifests as hirsutism, acne etc.
in hypercortisolism.
3. Adrenal androgens
a. This has a role in libido and growth of pubic and axillary hair.
b. In the salt wasting type of CAH there is increased production of adrenal
androgens and this manifests in girls as ambiguous external genitalia at birth due
to the virilising effect of the adrenal androgens. Although boys may have normal
genitalia at birth, they may develop precocious puberty, if left untreated.
B. Adrenal medulla
It secretes the catecholamines (adrenaline, noradrenaline and dopamine), which increase the
basal metabolic rate, increase the rate and force of cardiac contraction and also stimulate
gluconeogenesis, lipolysis and ketogenesis. It plays a major role during the fight or flight events.
Excess adrenal medulla activity is noticed in conditions like pheochromocytoma and
neuroblastoma.
7. Puberty
● Defined as
○ attainment of fertility
○ associated with maturation of gonads
○ and appearance of primary and secondary sexual characteristics
● Normal age of puberty
○ Girls 8 – 14 years
○ Boys 9 – 15 years
Initiation of puberty
Increase in pulsatile release of GnRH
Nocturnal LH pulses
Puberty
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Before puberty, the pulsatile release of GnRH was inhibited by

● GABA
● Opioids
● Melatonin
● Neuropeptide Y
At puberty, pulsatile release of GnRH is initiated by
● Glutamate
● Norepinephrine
● Kisspeptin
Applied aspects
● Constitutional delay in growth and puberty
● Precocious puberty
8. Insulin and its analogues

● Conventional insulin
○ Regular insulin
○ NPH
● Insulin analogues
○ Aspart
○ Lispro
○ Glulisine
○ Glargine
○ Degludec
● Advantages of insulin analogues over conventional insulin
○ Modified pharmacokinetics but similar pharmacodynamics
○ Greater stability
○ Greater consistency
○ Glargine and degludec mimic physiological release of insulin (peakless action)
● Classification based on duration of action
○ Ultrashort acting
■ Aspart
■ Lispro
■ Glulisine
○ Short acting
■ Regular insulin
○ Intermediate acting
■ NPH
○ Long acting
■ Glargine
○ Ultralong acting
■ Degludec
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Characteristics of insulin and its analogues
Name Onset of action (min) Peak action in (hr) Duration of action (hr)
Lispro 10 1 4
Regular insulin 20 2 8
NPH 60 4 12
Glargine 60 Peakless action 24
Degludec 60 Peakless action 48
Applied aspects
● Basal bolus regimen is now considered as the standard of care. The twice daily split-mix
regimen offered inadequate glycemic control and hence is no longer recommended.
● Insulin can either be administered as multiple daily injections or by continuous
subcutaneous insulin infusion (insulin pump). The pump is programmed to deliver insulin
at a slow continuous basal rate with pre-meal boluses. Latest models have sensors with
CGMS (continuous glucose monitoring system) so that the pump can automatically
decrease the rate of insulin infusion when blood glucose levels are dropping and increase
it when the glucose levels begin to rise.
● The usual starting dose in T1DM is 1 U/kg/day with half of this dose given as long acting
insulin eg. glargine (basal) and the rest divided into pre-meal boluses.
For example, a 20 kg child may require 10 U glargine at bedtime along with 3 U lispro
thrice a day with meals
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CRITICAL CARE
1. Inotropes
Inotropes are medications used to increase cardiac contractility in patients with shock.
Types of receptors and expected physiological response
Receptor Physiological response

