The thyroglossal duct cyst is the most common congenital anomaly of the central portion of the neck. The thyroglossal duct cyst is intimately related to the central portion of the hyoid bone and usually elevates along with the larynx during swallowing. Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during the developmental stages.

The characteristic cells in granulomatous inflammation are giant cells, formed from merging macrophages and epithelioid cells elongated with granular eosinophilic cytoplasm. Granulomatous reactions are seen in patients with tuberculosis. A tuberculous/caseating granuloma is characterised by a zone of central necrosis lined with giant multinucleated giant cells (Langhans cells) and surrounded by epithelioid cells, lymphocytes and fibroblasts. The caseous zone is present due to the damaged and dead giant cells and epithelioid cells.
Mast cells are only few in number and fibroblasts lay down collagen.
Basophils are not present.
The giant cell made up of macrophages are the most abundant cells in this inflammatory process.

Among the given options, the most likely cause for the patient’s presenting symptoms is acute interstitial nephritis secondary to anti-tubercular therapy (ATT)Drug-induced acute interstitial nephritis can occur following treatment with beta-lactams, sulphonamides, rifampicin, ethambutol, and erythromycin. They can cause an acute allergic reaction with the infiltration of immune cells.Acute interstitial nephritis is said to be the most common renal complication in patients undergoing anti-TB treatment. Rifampicin is the most implicated drug, although ethambutol can also be a cause. The pathogenesis involves an immune-complex mediated acute allergic response, which leads to their deposition on renal vessels, the glomerular endothelium, and the interstitial area. Other options:Isoniazid does not affect the kidneys. Pulmonary-renal syndrome is a feature of Goodpasture’s syndrome. It is characterized by renal failure and lung haemorrhage. Severe cardiac or renal failure ensues and is complicated by pulmonary oedema, systemic lupus erythematosus, Henoch-Schönlein purpura, and cryoglobulinemia.

The boy is most likely to have sustained an injury to his brachial plexus as a result of upward traction of his arm for an extended period of time. We can rule out the topmost nerve roots of the brachial plexus, C6 and C7 as these supply the larger muscles of the arm responsible for moving the shoulder, the elbow and the wrist. The anatomical structure affected is therefore the T1 nerve root which is responsible for movement of the muscles in the hand. This type of injury is called a Klumpke’s Palsy, which is the result of a hyper-abducted trauma to the arm, damaging the C8 and T1 nerve roots. While the radial and ulnar nerve also innervate the hand, the history given points to Klumpke’s palsy as the best explanation for this mechanism of injury.

Cytomegalovirus (CMV) is the most frequent cause of congenital infection worldwide, with an estimated incidence in developed countries of 0.6–0.7% of all live births.The clinical spectrum of congenital CMV infection varies widely, from the complete absence of signs of infection (asymptomatic infection) to potentially life-threatening disseminated disease. At birth, 85–90% of infected infants are asymptomatic, and 10–15% present with clinical apparent infection (symptomatic disease).The presentation in this latter group is a continuum of disease expression whose more common findings are petechiae, jaundice, hepatomegaly, splenomegaly, microcephaly, and other neurologic signs.

Haemolytic uremic syndrome belongs to a heterogeneous group of disorders characterized by a triad of thrombocytopenia, microangiopathic haemolytic anaemia, and acute kidney injury. It is one of the most common causes of renal injury in children. The clinical findings are due to thrombotic microangiopathy, which leads to arterioles and capillary wall thickening along with endothelial swelling and detachment. The significant laboratory findings include increased white cell count, raised serum urea and creatinine, increased serum LDH, decreased platelet count, haematuria, and proteinuria.

Low oxygen delivery in hypotension, hypoxia, oedema, intracranial hypertension or changes in cerebral blood flow should all be prevented to avoid secondary brain injury. There is no evidence to suggest that hypothermia prevents secondary brain injuries.

Rhabdomyosarcoma originates from skeletal muscle cells. A biopsy is needed for grading according to microscopy. Most patients are adult females.

