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Indian J Crit Care Med
Indian J Crit Care Med
IJCCM
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine
0972-5229
1998-359X
Jaypee Brothers Medical Publishers

10.5005/jp-journals-10071-24703
Letter to the Editor
Author Response
Agrwal Shipra 1https://orcid.org/0000-0001-6698-6691

Pallavi 2https://orcid.org/0000-0001-9211-5793

Jhamb Urmila 3https://orcid.org/0000-0003-1734-3504

Saxena Romit 4https://orcid.org/0000-0002-8518-5504

1 Department of Pediatrics, ESIC Medical College and Hospital, Faridabad, Haryana, India
2–4 Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
Pallavi, Department of Pediatrics, Maulana Azad Medical College, New Delhi, India, Phone: +91 9999704599, e-mail: pallavi86.delhi@gmail.com
5 2024
30 4 2024
28 5 518519
Copyright © 2024; The Author(s).
2024
https://creativecommons.org/licenses/by-nc/4.0/ © The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
How to cite this article: Agrwal S, Pallavi, Jhamb U, Saxena R. Author Response. Indian J Crit Care Med 2024;28(5):518–519.

Keywords

Neuroimaging
Paroxysmal sympathetic hyperactivity
Pediatric intensive care unit
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pmcWe thank the authors for showing keen interest in our study and providing insightful reviews. We will attempt to address your concerns below.

We agree that PSH can be associated with hyperthyroidism, hypercorticism, or hyperadrenalism due to stimulation of the sympathetic nervous system, which should have been excluded. However, none of our patients was suffering from any of these uncommon conditions. Our patients were continuously monitored. They did not have clinical features of any cardiac comorbidities such as heart failure, malignant ventricular arrhythmias, atrial fibrillation, myocardial infarction, Takotsubo syndrome (TTS), pulmonary hypertension, or stress cardiomyopathy.

We understand the need for the results of cerebral imaging in our study. Computed tomography (CT) or MRI could be done in 28 cases and in the rest 26 either it was not planned or could not be done due to the sickness of the child. Table 1 summarizes the imaging findings.

Table 1 Cerebral imaging details

S. No	Diagnosis	Total cases	CT/MRI findings	
1	Meningoencephalitis	11	MRI was done in 3 cases (Normal in 1 and suggestive of herpes encephalitis in 2)	
2	Bacterial meningitis	5	CT done was normal in 1, Subdural empyema on USG in one and neuroimaging not done in rest 3	
3	Tubercular meningitis	3	Basal exudates and hydrocephalous was seen in all 3 cases	
4	Traumatic brain injury	1	Skull fracture and intracranial hemorrhage	
5	Stroke	1	Infarct in brain	
6	Inborn error of metabolism	2	Normal MRI in both	
7	Enteric encephalopathy	3	CT was done in normal in 1 case and not done in other 2	
8	NCC	1	Multiple granulomas on MRI	
9	Metabolic encephalopathy	1	Neuroimaging not done	
10	Intracranial tumors	3	The two cases had posterior fossa mass on MRI and one had Pineal gland tumor on MRI. All cases came to the pediatric intensive care unit (PICU) postoperatively	
11	Acute encephalomyelitis	1	Changes of ADEM on MRI	
12	Brain abscess	2	Frontal lobe abscess on CT in both	
13	Hepatic encephalopathy	1	Neuroimaging was not done as patient was sick to be transferred	
14	Dengue encephalopathy	3	Neuroimaging was not done	
15	Seizure disorder with status epilepticus	2	CT was normal in one and could not be done in other	
16	Transverse myelitis	1	Changes suggestive of myelitis in spinal cord and one calcified nodule in brain	
17	Acyanotic congenital heart disease with hypoxic brain injury	1	Hypoxic brain injury on MRI	
18	Meningomyelocoele	1	Hydrocephalous on CT	
11	Uremic encephalopathy	1	MRI was normal	
12	Gullen Barre syndrome	5	CT was normal in all	
13	Post diphtheritic polyneuropathy	5	Neuroimaging not done	

The author has highlighted the importance of the medications as a likely cause of the PSH, however, none of our patients received any cholinergic drugs. About 4–5 of our patients were getting adrenergic agents but we do not have complete data on this. Severe kidney injury causing uremic encephalopathy was found in one patient and the rest had mild-moderate AKI which was not causing encephalopathy. Data on acidosis, alkalosis, and electrolyte imbalances was not recorded in these patients.

We agree that incidence is defined as a number of patients/100,000/year and we have calculated the frequency for only a single center, which does not mean “incidence” per definition. Though many similar studies have used this word.1–3 We also accept there has been a typographical mistake in the discussion section and it should be four patients suffered from meningoencephalitis including bacterial, tubercular, and viral (and not viral meningoencephalitis).

Regarding the discrepancy between the “Data collection” section and the “Outcome variables” section, this outcome (i.e., survival) was mentioned for the sake of completeness of data, and it was not the primary or secondary objective of the study.

Orcid

Shipra Agrwal https://orcid.org/0000-0001-6698-6691

Pallavi https://orcid.org/0000-0001-9211-5793

Urmila Jhamb https://orcid.org/0000-0003-1734-3504

Romit Saxena https://orcid.org/0000-0002-8518-5504

Source of support: Nil

Conflict of interest: None
==== Refs
References

1. Kirk KA Shoykhet M Jeong JH Tyler-kabara EC Henderson MJ Bell MJ et al. Dysautonomia after pediatric brain injury Dev Med Child Neurol 2012 54 8 750 764 10.1111/j.1469-8749.2012.04322.x
2. Fernandez-Ortega JF Prieto-Palomino MA Garcia-Caballero M Galeas-Lopez JL Quesada-Garcia G Baguley IJ Paroxysmal sympathetic hyperactivity after traumatic brain injury: Clinical and prognostic implications J Neurotrauma 2012 29 7 1364 1370 10.1089/neu.2011.2033 22150061
3. Fernandez-Ortega JF Prieto-Palomino MA Munoz-Lopez A Lebron-Gallardo M Cabrera-Ortiz H Quesada-Garcia G Prognostic influence and computed tomography findings in dysautonomic crises after traumatic brain injury J Trauma 2006 61 5 1129 1133 10.1097/01.ta.0000197634.83217.80 17099518