Alpha Systemic vasoconstriction
Beta-1 Increased cardiac contractility (inotropy)
Increased heart rate (chronotropy)
Beta-2 Systemic vasodilation
Dopaminergic Increased renal blood flow
A. Dopamine
Mechanism
● At low doses (2-5 mcg/kg/min), it acts on dopaminergic receptors and increases
the renal blood flow.
● At moderate doses (5-10 mcg/kg/min), it acts on beta-1 receptors and enhances
inotropy and chronotropy, thereby increasing the cardiac output.
● At high doses (>10 mcg/kg/min), it acts on alpha receptors and causes systemic
vasoconstriction.
The typical indication of dopamine is fluid refractory septic shock.
The usual starting dose is 5-10 mcg/kg/min.
B. Dobutamine
Mechanism
● It acts on beta-1 and beta-2 receptors.
○ By acting on beta-1 receptors, it enhances inotropy and chronotropy,
thereby increasing the cardiac output.
○ By acting on beta-2 receptors, it causes systemic vasodilation, thereby
decreasing the afterload.
The typical indication for dobutamine is normotensive cardiogenic shock due to a primary
myocardial pathology eg. myocarditis or congenital heart disease.
The usual starting dose is 5-10 mcg/kg/min.
C. Adrenaline
Mechanism
● At low doses (0.05-0.3 mcg/kg/min), it acts on beta-1 and beta-2 receptors and
causes enhanced inotropy and chronotropy and also vasodilation.
● At high doses (>0.5 mcg/kg/min), there is a predominant alpha receptor mediated
systemic vasoconstriction. This leads to an increase in SBP, DBP and MAP.
Although the heart rate increases, the cardiac output falls due to increased
afterload contributed by systemic vasoconstriction.
Fluid refractory dopamine refractory cold septic shock is a typical indication for adrenaline.
The usual starting dose is 0.1-0.3 mcg/kg/min.
D. Noradrenaline
Mechanism
180
The mechanism of action is predominant alpha receptor mediated systemic

vasoconstriction along with mild beta-1 mediated inotropy but without chronotropy. It is
an attractive agent because it effectively increases BP with only minimal tachycardia and
also has mild inotropy.
Fluid refractory warm shock with hypotension is a typical indication for noradrenaline.
The usual starting dose is 0.05-0.15 mcg/kg/min.
E. Milrinone
Mechanism
● Milrinone is a phosphodiesterase inhibitor and it increases the cytosolic cAMP
levels by inhibiting its breakdown.
● Milrinone causes enhanced inotropy and lusitropy (improved diastolic relaxation).
It also causes vasodilation of both arteries and veins, resulting in decreased
preload and afterload.
● Potent vasodilation can result in hypotension and hence it is to be used with
caution in patients with borderline low BP.
Catecholamine refractory cold shock (with normal BP) is a typical indication for milrinone.
A loading dose of 50 mcg/kg is given over 60 minutes, followed by a maintenance infusion rate
of 0.5 mcg/kg/min usually.
F. Adverse effects of inotropes

Arrhythmias
Extravasation can cause limb ischaemia resulting in gangrene
2. Paracetamol toxicity
Toxic dose
> 100 mg/kg/day
Mechanism
● Accumulation of toxic metabolite N-acetyl benzo quinone imine (NABQI)
● Depletion of glutathione
Clinical features
Stage I – nonspecific symptoms; LFT normal
Stage II – Clinical features similar to hepatitis; LFT and PT/INR begin to rise
Stage III – Fulminant hepatic failure
Stage IV – Recovery
Management
● If the patient is seen after 4 hours after ingestion, we can estimate paracetamol levels and
prognosticate using Rumack Matthews nomogram.
○ <100 mcg/mL - no toxicity
○ 100-200 mcg/mL - possible liver injury
○ >200 mcg/mL - definite liver injury
● Can use activated charcoal upto 4 hours of ingestion
● NAC 150 mg/kg over 1 hr, then 50 mg/kg over 4 hrs and finally 100 mg/kg over 16 hrs
● King’s college criteria for liver transplant (rule of 3) : pH after resuscitation <7.3 (or)
All 3 present : Creatinine >3.3, Encephalopathy stage >3, PT in 3 digits (>100)
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Supportive treatment of fulminant hepatic failure
3. Acute iron toxicity