The azygos lobe is usually well seen on the chest radiograph, where it is limited by the azygos fissure, a fine, convex (relative to the mediastinum) line that crosses the apex of the right lung.

Celiac disease is classified as a Type IV hypersensitivity mediated by T-cell response. Negatively charged gliadin has been shown to induce interleukin 15 in the enteric epithelial cells, stimulating the proliferation of the natural killer cells and intraepithelial lymphocytes to express NK-G2D, a marker for natural killer T lymphocytes.

As there is lymphadenopathy already present in this patient, doing a biopsy of the lymph nodes will rule out metastasis of any underlying tumour.

Answer: Transposition of the great arteriesTransposition of the great arteries (TGA) is the most common cyanotic congenital heart lesion that presents in neonates. The hallmark of transposition of the great arteries is ventriculoarterial discordance, in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventricle.Infants with transposition of the great arteries (TGA) are usually born at term, with cyanosis apparent within hours of birth.The clinical course and manifestations depend on the extent of intercirculatory mixing and the presence of associated anatomic lesions. Note the following:Transposition of the great arteries with intact ventricular septum: Prominent and progressive cyanosis within the first 24 hours of life is the usual finding in infants if no significant mixing at the atrial level is evident.Transposition of the great arteries with large ventricular septal defect: Infants may not initially manifest symptoms of heart disease, although mild cyanosis (particularly when crying) is often noted. Signs of congestive heart failure (tachypnoea, tachycardia, diaphoresis, and failure to gain weight) may become evident over the first 3-6 weeks as pulmonary blood flow increases.Transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: Infants often present with extreme cyanosis at birth, proportional to the degree of left ventricular (pulmonary) outflow tract obstruction. The clinical history may be similar to that of an infant with tetralogy of Fallot.Transposition of the great arteries with ventricular septal defect and pulmonary vascular obstructive disease: Progressively advancing pulmonary vascular obstructive disease can prevent this rare subgroup of patients from developing symptoms of congestive heart failure, despite a large ventricular septal defect. Most often, patients present with progressive cyanosis, despite an early successful palliative procedure.

Answer: Surveillance annual flexible sigmoidoscopy from age 13 years until age 30 years. Familial adenomatous polyposis (FAP) is the most common adenomatous polyposis syndrome. It is an autosomal dominant inherited disorder characterized by the early onset of hundreds to thousands of adenomatous polyps throughout the colon. If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. In addition, an increased risk exists for the development of other malignancies.Most patients with FAP are asymptomatic until they develop cancer. As a result, diagnosing presymptomatic patients is essential.Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.Nonspecific symptoms, such as unexplained rectal bleeding (haematochezia), diarrhoea, or abdominal pain, in young patients may be suggestive of FAP.In a minority of FAP families a mutation cannot be identified and so annual flexible sigmoidoscopy should be offered to at risk family members from age 13–15 years until age 30, and at three to five year intervals thereafter until age 60 years.

Febrile seizures are convulsions that can happen when a child, most often between the ages of six months and three years, has a fever. They usually last for less than five minutes and although the child may lose consciousness, they are relatively harmless. However, sometimes they can last for up to 15 minutes and when they are termed complex febrile seizures.

These cardiovascular findings are suggestive of coarctation of the aorta, which is common among patients with Turner’s syndrome. Physical features of Turner’s syndrome include a short neck with a webbed appearance, a low hairline at the back of the head, low-set ears, and narrow fingernails and toenails that are turned upward.Atrioventricular septal defect is the most common cardiac anomaly in Down’s syndrome. Structural heart defects at birth (i.e., ventricular septal defect, atrial septal defect, patent ductus arteriosus) are common in Edward’s syndrome. Pulmonary stenosis with or without dysplastic pulmonary valve and hypertrophic cardiomyopathy are common in Noonan’s syndrome. Supravalvar aortic stenosis and peripheral pulmonary stenosis are found in William’s syndrome.

The recurrent laryngeal nerve (RLN) innervates all of the intrinsic muscles of the larynx except for the cricothyroid muscle, which is innervated by the superior laryngeal nerve (SLN).Patients with unilateral vocal fold paralysis present with postoperative hoarseness or breathiness. The presentation is often subacute. At first, the vocal fold usually remains in the paramedian position, creating a fairly normal voice. Definite vocal changes may not manifest for days to weeks. The paralyzed vocal fold atrophies, causing the voice to worsen. Other potential sequelae of unilateral vocal-fold paralysis are dysphagia and aspiration.Bilateral vocal-fold paralysis may occur after total thyroidectomy, and it usually manifests immediately after extubation. Both vocal folds remain in the paramedian position, causing partial airway obstruction. Patients with bilateral vocal-fold paralysis may present with biphasic stridor, respiratory distress, or both. On occasion, the airway is sufficient in the immediate postoperative period despite the paralyzed vocal folds. At follow-up, such patients may present with dyspnoea or stridor with exertion.

Trisomy 21 (Down’s syndrome)is a genetic disorder characterized by the presence of an extra copy of chromosome 21 in all the body cells, mostly due to non-disjunction during gametogenesis. Robertsonian translocation occurs only in about 2-4% of the cases. A variety of clinical features are found in trisomy 21 due to multi-system involvement but the hallmark is hypotonia, which is present in almost all the cases of trisomy 21. Different types of leukemias are also found in association with down’s syndrome, but they are not the hallmark. Atlantoaxial subluxation is secondary to hypotonia, which induces joint and ligament laxity. Other clinical findings are hypothyroidism, Alzheimer’s disease, Hirschsprung’s disease, and pulmonary hypertension.

Anorexia nervosa is a serious, psychiatric eating disorder characterized by distorted self-image due to which abnormal eating behaviours are adopted. This disorder affects multiple bodily systems, including the gastrointestinal system. The GI manifestations of anorexia are enlarged salivary glands due to purging behaviour, gastritis, gastroparesis, acute gastric dilatation, superior mesenteric artery syndrome, elevated liver transaminases, which cause hepatocyte apoptosis leading to cirrhosis, and steatosis leading to fatty liver. Hepatosplenomegaly is not a recognized complication of anorexia nervosa.

Androgen excess is one of the most common causes of advanced bone age. It usually occurs in precocious puberty or congenital adrenal hyperplasia.

Teenagers may have poor eating habits and neglect to take their vitamin supplements. They are less likely than older women to be of adequate pre-pregnancy weight or to gain an adequate amount of weight during pregnancy. Low weight gain increases the risk of having a low birthweight baby. Weight gain is maximal during the 2nd trimester.aPTT and gallbladder emptying is decreased during pregnancy whereas d-dimers is increased.

According per the national guidelines, 5 inflation breaths should be given with a gas pressure of 30cmH2O for term babies. Each breath should be given for 2-3 seconds. Pre-term babies should be aerated with a lower pressure of 20-25cmH2O.

As this boy didn’t have a previous history, a structural abnormality is unlikely. Parents should be asked to take the child to the bathroom to void before bedtime. Either alarm therapy or pharmacologic therapy should be considered if the above method doesn’t work after 3 months. From the above 2 therapies, neither one is superior than the other, so alarm therapy should be tried first.

Minimal change glomerulonephritis presents with mild or benign urinalysis findings. However, proteinuria together with the presence of oval fat bodies are typical.Minimal change glomerulonephritis (nephropathy) accounts for most cases of childhood nephrotic syndrome and 20–25% of adult nephrotic syndrome.

The blood-brain barrier (BBB) is a term used to describe the unique properties of the microvasculature of the central nervous system (CNS). CNS vessels are continuous nonfenestrated vessels, but also contain a series of additional properties that allow them to tightly regulate the movement of molecules, ions, and cells between the blood and the CNS.Blood vessels are made up of two main cell types: Endothelial Cells (ECs) that form the walls of the blood vessels, and mural cells that sit on the abluminal surface of the EC layer. The properties of the BBB are largely manifested within the ECs, but are induced and maintained by critical interactions with mural cells, immune cells, glial cells, and neural cells, which interact in the neurovascular unit.Astrocytes are a major glial cell type, which extends polarized cellular processes that ensheath either neuronal processes or blood vessels.This includes regulating the contraction/dilation of vascular smooth muscle cells surrounding arterioles as well as PCs surrounding capillaries. Astrocytes have been identified as important mediators of BBB formation and function because of the ability of purified astrocytes to induce barrier properties.