Toxic dose
● Mild – moderate toxicity : 20-60 mg/kg
● Severe toxicity : >60 mg/kg
Clinical features
Stage I (1-6 hrs) – Non specific symptoms
Stage II (6-24 hrs) – Hypovolemia & acidosis present, but clinically may seem stable
Stage III (24-48 hrs) – Cardiac dysfunction, hepatic failure, seizures, coma
Stage IV (6 days – 6 weeks) – Recovery with GI scarring
Management
● No role for activated charcoal
● Whole bowel irrigation
● Desferroxamine
○ Start at 10 mg/kg/hour and gradually increase to 15 mg/kg/hour
○ Continue till 24 hours after vinrose urine colour disappears
○ Indications
■ Iron level > 500 mcg/dL
■ Iron tablets visible on X-ray abdomen
■ Presence of Stage II and Stage III features
● Supportive measures for liver failure, acidosis, hypovolemia etc.
4. Methemoglobinemia
● Methemoglobinemia is haemoglobin with iron oxidised to ferric (Fe3+) state from

ferrous state (Fe2+). Ferric iron is unable to bind and transport oxygen.
● Causes
○ Induced by drugs/chemicals – naphthalene, dapsone, local anaesthetics
○ It may also be seen in babies receiving INO (<5% MetHb is safe while on INO)
○ Slate grey cyanosis unresponsive to increase in FiO2
○ Poor feeding, lethargy, irritability, seizures, coma
● Consequences
○ Decreased oxygen binding by MetHb and impaired oxygen transport to tissues
○ ODC is shifted to left paradoxically, increasing the affinity of normal Hb to
oxygen, further compromising oxygen delivery to tissues
● Investigations
○ SpO2 is unreliable. PaO2 measurement is important.
○ Quantitative MetHb can be measured using a co-oximeter
○ Spectrophotometry
○ G6PD level estimation prior to therapy
● Management
○ 100% oxygen to maximise tissue oxygen delivery
○ If MetHb level < 30%
■ Observe for 24-48 hours (= t½ of MetHb)
182
■ Remove offending agent

○ If MetHb level 30-50%
■ IV methylene blue 1-2 mg/kg diluted and slow IV over 5-10 minutes
■ Repeat every 30-60 minutes if still symptomatic or MetHb >30%
■ (Max dose 7 mg/kg)
■ If the offending agent has long t½ (eg. dapsone), use 0.1 mg/kg/hr infusion
○ If MetHb level > 50% / child is G6PD deficient / no response to methylene blue
■ Exchange transfusion
■ Hyperbaric oxygen
5. Oxygenation index
● The oxygenation index (OI) is used as a marker of severity of hypoxemic respiratory
failure in children.
● The equation for OI is :
OI = mean airway pressure (MAP) x FiO2 x 100 ÷ PaO2
● Oxygen saturation index (OSI) is a noninvasive measurement and has been shown to be a
reliable surrogate marker of OI.
● The equation for OSI is :
OSI = MAP x FiO2 x 100 ÷ SpO2
● MAP values will be calculated by the ventilator and will be available on the ventilator
screen.
● The formula for MAP is :
For volume control ventilation,
MAP = 0.5 x (PIP - PEEP) x (Ti/Ttot) + PEEP
For pressure control ventilation,

MAP = (PIP - PEEP) x (Ti/Ttot) + PEEP
PIP : peak inspiratory pressure
PEEP : peak end expiratory pressure
Ti : inspiratory time
Ttot : cycle time
Applied aspects
1. ARDS severity is graded by using OI and OSI
Category OI OSI
Mild ARDS 4-8 5-7.5
Moderate ARDS 8-16 7.5-12.3
Severe ARDS >16 > 12.3
2. OI >40 is an indication for starting ECMO in children with ARDS
3. Postductal OI >25 is one of the criteria to be satisfied prior to initiating INO in a baby with
PPHN and hypoxemic respiratory failure
183
6. ICP monitoring
● The normal intracranial pressure (ICP) is 5-15 mm Hg.
● ICP monitoring can be done by invasive and non-invasive methods.
A. Invasive method of ICP monitoring
● It is the most accurate way to measure ICP.
● Additionally, invasive ICP monitoring via an external ventricular drain provides a
therapeutic option to drain the CSF and hence reduce ICP, if required, in case of
high pressures during monitoring.
● Indications of invasive monitoring
○ Although invasive ICP monitoring is most commonly used in the
management of severe traumatic head injury, it may also be used
occasionally in hydrocephalus or conditions at high risk of developing
hydrocephalus (eg. subarachnoid haemorrhage)
● Contraindications
○ Bleeding disorders
○ Scalp infection
○ Brain abscess
● Procedure
○ An incision is made at Kocher’s point and a burr hole is made
○ The dura is opened and a catheter is inserted into the anterior horn of the
lateral ventricle. CSF will appear in the catheter
○ Confirm drain placement after suturing with CT
○ Attach the catheter to a transducer to measure the pressure transmitted
from CSF in the ventricles
● ICP monitoring waveforms (depicted in image A)
○ Percussion wave (P1) - represents arterial pulsation
○ Tidal wave (P2) - represents brain compliance
○ Dicrotic wave (P3) - represents aortic valve closure
○ Normally the height order of the waves is P1 > P2 > P3
○ With decreasing brain compliance, the following changes are noticed
■ Waveform amplitude will increase
■ Rising P2 above P1 and P3
■ Appearance of Lundberg A waves - Lundberg A waves signify a
sustained increase in ICP for 5 to 10 minutes. They reflect reduced
cerebral compliance and impending herniation
184
B. Non-invasive methods of ICP monitoring

Non-invasive screening can be done in patients in whom there is relatively low suspicion of
elevated ICP, but the possibility needs to be ruled out. The following methods may be used :
1. Bedside methods like periodic assessment of GCS/AVPU, anterior fontanelle and head
circumference.
2. Imaging modalities like CT or MRI brain may show features like mass effect, midline
shift, cerebral edema or hydrocephalus, which suggest raised ICP
3. Transcranial doppler to monitor changes in the cerebral blood flow
4. Optic nerve sheath diameter - elevation in ICP can transmit through the CSF in the
subarachnoid space, leading to dilation of the optic nerve sheath, which can be detected
using transocular USG.
185

Applied Basic Sciences in Paediatrics Second Edition 2023 by Alfred Thomas Mario

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Contents

S. No. Chapter Page number

3. Biochemistry & Genetics 16

4. Microbiology & Immunology 26

10. Haemato-oncology 125

11. Neurology 139

12. Pulmonology 160

13. Endocrinology 169

14. Critical Care 180

15. Feedback received for the first edition 186

1. Deciduous and permanent teething

2. Bone age in the assessment of growth

3. Types of body build

5. Cleft lip and palate

2nd Stapes Stapedius Stapedial VII

3rd Hyoid body inf ½ Stylopharyngeal CCA, ICA IX

4th Thyroid cartilage Cricothyroid# Arch of aorta Sup laryngeal (X)

6th Cricoid cartilage All larynx muscles PA Rec laryngeal (X)

Tips on how to remember most of the table for the exam

B. Milk ejection reflex

3. Principle behind ORS

○ Concerned with Inspiration

B. Chemical regulation of respiration

CO2 crosses BBB

○ Plasma oncotic pressure (πc) opposes filtration and

Arterial end Venous end

NFP ∝ (Pc – Pi) – (πc – πi)

Phases of gastric secretion

10. Hearing assessment

B. Brainstem Evoked Response Audiometry (BERA) / Auditory Brainstem Response

● LTB4 is produced in neutrophils. It is the most potent chemotactic agent.

● This pathway is affected in homocystinuria

○ Oil drop cataract

5. Essential amino acids

6. Non essential amino acids

7. Serum amino acid pattern in protein energy malnutrition

8. Glucose tolerance test

10. Urine metabolic screening

11. Ketone bodies

14. Chromosomal translocation

15. Inborn error of metabolism

16. Urea cycle defects

● Urea cycle defects

17. Organic acidemia

○ Acute crisis (encephalopathy)

Ascaris lumbricoides egg (fertilised) Trichuris trichura egg

3. Screening tests for blood transfusion

4. Types of culture media

Antibiotic sensitivity testing

1. Disc diffusion method of Kirby Bauer

Automation in blood culture

Purified HIV antigen is adsorbed onto the test container

Serum sample to be tested is added to the container

Anti-human Ig conjugated with an enzyme is then added to the container

9. Mechanisms of antibiotic resistance in bacteria

11. Group B Streptococcus

Example – Streptococcus agalactiae

Differentiation Group A Streptococci Group B Streptococci

12. Atypical mycobacteria

13. Gas gangrene