Insufficient surfactant production in premature infants leads to respiratory distress syndrome or surfactant deficient lung disease (SDLD), characterized by structurally immature lungs. There are many risk factors of this disease, some of them include male gender, caesarean section, infants of diabetic mothers, being the second born of the premature twins, perinatal asphyxia, sepsis, and hypothermia. Maternal hypertension is not a recognized risk factor for respiratory distress syndrome| instead, pregnancy-induced hypertension and chronic maternal hypertension are the protective factors against this disease.

The gastrocolic reflex is a physiological reflex that involves increase in colonic motility in response to stretch in the stomach and by-products of digestion in the small intestine. It is shown to be uneven in its distribution throughout the colon, with the sigmoid colon affected more than the right side of the colon in terms of a phasic response. Various neuropeptides have been proposed as mediators of this reflex, such as serotonin, neurotensin, cholecystokinin and gastrin.

PDA is particularly common in premature babies and it is managed by indomethacin administration. However, if PDA is not the only defect, prostaglandin E1 can be administered in order to keep the ductus open until the surgery takes place.

Removal of foreign bodies from the ear is indicated whenever a well-visualized foreign body is identified in the external auditory canal. Insects are better extracted with suction than with forceps or hooks. From the given answers, irrigation with warm water is the most suitable answer.

The most probable diagnosis in this patient would be Friedreich’s ataxia.Friedreich’s ataxia is also called spinocerebellar degeneration. It is an autosomal recessive condition. The onset of ataxia is around ten years of age. Intelligence is preserved. Cerebellar impairment, distal muscle weakness, pes cavus, hammer-toes and progressive kyphoscoliosis are present. Deep tendon reflexes are absent, particularly the ankle jerk. Loss of vibration and position sense occurs because of degeneration of the posterior columns. Hypertrophic cardiomyopathy can occur with progression to congestive cardiac failure.Other options:- Ataxia Telangiectasia: ataxia develops earlier, around two years of age, with loss of ambulation by adolescence. Nystagmus is present. Telangiectasia becomes evident by mid-childhood and is found on bulbar conjunctiva, over the bridge of the nose and on the ears. These children have an increased risk of developing lymphoreticular malignancies.- Abetalipoproteinemia: begins in childhood with steatorrhea and failure to thrive. Neurological symptoms appear in late childhood. These include ataxia, retinitis pigmentosa, peripheral neuritis, abnormalities in position and vibration sense, muscle weakness and mental retardation. Vitamin E is undetectable in serum in these patients.- Acute cerebellar ataxia: occurs in children of 1-3 years of age and is a diagnosis of exclusion. It often follows acute viral infections like varicella, coxsackievirus or echovirus by 2-3 weeks. It is an autoimmune response to a viral agent affecting the cerebellum. Prognosis is excellent with complete recovery present. Very small numbers have long term sequelae like ataxia, incoordination, speech disorder and behavioural problems.- Acute labyrinthitis: It is difficult to differentiate acute labyrinthitis from acute cerebellar ataxia in a toddler. It is associated with middle ear infections, vertigo and vomiting.

Answer: Inflammatory bowel diseaseThe inflammatory bowel diseases (IBDs), including ulcerative colitis and Crohn disease, are chronic inflammatory disorders of the gastrointestinal tract most often diagnosed in adolescence and young adulthood, with a rising incidence in paediatric populations. Inflammatory bowel disease is caused by a dysregulated mucosal immune response to the intestinal microflora in genetically predisposed hosts. Although children can present with the classic symptoms of weight loss, abdominal pain, and bloody diarrhoea, many present with nonclassical symptoms of isolated poor growth, anaemia, or other extraintestinal manifestations.Colorectal Carcinoma (CRC) is rare in patients less than 20 years of age.